Content Validity of a High-Fidelity Surgical Middle Ear Simulator: A Randomized Prospective International Multicenter Trial

OBJECTIVE

After demonstration of face validity of a surgical middle ear simulator (SMS) previously, we assessed the content validity of the simulator with otolaryngology residents.

STUDY DESIGN

Multicenter randomized prospective international study.

SETTING

Four academic institutions.

METHODS

Novice participants were randomized into control, low-fidelity (LF), and high-fidelity (HF) groups. Control and LF produced 2 recordings from 2 attempts, and HF produced 4 recordings from 10 attempts, with trials 1, 4, 7, and 10 used for scoring. Three blinded experts graded videos of the simulated stapedectomy operation using an objective skills assessment test format consisting of global and stapedotomy-specific scales.

RESULTS

A total of 152 recordings from 61 participants were included. Baseline characteristics did not differ significantly between groups. Depending on the step of the operation, inter-rater reliability ranged from 24 to 90%. For LF and HF, years of training was significantly associated with improved scores in certain objective skills assessment test subparts. HF outperformed the control group on stapes and global scores ( p < 0.05). The HF group demonstrated improvement in global score over trials, but plateaued after four trials. Scores varied greatly for participants from different institutions in certain operative steps, such as transecting incudostapedial joints, likely due to differences in instrumentation and time elapsed since manufacture.

CONCLUSION

Practice with SMS led to better performance in both global and stapes-specific scores. Further studies are needed to examine construct validity and to create otology-appropriate grading systems. Variables like instrumentation and decline in flexibility of the simulator after 12 months greatly affect performance on the simulator.

Management of eagle syndrome

PURPOSE OF REVIEW

Eagle syndrome is a challenging clinical presentation with important potential complications. It can be misdiagnosed due to lack of awareness; this review provides information in terms of diagnosis and management of eagle syndrome.

RECENT FINDINGS

The importance of early diagnosis of this rare disease is preventing the delay in clinical-surgical treatment. As there is not a universally accepted cut-off for styloid process length, the diagnosis should be confirmed by length of process greater than one-third of the length of mandibular ramus in addition to other clinical symptoms and signs. There are both surgical and pharmacological treatment options for these patients.

SUMMARY

Eagle syndrome is a rare clinical condition and its diagnosis is made by physical examination and radiography. When it is suspected by physical examination, definitive diagnosis is confirmed by computed tomography scans of the skull, as the gold standard. Location, degree of elongation of styloid process, and severity and reproducibility of symptoms are important factors in deciding the most appropriate approach. Surgery is frequently the treatment of choice in Eagle syndrome patients. With proper diagnosis and treatment, the prognosis is favourable and recurrence is uncommon.

A study of efficacy of nigella sativa in treatment of Meniere's disease: A randomized, placebo controlled clinical trial

Purpose

Meniere's disease (MD), first introduced by Prosper Meniere, is characterized mainly by vertigo, tinnitus, aural fullness and sensorineural hearing loss. Though the exact pathophysiology of MD is unknown, immunologic and inflammatory interactions are possible underlying mechanisms involved in MD. This study is aimed to investigate the immunomodulatory and anti-inflammatory effect of Nigella sativa on MD as a therapeutic agent.

Methods

We divided 40 patients with definite MD into two groups of 20 cases. The study group received 1 g of Nigella sativa oil daily for three months and the control group received a placebo. Changes in hearing, tinnitus and vertigo were estimated by pure tone audiometry, tinnitus handicap inventory questionnaire and dizziness handicap inventory questionnaire, respectively.

Results

At the end of the study we did not observe any significant improvement in study's group hearing threshold, tinnitus and vertigo compared to the control group.

Conclusions

In this study, statistical analysis showed that Nigella sativa failed to improve signs and symptoms of MD. However, further investigations with a larger study population are needed to ascertain the current conclusion.

Perception of timbre in adult Cochlear implant users: Comparison of Iranian and Western musical instruments

OBJECTIVES

Cochlear implants (CI) have dramatically improved speech perception for patients with sensorineural hearing impairment. However, listening to music is a great challenge for them. This study examined the perception and appraisal of Iranian musical instruments comparing with similar Western instruments.

METHODS

Eleven adult CI users and 25 normal hearing (NH) individuals participated in this study. Musical stimuli of three commonly heard instrument pairs were prepared. Participants were asked to identify the instruments and rate their appraisal on a ten-point Likert scale (0 = dislike very much, 10 = like very much).

RESULTS

The instrument recognition rate was 40.6% among the CI users, and the mean appraisal score was 5.2 ± 2.7. NH listeners had none significant higher scores on both tasks with a recognition rate of 50.0% and the mean appraisal score of 6.9 ± 1.5. Iranian instruments were more recognized in both groups. Regarding their appraisal, the mean score for both types was almost equal in the NH group, while CI users more appraised Iranian instruments.

CONCLUSION

In addition to better recognition of Iranian instruments, they were particularly better appraised in the CI group. Iranian instruments provide suitable musical pieces for CI recipients that can be considered in rehabilitation programs.

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.

The Value of Spiral Chest Computed Tomography Scan in the Diagnosis of Asymptomatic Coronavirus Carriers among Paranasal Sinus and Pharynx Surgery Candidates

Introduction  The nasopharynx and oropharynx are the main colonization sites of coronavirus. Therefore, patients with paranasal sinuses and pharyngeal problems (ear, nose, and throat [ENT] patients) predispose coronavirus infection.

Ear, nose, and throat patients with concomitant asymptomatic coronavirus infection may develop severe pneumonia following surgical procedures. As a result, presurgical screening for coronavirus infection is a substantial concern.

Objective  We evaluated the usefulness of a spiral chest computed tomography (CT) scan in the diagnosis of asymptomatic coronavirus infection in the presurgical assessment of ENT patients

Methods  In this study, candidates of paranasal sinus or pharyngeal surgery were evaluated for coronavirus infection. Patients with neither history of coronavirus disease 2019 (COVID-19) nor compatible symptoms and signs were screened for asymptomatic coronavirus infection. These patients composed two groups: the first group underwent a reverse transcription polymerase chain reaction (RT-PCR) test of nasopharyngeal sample and spiral chest CT scan, but for the second one, only the latter was performed.

Results  In the first group, which consisted of 106 patients, 11 (10.4%) cases had positive RT-PCR test results, and 17 (16%) patients showed positive findings in favor of coronavirus infection in the spiral chest CT scan. In the second group, which consisted of 173 patients, 34 (19.7%) cases had positive chest CT scan results.

Conclusion  The chest CT scan has a valuable role in the early diagnosis of asymptomatic coronavirus carriers in patients highly predisposed to infection, especially in low resource areas, where the RT-PCR test is unavailable.

Minimally invasive trans-tympanic eustachian tube occlusion animal model

OBJECTIVE

Eustachian tube dysfunction is believed to be involved in the pathogenesis of many middle ear diseases including chronic suppurative otitis media. We aimed to describe a simple and reliable animal model of Eustachian Tube obstruction to further research into middle ear disorders.

STUDY DESIGN

Prospective cohort study in animals.

SETTING

University laboratory.

SUBJECTS AND METHODS

30 mice C57Bl/6J (n = 15) and CBA/CaJ (n = 15) aged 6-8 weeks received transtympanic Eustachian tube occlusion on left ear trough an acute tympanic membrane perforation using thermoplastic latex used in dental procedures (gutta percha). Control mice (n = 6) received tympanic membrane perforation only. At two and four weeks, the mice were observed for signs of Eustachian tube dysfunction and compared to control ears. ET dysfunction was defined as presence of effusion in the middle ear.

RESULTS

100% (n = 30) of the treated ears had otoscopic signs of Eustachian tube dysfunction at two weeks and the endpoint time of four weeks, compared to 0% in control mice (0/6). Temporary head tilt lasting up to 2 days were observed in 3 mice (10%). No other potential adverse events were recorded. No bacterial growth was determined in the middle ear fluid.

CONCLUSION

We describe a technically easy and reliable method for Eustachian tube occlusion in mice with an excellent success rate and minimal morbidity.

Music Appreciation of Cochlear Implant Users versus Normal Hearing Individuals

Introduction

Cochlear implants (CI) provide speech perception for patients with sensorineural hearing impairment; nonetheless, listening to music is a daunting challenge for them. The present study aimed to compare Iranian CI users and normal hearing (NH) controls in terms of musical habits and appreciation and investigate the possible effect of background variables.

Materials and Methods

A total of 37 CI users who underwent surgery at least 18 months before the study and 59 NH listeners were enrolled in this study. The participants were assigned to two age groups: group A (patients ≥15 years old) and group B (patients <15 years old). They were asked to complete the questionnaires to assess their music engagement.

Results

In group A, the mean score of music importance was significantly higher in CI users (8.7±2.1), as compared to that in NH subjects (5.8±2.3) (P=0.005). Participation in professional musical training and singing with music was not significantly different between the groups. In group B, the mean score of desire for music was not significantly different between CI users (8.2±1.8) and NH subjects (7.7±2.0). They participated in professional musical training and had a reaction to music almost equally. Singing with music was significantly less common in the CI group (CI 16[61.5%], NH (40[85.1%]) (P=0.023). Selected background variables had no significant effect on the music tendency and habits of CI users.

Conclusions

Iranian CI users tended to have a high level of music appreciation in both adult and children groups. Moreover, CI users and NH controls did not significantly differ in the importance of music, devoted time, participation in musical activities, and musical habits.

Association of Pro-inflammatory Cytokine Gene Polymorphism with Meniere's Disease in an Iranian Sample

Meniere's disease (MD) is known as a rare chronic disorder of the inner ear with elevated serum levels of pro-inflammatory cytokines like tumor necrosis factor (TNF)-α, Interleukin (IL)-1, and IL-6. This study aims to evaluate genes polymorphism in some pro-inflammatory cytokines in a group of Iranian MD patients compared to the healthy controls. In this case-control study, 25 MD patients and 139 healthy controls were enrolled. DNA was extracted from blood samples, and single nucleotide polymorphisms were detected using polymerase chain reaction with sequence-specific primers assay. MD patients and controls were examined in terms of allele, genotype, and haplotype frequency of pro-inflammatory cytokine genes. Only the frequencies of alleles A/G at position -238 in the promoter of the TNF-α gene differed significantly between MD patients and healthy controls. G to A allele ratio was 23 and 3.6 in MD and controls, respectively. In individuals with MD, genotype GG was found to be significantly more prevalent at position -238 of the TNF-α gene promoter sequence. In addition, the heterozygote AG variant of -238 A/G TNF-α gene polymorphism was lower in MD patients than controls. Compared to the control group, the haplotype TNF- (-308, -238) AG was higher in MD patients, although not statistically significant. This is the first study that we know of that evaluates the frequencies of pro-inflammatory cytokine genes in an Iranian MD sample. This study shows the association between TNF-α and susceptibility to MD.

Vibration-induced nystagmus in patients with chronic unilateral Meniere's disease

Background and Aim: Meniere's disease (MD) is one of the inner ear disorders associated with fluctuating hearing loss, vertigo, ear fullness, and tinnitus. Vestibular stimulation delas with the int­egrity of the peripheral vestibular system and may cause nystagmus due to the functional asy­mmetry between right and lef peripheral vesti­bular system. This study aimed to assess the vibration-induced nystagmus (VIN) in patients with chronic unilateral MD and investigate the effectiveness of this test in detecting the affected ear in these patients. Methods: This study was conducted on 29 pati­ents with chronic unilateral MD. For this pur­pose, spontaneous nystagmus (SN) and VIN at frequencies of 30 Hz and 100 Hz were recorded by videonystagmography test under five recor­ding conditions. The vibratory stimulation was presented to both healthy and affected ears. Coll­ected were analyzed in SPSS v.22 software. Results: Vibratory stimulation compared to the unstimulated condition, revealed a significant difference in eye movements for both healthy and affected ears. Moreover, the difference between VIN and SN in the affected ear was much greater than in the healthy ear. Conclusion: In patients with chronic unilateral MD, 100 Hz vibratory stimulation of the affected ear induces more reliable nystagmus than 30 Hz stimulation and unstimulated condition. The VIN test can be used for the evaluation of the vesti­bular system function and is a promising techni­que to detect the MD ear. Keywords: Meniere's disease; spontaneous nystagmus; vibration-induced nystagmus; chronic; definite; vestibular vibrator

Radiologic evaluation of the mastoid segment of the facial nerve tract in the intact temporal bone

PURPOSE

To localize the facial nerve course in the mastoid segment and to measure its distances relative to the tympanic membrane.

METHODS

This is a cross-sectional descriptive study. During 2019 in a tertiary hospital, 129 non-contrast and non-pathologic temporal CT images were studied in a tertiary hospital. Facial nerve distances were measured from the planes passing through the annulus in the axial cross-sections at superior, umbo, and inferior levels of the tympanic membrane. It was done in two different dimensions which are anteroposterior (toward the plane of the ear canal wall) and mediolateral (toward the plane of the tympanic membrane).

RESULTS

The least mean anteroposterior distance between the facial nerve and the posterior ear canal wall was at the level of umbo (3.66 ± 0.76 mm). The nearest point of the nerve toward the tympanic membrane was the inferior level (- 0.03 ± 0.81 mm). Overall external ear canal lengths were statistically significantly lower in women rather than men. There was a reverse correlation between the age and the ear canal length.

CONCLUSION

Posterior canalplasty seems to be safe unless dissection does not cross the plane of annulus. In this study, the safe margin was 1.4 mm in posterior canal wall drilling. It also should be performed carefully if it extends to the inferior side of the canal. Measuring the mediolateral dimension of the nerve toward the annulus in the axial CT images seems to be practically beneficial, especially in the inferior where the ear canal wall turns and might not act as a good landmark. Paying attention to this plane may reduce the risks of nerve injury in any procedures with transcanal approaches, particularly in inferior canaloplasty.

A novel mouse model of chronic suppurative otitis media and its use in preclinical antibiotic evaluation

Chronic suppurative otitis media (CSOM) is a neglected pediatric disease affecting 330 million worldwide for which no new drugs have been introduced for over a decade. We developed a mouse model with utility in preclinical drug evaluation and antimicrobial discovery. Our model used immune-competent mice, tympanic membrane perforation and inoculation with luminescent Pseudomonas aeruginosa that enabled bacterial abundance tracking in real-time for 100 days. The resulting chronic infection exhibited hallmark features of clinical CSOM, including inhibition of tympanic membrane healing and purulent ear discharge. We evaluated the standard care fluoroquinolone ofloxacin and demonstrated that this therapy resulted in a temporary reduction of bacterial burden. These data are consistent with the clinical problem of persistent infection in CSOM and the need for therapeutic outcome measures that assess eradication post-therapeutic endpoint. We conclude that this novel mouse model of CSOM has value in investigating new potential therapies.

Postoperative Venous Thromboembolism after Neurotologic Surgery

Objective  This study aimed to determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing neurotologic surgery at a single center. Methods  The records of adults undergoing neurotologic surgery from August 2009 to December 2016 at a tertiary care hospital were reviewed for VTE within 30 postoperative days. Particular attention was focused on postoperative diagnosis codes, imaging, and a keyword search of postoperative notes. Caprini risk scores were calculated. Results  Among 387 patients, 5 experienced postoperative VTE including 3 cases of pulmonary embolism (PE) and 2 cases of isolated deep vein thrombosis (DVT). All patients were given sequential compression devices perioperatively, and none received preoperative chemoprophylaxis. Patients with Caprini score > 8 had a significantly higher rate of VTE compared with those < 8 (12.5 vs. 1%, p  = 0.004). Receiver operating characteristic analysis revealed the Caprini risk assessment model to be a fair predictor of VTE, with a C-statistic of 0.70 (95% confidence interval [CI]: 0.49-0.92). Conclusion  While no specific validated VTE risk stratification scheme has been widely accepted for patients undergoing neurotologic surgery, the Caprini score appears to be a useful predictor of risk. The benefits of chemoprophylaxis should be balanced with the risks of intraoperative bleeding, as well as the potential for postoperative intracranial hemorrhage.

The Role of Neutrophils in Pseudomonas aeruginosa Chronic Suppurative Otitis Media

Chronic suppurative otitis media is largely due to biofilm-forming bacteria, of which a common pathogen is Pseudomonas aeruginosa. Neutrophils are well-known to have various contributions in both promoting and restricting bacterial growth in other biofilm-mediated diseases, as they are one of the first cells recruited to sites of infection. Herein we propose that 1) fluorescent P. aeruginosa develop into biofilms and form chronic infections in the middle ear of a mouse model of Eustachian tube obstruction and acute tympanic membrane wounds; 2) this biofilm reduces functional capacity of professional phagocytes; 3) biofilm initiates apoptosis of responding neutrophils; and 4) neutrophils contribute to disease burden. We also determine neutrophil subsets with a leading role in the establishment of bacterial biofilm-mediated disease, and test the capacity of polymorphonuclear leukocytes to suppress planktonic infection.

Neutrophil function is quantified as a measure of phagocytosis and the production of extracellular traps; we also measure cell survival and clearance via efferocytosis to determine host-mediated barriers to this recalcitrant infection. Using flow cytometry coupled with fluorescent-tagged P. aeruginosa, we are able to assess middle ear effusion post-inoculation and develop a timeline of response to chronic infection in our novel CSOM model.

Importantly, this study establishes a model system for further immunological and translational studies, including testing of topical therapeutics. The results of this work will also inform potential efforts of neutrophils as predictors for disease exacerbation and guide additional therapeutic development for an illness affecting millions of children globally.

Study of steroid effects on graft and inner ear outcomes in tympanoplasty: Randomized controlled trial

More studies are needed to investigate the side effects of steroids in tympanoplasty, owing to the paucity of such studies in the literature. This randomized, controlled clinical trial included 59 patients with chronic otitis media who underwent tympanoplasty and were randomized after surgery to a systemic steroid or no steroid treatment. Patients were randomized into two groups. Perforation size, graft outcome, and complications such as tinnitus and hearing loss were compared between the two groups. Postsurgical steroid injection had no effect on graft outcome (p = 0.927) or tinnitus (p = 0.478). Tympanic membrane perforation (p = 0.92), plaque size (p = 0.94), bleeding amount (p = 0.38), and mucosal status (p = 0.96) during surgery had no effect on graft outcome after the tympanoplasty. In conclusion, administration of steroids after tympanoplasty failed to improve outcome and may put the patient at risk of side effects.

The Effects of the Vestibular Rehabilitation on the Benign Paroxysmal Positional Vertigo Recurrence Rate in Patients with Otolith Dysfunction

BACKGROUND AND OBJECTIVES

Although repositioning maneuvers have shown remarkable success rate in treatments of benign paroxysmal positional vertigo (BPPV), the high recurrence rate of BPPV has been an important issue. The aims of present study were to examine the effects of otolith dysfunction on BPPV recurrence rate and to describe the effect of vestibular rehabilitation exercises on BPPV recurrence in BPPV patients with concomitant otolith dysfunction. Subjects and.

METHODS

Forty-five BPPV patients included in this study (three groups). Patients in group 1 had no otolith dysfunction and patients in groups 2 and 3 had concomitant otolith dysfunction. Otolith dysfunction was determined with ocular/cervical vestibular evoked myogenic potential (oVEMP and cVEMP) abnormalities. Epley's maneuver was performed for the patients in all groups but patients in group 3 also received a 2-month vestibular rehabilitation program (habituation and otolith exercises).

RESULTS

This study showed that BPPV recurrent rate was significantly higher in patients with otolith dysfunction in comparison to the group 1 (p<0.05). Vestibular rehabilitation resulted in BPPV recurrence rate reduction. Utricular dysfunction showed significant correlation with BPPV recurrence rate.

CONCLUSIONS

Otolith dysfunction can increase BPPV recurrence rate. Utricular dysfunction in comparison to saccular dysfunction leads to more BPPV recurrence rate. Vestibular rehabilitation program including habituation and otolith exercises may reduce the chance of BPPV recurrence.

Risk of posterior semicircular canal trauma when using a retrosigmoid approach for acoustic neuroma surgery and role of endoscopy: An imaging study

The rate of hearing preservation after vestibular schwannoma surgery is variable and is not as high as expected, possibly due to injuries to the posterior semicircular canal while exposing the tumor. The aim of this study was to estimate the risk of posterior semicircular canal injuries using temporal bone computed tomography (CT) scan findings. Temporal bone CT scans of 30 patients selected between 2013 and 2015 were studied. The median age of the patients was 40 years. Two planes were studied: (1) the axial plane that shows the common crus of the posterior semicircular canal and (2) the coronal plane that shows the two crura of the posterior semicircular canal. Five lines were drawn and four angles and three distances were measured. In this study, we divided the patients into three groups consisting of 10 patients each: (1) patients with no evidence of inflammatory or neoplastic disease, (2) those with chronic ear disease, and (3) those with vestibular schwannomas. The portion of the internal auditory canal that was exposed by drilling while preserving the posterior semicircular canal was 53 to 64% and 61 ± 9% in whole temporal bones in the three groups. The mean angle of vision with an endoscope was less than 105° in 56% of cases, which means even with a 30° endoscope, the fundus could not be visualized. Therefore, according to our data, it seemed impossible to expose the whole length of the internal auditory canal from the porus to the fundus without causing injury to the posterior semicircular canal. However, the use of endoscopes may help to prevent injury.

Effects of anesthesia with nitrous oxide on tympanoplasty outcomes: a randomized controlled trial

OBJECTIVES

To investigate effects of nitrous oxide (N₂O), as inhalational anesthetic agent, on tympanoplasty outcomes.

METHODS

In this randomized controlled trial, patients were randomized into two groups: 39 patients who received N₂O as an inhalant anesthesia and 47 patients who did not receive. All were operated on with standard type of ear surgery. The protocol for the two groups was identical. Before surgery baseline audiometry was performed. Postoperative audiological controls were carried out at 3 months.

RESULTS

There was no statistically significant difference between two groups regarding graft outcomes. No significant differences were found between the two groups regarding air-bone gap or bone conduction hearing level.

CONCLUSIONS

Nitrous oxide usage does not seem to have significant impact on graft or hearing outcome of patients undergoing surgical repair of tympanic membrane.

Results of Type I Tympanoplasty Using Fascia with or without Cartilage Reinforcement: 10 Years' Experience

INTRODUCTION

There remains controversy about the optimal kind of graft to repair tympanic membrane. The purpose of this study was to evaluate the anatomical and auditory outcomes of type I tympanoplasty using fascia with or without cartilage reinforcement.

MATERIALS AND METHODS

This retrospective cohort study was conducted from 2005 to 2015. All cases were surgically treated by a single surgeon. We excluded cases in which the etiology of chronic otitis media was cholesteatoma. According to the use of cartilage reinforcement in the posterosuperior part of the graft, patients were divided into two groups, and the results of anatomical and auditory evaluation were compared between the two groups. The anatomical outcome was grafting success and the auditory outcome was improvement of air bone gap (ABG).

RESULTS

A total of 320 patients were classified in Group A (tympanoplasty with fascia temporalis only) and 346 were in Group B (tympanoplasty with cartilage reinforcement). All patients were followed for at least 2 years. The overall success rate in the two groups was 91.6% and 93.4%, respectively (P=0.3). The most common cause of failure in the two groups was re-perforation (5.6% and 3.8%, respectively). The improvement of ABG in two groups was 18.5 dB and 3.2 dB, respectively. The difference between two groups was statistically significant (P<0.001).

CONCLUSION

In patients with dry perforation of the tympanic membrane, the anatomical success with tympanoplasty with fascia only or with cartilage reinforcement was similar. However, hearing improvement in the fascia only group was greater than in the group undergoing cartilage reinforcement.

Conservative versus Surgical Therapy in Managing Patients with Facial Nerve Palsy Due to the Temporal Bone Fracture

Facial nerve paralysis is classified into immediate or delayed-onset palsy, and affected patients should be treated through conservative or surgical therapy. Appropriate treatment is somewhat debated as well as proper time for performing surgery. This study aimed to assess treatment outcome between conservatively and surgically treated groups and to determine the appropriate time of surgery in selected patients for surgery. Twenty-four patients from April 2008 to July 2015 were included. Performing decompression surgery within the first 2 months following the trauma accompanies a better prognosis ( p -value < 0.05). Eleven patients were managed conservatively, and 4 of them demonstrated immediate onset and 7 indicated delayed onset. Nine patients obtained normal nerve function, one patient had partial palsy, and one of them had complete palsy. There was no significant difference in the rate of recovery between types of the treatment ( p -value > 0.05). Decompression surgery is recommended in the first 2 months after the trauma for immediate onset and also complete degeneration on electroneuronography.

Efficacy of Intralipid infusion in reducing amphotericin-B-associated nephrotoxicity in head and neck invasive fungal infection: A randomized, controlled trial

Amphotericin B deoxycholate (ABD) is the best therapeutic agent available for the treatment of most systemic fungal infections. However, some untoward adverse effects such as nephrotoxicity may limit its appropriate therapeutic use. We conducted a randomized, controlled trial ofthe infusion of fat emulsion (Intralipid) shortly after the infusion of ABD to evaluate its effects on reducing ABD-associated nephrotoxicity. Our patient population was made up of 31 patients who were randomized into two groups: an intervention group (n = 16) and a control group (15 patients). There were no statistically significant differences between the two groups in demographic or clinical variables. All patients received 1mg/kg/day of ABD in dextrose 5%. In addition, the patients in the intervention arm received Intralipid 10%, which was started as soon as possible within 1 hour after the infusion of ABD. ABD-associated nephrotoxicity was defined as a minimum 50% increase in baseline serum creatinine to a minimum of 2mg/dl. We also measured daily serum creatinine changes during the first 2 weeks of treatment, and we compared some other relevant indices of renal function, as well as ABD-related hypokalemia. We found no statistically significant differences between the two treatments in terms of ABD-associated nephrotoxicity or any of the other indices. We conclude that the administration of Intralipid 10% early after infusion of ABD in dextrose 5% does not have any effect in decreasing ABD-associated nephrotoxicity or hypokalemia.

Comparison of cartilage with temporalis fascia tympanoplasty: A meta-analysis of comparative studies

OBJECTIVE

To systematically review the results of type 1 tympanoplasty with temporalis fascia (TF) versus cartilage in patients with chronic otitis media (COM) for graft integration and hearing improvement.

DATA SOURCES

The English language literature (until June 1, 2016) was searched, using Medline (via PubMed), Scopus, ProQuest, Ovid, Cochrane database, and Google Scholar.

REVIEW METHODS

A comprehensive review of the literature was performed. Prospective and retrospective studies enrolling patients with COM were included. Relevance and validity of selected articles were evaluated. Heterogeneity was assessed using I² statistics. For dichotomous variables, absolute rate differences, and number needed to treat (NNT) were calculated. For continuous variables, standard mean differences were calculated.

RESULTS

A total of 11 prospective and 26 retrospective studies involving 3,606 patients were included. In general, the overall graft integration rates of cartilage and fascia tympanoplasty were 92% and 82%, respectively (NNT = 11.1, P < 0.001). Although there was no significant difference in the air-bone gap (ABG) closure of < 10 dB between the two groups, the subanalysis of prospective studies showed that patients in the TF group had less mean postoperative ABG (P = 0.02). Subgroup analysis of palisade grafts compared with that of TF graft revealed a significant difference in the graft integration rate favoring cartilage tympanoplasty (P = 0.01).

CONCLUSION

Cartilage grafting seemed to show a higher graft integration rate compared with TF grafting. Both cartilage and fascia tympanoplasty provided similar improvements in the hearing outcome postoperatively. Large prospective trials are necessary to collect high-quality data.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:2139-2148, 2017.

Otological findings in pediatric patients with hypogammaglobulinemia

The main clinical presentation of patients with primary antibody deficiency (PAD) incorporates upper respiratory tract infections comprising otitis media, sinusitis and pneumonia. This study was designed to investigate clinical and paraclinical otological complications in major types of PAD. A cross sectional study was conducted on 55 PAD patients with diagnosis of selective IgA deficiency, common variable immunodeficiency (CVID), X-linked agammaglobulinemia (XLA), and hyper IgM syndrome. All patients underwent otological examinations, audiometry, and auditory brain stem response. Otological complications were detected in 54.5% of PAD patients. Conductive hearing loss was the main finding amongst PID patients (73.3%) followed by sensorineural hearing loss which was present in 8 cases. Otitis media with effusion (21.8%), chronic otitis media (27.2%), tympanosclerosis with intact tympanic membrane (5.4%) and auditory neuropathy (3.6%) were most important found complications. CVID and XLA patients with prophylactic usage of antibiotics had lower rate of audiological complications (p=0.04) and otitis media with effusion (p=0.027). As our results showed, asymptomatic otological findings were not rare in PAD patients; therefore, a systematic otological investigation is recommended as an integral part of the management and follow-up of these patients.

The Prevalence of Asthma among the Students (7-18 Years Old) in Tehran during 2002-2003

Asthma is one of the most common problems of childhood, responsible for a significant proportion of abstinence from school because of chronic illness. This study was carried out among the school-aged children (7-18 years) in Tehran schools during 2002-2003, in order to determine the frequency of asthma. According to the recommendation of WHO (World Health Organization), we designed a questionnaire, containing 8 standard questions, and the students were given necessary information to complete the questionnaires. The pre-high and high schools students completed the questionnaires but the parents of primary school students completed them on their behalf. The prevalence of asthma was 35.4% in Tehran; this prevalence was higher in the boys (37.1%), as compared to the girls (33.5%). The prevalence of this disease has been estimated about 39.5% in pre-high schools, 35.4% in high schools and 31.6% in primary students. Based on this survey, the most common clinical manifestations of asthma were: prolonged cough lasting more than 10 days (22.4%), and exercise induced wheezing or dyspnea (16.9%), followed by repeated dyspnea or wheezing (6.4%). The prevalence of asthma is high among the students of Tehran schools and it needs more careful screening programs along with additional information to the patients and parents about the disease.

Mortality in primary immunodeficient patients, registered in Iranian primary immunodeficiency registry

Primary immunodeficiencies (PID) are a group of disorders, characterized by an unusual susceptibility to infections. Delay in diagnosis results in increased morbidity and mortality in affected patients. The purpose of this study was to determine the mortality rate of Iranian immunodeficient patients referred to Children Medical Center Hospital affiliated to Tehran University of Medical Sciences over a period of 20 years.In this study, records of 235 (146 males, 89 females) patients with immunodeficiency who were diagnosed and followed in our center, during 22 years period (1979-2001) were reviewed. The diagnosis of immunodeficiency was based on the standard criteria. The cause of death was determined by review of death certificates.Antibody deficiency was the most common diagnosis made in our patients. The overall five-year survival rate was 22.7% in our studied patient group; this was greatest in antibody deficiency. During the 22 year period of study, 32 patients died. As some of the patients could not be located, the true mortality rate ranged between 13.6% and 17.5%. The main leading cause of death were lower respiratory tract involvement in 14 cases (44%). The most common pathogenic microorganisms causing fatal infections were psudomonas and staphylococcus in 9 cases (28.1%) followed by E. coli in 7 (21.9%), tuberculosis in 13 (40.6%) and salmonella in 1 (3.1%).Based on our study, delay in diagnosis in patients with PID results in tissue and organ damage and several complications. Mortality and morbidity are increased in undiagnosed patients.

Multicentric giant cell tumor: metachronous central and peripheral involvement

Giant cell tumors are rare in the head and neck region. The most frequently involved sites of giant cell lesions in the head and neck are the maxilla and mandible, whereas the sphenoid and temporal bones are rarely involved. This tumor is usually located in the long bones of limbs. Reparative granuloma and brown tumor of hyperparathyroidism must be included in the differential diagnosis. Here we report the clinical and radiologic findings of a multicentric giant cell tumor with skull base involvement in a female patient. This case report demonstrates the similar pathophysiology of peripheral and central giant cell tumors.

Prophylactic antibiotics in otolaryngologic surgeries: from knowledge to practice

INTRODUCTION

The management and use of antimicrobial drugs has clinical, economic, and environmental implications. In many countries, antimicrobial drugs are the most frequently prescribed therapeutic agents. Therefore, health-care policy should focus on how to establish a rational attitude toward antibiotics. This study was performed to investigate antibiotic usage as a prophylactic regimen in head and neck surgeries.

MATERIALS AND METHODS

This study was a retrospective case series. Patients undergoing otolaryngology surgeries in a tertiary referral otolaryngology center were included. Members of operating room staff that were unaware of the study objectives collected patients' data using a questionnaire that contained information regarding general medical condition, disease, surgical procedure, and prophylaxis regimen and duration.

RESULTS

Excluding infected patients, we studied 1349 patients during a four-month period who needed prophylactic antibiotics. A total of 34 different types of surgical procedures were performed. Out of the total number of patients, 503 (37.0%) received a parenteral antibiotic directly before surgery. The main antibiotics used before surgery were cephalosporins (94.9%). All of the 1349 patients were administered antibiotics after the procedure. These antibiotics where given with a mean number of doses of 4.81 (range: 1-68), and also consisted of mostly cephalosporins.

CONCLUSION

Our results indicate that prophylactic antibiotics were being significantly misused in a tertiary referral center of a university hospital. Although teaching the principles of prophylaxis to physicians is important, we think that finding a way to bring this knowledge to practice is more important.

What is expected of the facial nerve in michel aplasia? Anatomic variation

We sought better understanding about the facial nerve anatomy in the rare inner ear Michel anomaly to help better define this aplasia and prevent potential complications in surgery on these patients. The data from computed tomography scans and magnetic resonance images of six Michel aplastic ears (three patients) were evaluated for a facial nerve course. Facial nerve course and anatomic landmarks were noted. Based on data obtained from this group of very rare patients, three different facial nerve anatomies were encountered. The first patient had normal-looking mastoid cells, normal middle ear ossicles, and a completely formed facial nerve canal through the middle ear. The second patient had pneumatized mastoid air cells despite an anomalous ossicular chain. This patient also had a facial nerve canal but not through the middle ear. In the third patient, although mastoid cells were present, neither ossicles nor a definite facial nerve canal could be detected. With guidance provided by the anatomy of the other parts of the ear, such as air cells and the ossicular chain, the danger zones posing a high probability of facial nerve injury can be predicted. Although all Michel aplasias may have aplastic petrous bone in common, there are some degrees of variation.

A new approach in open rhinoplasty: new alar rim raising technique

BACKGROUND

The relationship of the alar rim to the columella and its contour has great aesthetic importance, and correcting its deformities is sometimes challenging, especially if it is hanging, asymmetrical, or sigmoid--especially in the African or Asian nose.

METHODS

The new method of alar rim incision is described here. This new approach combines the alar rim incision and incisions necessary for external rhinoplasty (modified external approach).

RESULTS

All 24 patients noticed improvement and were satisfied with the results. Alar function was preserved in all cases. There were no complications, but two cases had asymmetrical alar width.

CONCLUSION

Our new incision for alar rim excision not only decreases incision lines in the limited area of the nose, resulting in decreased risk of tissue compromise, but also provides a controlled method to remove excessive skins of the rim.

Prevention of adhesion after endoscopic sinus surgery: role of mitomycin C

Adhesions after endoscopic sinus surgery (ESS) are a potential cause of surgical failure. Mitomycin-C (MMC) is recently proposed as a solution for these adhesions. This study was performed to investigate the effect of Mitomycin C in reducing scar formation and adhesion in the nasal mucosa after endoscopic nasal surgery. This double blind randomized clinical trial study was performed on 37 patients with bilateral chronic rhinosinusitis. At the end of ESS, randomly impregnated mesh with MMC was placed in one side and another mesh impregnated with saline in the opposite side for 5 minutes. Patients were followed at least for three months, and the results of diagnostic endoscopy were recorded. Post operative adhesion occurred in 12 (32.4%) patients (2 bilateral/10 unilateral). Among total of 14 adhesions, 4 (10.8%) were in the MMC side and 10 (27%) in the control side. This differences was close to statistically significant (P=0.058). MMC may reduce adhesions after ESS, but further studies with different doses, sample size and frequent use of topical MMC is recommended.

Nasal vestibular huge keratoacanthoma: an unusual site

Keratoacanthoma (KA) is a rapidly growing, low-grade neoplasm of pilo-sebaceous and hair follicle units which most often appears on the sun-exposed skin of the middle aged and older persons with multiple or localized occurrence. This tumor is dome-shaped nodule with a central keratinous plug. The etiology of this tumor is not obvious. Exposure to excessive sunlight is the most frequently noted responsible factor in the etiology of KA. About 80% of the tumors occur on the face. The histological features of the KA are often very similar to those of a cutaneous squamous cell carcinoma; however, the tumor structure usually provides a basis for their difference. There are many unusual cases of keratoacanthoma reported regarding site, size or other specifications. In this study, we excised a mass of nasal vestibule, a site far away sun-exposure. To our knowledge, this is the first case of nasal vestibular keratoacanthoma. For a clinician and a pathologist it is important to consider a benign lesion like Keratoacanthoma (KA) in the differential diagnosis of ulcerated nasal lesions and pay attention to differ it from Squamous Cell Carcinoma (SCC) which has a different and aggressive management.

Mastoid bone as a new graft material in rhinoplasty

BACKGROUND

The management of certain nasal deformities, especially after prior rhinoplasty, may require grafting material. In this study we describe the use of mastoid bone as a viable and low morbidity autologous graft.

METHODS

Mastoid bone was used for nasal augmentation, smoothing dorsal nasal irregularities, or augmentation of radix. Candidates for mastoid bone graft were patients undergoing primary rhinoplasty suffering from low radix or saddle nose deformity and candidates for secondary rhinoplasty suffering from prior overresection of the osteocartilaginous structures.

RESULTS

Fifty-six patients met the study criteria. Eighteen patients underwent secondary rhinoplasty and suffered from prior overresection of osteocartilaginous structures and 38 patients underwent primary rhinoplasty. Of these, 18 patients had a low radix and 20 patients had a saddle nose deformity. Follow-up was 6-49 months (mean, 23 months). All cases resulted in an augmented straightened nasal dorsum, increased tip projection, and adjusted radix. There were no cases of graft infection. In two cases the graft was displaced requiring revision. The amount of graft absorption even after 2 years follow-up was acceptable. There were no donor site complications.

CONCLUSIONS

The mastoid bone graft provides adequate autologous bone in most cases of primary or revision rhinoplasty. The donor site carries low morbidity and a well camouflaged scar. It is easily accessible especially for the otolaryngologist who is accustomed to operating on the mastoid bone.

Lymphoma of mucosa-associated lymphoid tissue in common variable immunodeficiency

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency characterized by reduced levels of all major immunoglobuline classes and recurrent c infections. The risk of non-Hodgkin's lymphoma (NHL) among patients with CVID was found to be increased in different studies. Mucosa-associated lymphoid tissue (MALT) lymphomas are a recently recognized sub-set of low-grade B-cell NHL composed of marginal zone-related cells. MALT lymphomas appear in the lymphoid tissues as a result of chronic inflammatory or autoimmune stimulation. This study briefly reviews previously published cases and reports a patient suffering from CVID with a history of chronic diarrhea and recurrent sinopulmonary infections. Despite treatment with intravenous immunoglobulin, chronic cough and wheezing progressed. Open lung biopsy showed a MALT lymphoma. Although a rare complication, pulmonary low grade B-cell lymphoma is a diagnosis that must be kept in mind in CVID patients with chronic pulmonary symptoms unresponsive to conventional therapies.

Immunologic evaluation of patients with recurrent ear, nose, and throat infections

PURPOSE

In this study, we aimed to study the frequency of possible underlying immunodeficiency responsible for susceptibility to ear, nose, and throat (ENT) infection.

MATERIALS AND METHODS

One hundred three (72 males and 31 females) consecutive children and adult patients with history of recurrent or chronic ENT infections, referred by otolaryngologists to the Department of Allergy and Clinical Immunology, Children's Medical Center, Tehran University of Medical Sciences (Tehran, Iran), were enrolled to the study from March 2003 to March 2006. For each patient, demographic information and medical histories of any ENT infections were collected by reviewing the patient's records. We measured immunoglobulin isotype concentrations and immunoglobulin (Ig) G subclasses by nephelometry and enzyme-linked immunosorbent assay methods, respectively. Of 103 patients, 75 received unconjugated pneumococcus polyvalent vaccine, and blood samples were taken before and 21 days after vaccination. Specific antibodies against whole pneumococcal antigens were measured using enzyme-linked immunosorbent assay method. Existence of bronchiectasis was confirmed in each patient using high resolution computed tomography scan.

RESULTS

Among 103 patients, 17 (16.5%) patients were diagnosed to have defects in antibody-mediated immunity including 6 patients with immunoglobulin class deficiency (2 common variable deficiency and 4 IgA deficiency), 3 with IgG subclass deficiency (2 IgG2 and 1 IgG3), and 8 with specific antibody deficiency against polysaccharide antigens. In our series, bronchiectasis was detected in 5 cases associated with primary immunodeficiency.

CONCLUSIONS

Long-standing history of ENT infections could be an alarm for ENT infections associated with primary antibody deficiency.

Surgical management of aneurismal dilation of vein and pseudoaneurysm complicating hemodialysis arteriovenuos fistula

BACKGROUND

Pseudoaneurysm (PS) and aneurismal dilation of vein (ADV) are recognized complications of arteriovenous fistulas (AVF) in patients on hemodialysis. We present our experience about surgical management of these complications, which resulted in AVF preservation for continuing hemodialysis.

MATERIAL AND METHODS

Twenty-two patients underwent surgical repair of an aneurismal dilation of vein or a pseudoaneurysm arising from a native AVF. In 14 patients the aneurismal dilation of vein arose from the venous limb of AVF and in eight patients the pseudoaneurysm arose from an arteriovenous anastomotic site in the antecubital and anterior part of arm. The mean follow-up period was 15 months. Clamp Aneurysm Repair (CAR) was performed to repair the aneurismal dilation of venous limb of AVF and Tourniquet Aneurysm Repair (TAR) was performed to repair PS that arose from AVF in the antecubital and anterior part of arm.

RESULTS

In eight of the 14 patients with aneurismal dilation of vein, who underwent CAR procedure, vascular access was preserved. In three patients with aneurismal dilation of vein in snuffbox and one in forearm, the AVF had failed due to prior venous thrombosis of AVF. In two of 14 patients, there was no need for preservation of AVF because of renal transplantation. The technical success rate and patency rate during follow up period in CAR method was 100%. In seven of eight patients with psudoaneurysm in the antecubital and anterior part of arm, who underwent TAR procedure, the AVF remained patent. The technical success rate in TAR method was 87.5%, and the patency rate was 87.5%. Overall, technical success rate was 95.45% and patency rate was 93.75%. During the 15 months of follow up period hemodialysis program through the repaired AVF sustained as desired.

CONCLUSIONS

The surgical methods used in our study could effectively repair the aneurismal dilation of vein and psudoaneurysm arising from a native AVF, and it lead to preservation of the AVF patency for continuing hemodialysis. These methods are technically feasible, safe and cost-effective procedures. It does not require dissection and additional incision for control of the vein and artery proximal and distal to the aneurismal dilation of vein and pseudoaneurysm; result in shorter time of procedure without complications.

Chromosomal radiosensitivity in patients with common variable immunodeficiency

Common variable immunodeficiency (CVID) is a heterogeneous group of primary immunodeficiency disorders. In addition to recurrent infections and autoimmunity, cancers are more prevalent in these patients than the normal population. Increased radiosensitivity may be a reason for the increased malignancies. To analyze chromosomal radiosensitivity of CVID patients, lymphocytes were cultured from 20 CVID patients. After irradiation (50, 100 cGy), metaphases were evaluated for chromosomal aberrations. Results were compared in patients, healthy individuals, and ataxia telangiectasia as positive controls. Before irradiation there was no difference between groups of patients, but after radiation, the incidence of all kinds of aberrations was higher in the CVID patients and this was statistically significant at 100 cGy (P<0.05). CVID patients appear to be susceptible to in vitro irradiation. These patients should be protected from unnecessary radiographic diagnostic and therapeutic procedures. Also, radiosensitivity may help classifying CVID patients.

Gastrointestinal manifestations in patients with common variable immunodeficiency

This study focuses on endoscopic and pathologic alterations of gastrointestinal (GI) disorders of Iranian patients with common variable immunodeficiency (CVID). Nineteen of 39 CVID patients (48%) had GI complaints. The most common symptom was chronic diarrhea (28%). In endoscopic examination of small intestines, 15 patients had no abnormal finding. Duodenal biopsy revealed villous atrophy in eight and nodular lymphoid hyperplasia in three patients. There was no statistically significant difference between patients with and patients without duodenal villous atrophy regarding the presence of chronic diarrhea, anemia, and absolute CD4+T cells. In three patients, biopsies of the colon showed chronic noncrypt-destructive colitis. GI problems pose a high morbidity to CVID patients and are second only to respiratory complications. CVID patients are at increased risk of infectious and inflammatory conditions in the GI tract. Early diagnosis of these complications improves the quality of life and well-being of patients.

Risk factors leading to hospital admission in Iranian asthmatic children

BACKGROUND

Asthma is one of the most common chronic diseases in the world, leading to an increased rate of hospitalization. We performed this study to better understand the factors leading to admission among asthmatic children.

METHODS

We performed a study among asthmatic children in a referral hospital for asthma and allergy in Tehran. Sixty-three cases were selected from asthmatic children admitted to the emergency room (ER) who still had an indication for ward or intensive care unit admission after primary treatment. Our control group was the asthmatic children discharged after primary treatment and patients who were referred to the asthma and allergy clinic (63 patients). Data were obtained by structured questionnaires filled out during clinical interviews.

RESULTS

There was a significant difference in mean age (5 years for cases vs. 6 years for controls; p = 0.049), personal and familial allergic history (69.8 and 57.1% for cases vs. 34.9 and 36.5% for controls; p < 0.01 and p = 0.02, respectively), history of recent respiratory infections (79.4% for cases vs. 49.2% for controls; p < 0.01), hospitalization history due to asthma (57.1% for cases vs. 23.8% for controls; p < 0.01) and regular use of inhaled corticosteroid (66.7% for cases vs. 33.3% for controls; p < 0.01).

CONCLUSIONS

Our findings confirm most previous observations, suggesting that recent respiratory infections, hospitalization, personal or familial allergy, disease severity and lower ages are important factors leading to hospitalization. We also found that regular clinical follow-up, regular use of inhaled corticosteroids, higher IgE levels and O2 saturation may lower the probability of hospitalization during asthmatic attacks.

Ataxia-telangiectasia in Iran: clinical and laboratory features of 104 patients

Ataxia-telangiectasia is a multisystem disorder characterized by progressive neurologic impairment, variable immunodeficiency, impaired organ maturation, x-ray hypersensitivity, oculocutaneous telangiectasia, and a predisposition to malignancy. To evaluate clinical and immunologic features of Iranian patients with ataxia-telangiectasia, the records of 104 patients with ataxia-telangiectasia (54 male, 50 female) with the age range of 1.6-23.5 years were reviewed. The Iranian Primary Immunodeficiency Registry was used as the data source. Progressive ataxia was seen in all the patients. Other symptoms were eye movement disorders (n = 84), slurred speech (n = 70), mental retardation (n = 10), and ocular (n = 87) and cutaneous (n = 73) telangiectasia. Three patients developed leukemia and lymphoma, and 17 patients had family history of malignancy. Positive correlation was seen between clinical immunologic symptoms and immunoglobulin deficiencies (P = 0.004). The predominant infections were sinopulmonary and acute and recurrent infections (78 cases). Infections included pneumonia (56 patients), otitis media (34 patients), and sinusitis (50 patients). Average serum alpha-fetoprotein level was 149 +/- 137 ng/dL. The incidence of ataxia-telangiectasia in Iran is high, possibly due to familial marriages. Treatment should be focused on supportive management to prolong survival.

ENT manifestations in Iranian patients with primary antibody deficiencies

OBJECTIVE

One hundred and nine patients with primary antibody deficiencies were selected in order to determine the frequency of ENT complications.

METHOD

Demographic information and ENT medical histories were collected for each patient. Duration of study for each patient was divided into two periods of before diagnosis and after diagnosis and the initiation of treatment.

RESULTS

Eighty-two of 109 patients (75.2 per cent) experienced ENT infections during the course of the disease (63: otitis media, 75: sinusitis and nine: mastoiditis). At the time of diagnosis, 52 (47.7 per cent) out of 109 patients presented with an ENT symptom. The frequencies of episodes were 27 for sinusitis and 25 for otitis media (one complicated with mastoiditis). After immunoglobulin replacement therapy the incidence of otitis media was reduced from 1.75 before treatment to 0.39 after treatment per patient per year (p = 0.008). The incidence of sinusitis also significantly decreased from 2.38 to 0.78 (p value = 0.011).

CONCLUSION

ENT infections are common medical problems in primary antibody deficiency patients. Persistent and recurrent ENT infections should be suspected as originating from a possible underlying immunodeficiency.

Supravalvular and valvular aortic stenosis in heterozygous familial hypercholesterolemia

OBJECTIVES

To report calcified aortic stenosis due to hypercholesterolemia in two siblings.

CASE PRESENTATION AND INTERVENTION

A 13-year-old boy with a history of dyspnea on exertion and a systolic murmur of aortic stenosis was referred to our center. Echocardiography showed combined valvular and supravalvular aortic stenoses with a good left ventricle systolic function and severe left ventricular hypertrophy. Two years later his 17-year-old sister was referred to the clinic with similar symptoms. Severe valvular aortic stenosis was detected by echocardiography. Selective coronary angiography showed significant involvement. The father had a history of hypercholesterolemia and confirmed coronary artery disease involving 3 vessels. Angiography showed anterioapical and inferiobasal hypokinesis with preserved left ventricle systolic function. The mother and the other two siblings did not have hyperlipidemia, thereby indicating heterozygous familial hypercholesterolemia in the two affected siblings. The siblings were managed with atrovastatin and nicotinic acid and cholestyramine was added stepwise. The father was treated with lovostatin.

CONCLUSION

This report shows that severe hyperlipidemia in very young patients may be a risk factor for valvulopathy.

Pulse tissue Doppler analysis of tricuspid annular motion in Iranian children

BACKGROUND

Quantitative assessment of right ventricular (RV) function has been difficult to assess non-invasively secondary to its non-geometric shape and respiratory-variable filling. With recent improvements in ultrasound equipment we are now able to study myocardial velocity changes, which is known as tissue Doppler imaging.

OBJECTIVES

To define normal indices of tricuspid pulse tissue Doppler echocardiography imaging in children and infants.

METHODS

We enrolled 100 healthy children with the age of 1 month-15 year old who were referred for echocardiography and had no cardiac lesion in primary echocardiography evaluations. Pulse tissue Doppler images of the lateral tricuspid annular motion were recorded using 4-chamber apical view. Simultaneous electrocardiography was used to correct annular motion time with electrical events.

RESULTS

Among our patients 9 were under 1 year, 46 between 10 and 15, 36 between 5 and 10, and 9 between 10 and 15. Infants had decreased peak early diastolic annular velocities and early diastolic annular velocity-to-diastolic annular velocity at atrial contraction ratios compared with the older group. Isovolumic relaxation time difference was not significant between two different groups. In this group of patients, deceleration time and isovolumic contraction time were lower too.

CONCLUSION

In this study we found out normal values for systolic and diastolic indices of pulse TDI imaging of tricuspid valve in Iranian healthy children. This can be a basis for RV function studies in different congenital cardiac disease.

Clinical and immunological features of 65 Iranian patients with common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency disease characterized by hypogammaglobulinemia and recurrent bacterial infections. The records of 65 patients with CVID (37 males and 28 females) in the age range of 24 to 537 months were reviewed. By the year 2003, 11 patients had died and seven patients could not be located. The total follow-up period was 221 patient-years. The median diagnostic delay (time between onset and diagnosis) in our patient group was 60 months. At the time of diagnosis, the baseline serum immunoglobulin G (IgG), IgM, and IgA levels were below the level normal for the patients' age; the medians for this group were 120, 10, and 0 mg/dl, respectively. All of the patients presented with infectious diseases at the time of onset, the most common of which were otitis media, diarrhea, pneumonia, and sinusitis. Acute and recurrent infections were also found in almost all of the patients, particularly involving respiratory and gastrointestinal systems. The most common infections, before diagnosis and during follow-up, were pneumonia, acute diarrhea, acute sinusitis, and otitis media. CVID should be considered in any patient with a history of recurrent infections and decreased levels of all serum immunoglobulin isotypes.

Distribution of primary immunodeficiency disorders diagnosed in the Children's Medical Center in Iran

Primary immunodeficiency disorders include a variety of diseases that render patients more susceptible to infections. To determine the percentage of different primary immunodeficiency disorders diagnosed in the Children's Medical Center Hospital affiliated to Tehran University of Medical Sciences in Iran, we retrospectively reviewed the charts of the patients being referred to our hospital for immunologic evaluation of recurrent infections during a 20 year period. Among these patients, antibody deficiencies were the most frequent ones and were found in 52.6% of patients (n = 130). T-cell disorders, phagocytic disorders and complement deficiencies were found to be present in 24.69% (n = 61). 22.2% (n = 55) and 0.4% (n = 1) respectively. On the whole, common variable immunodeficiency was the most frequent disorder (n = 65), followed by ataxia telangiectasia (n = 39), X-linked agammaglobulinemia (n = 33), chronic granulomatous disease (n = 29) and selective IgA deficiency (n = 20). This study reveals that antibody deficiencies are the most common type of disorders as shown in other studies. A comparative study shows some differences between our results and other registries. This article also indicates that immunodeficiency disorders should be considered in patients with recurrent infections.