Paediatric auditory brainstem implantation: The South Asian experience

INTRODUCTION

Paediatric Auditory Brainstem Implantation (ABI) is indicated for children with congenital cochlear aplasia, absent/hypoplastic vestibulocochlear nerve, for whom cochlear implantation is not possible. Knowledge of the anatomical landmarks and variants in anatomy of the brainstem is vital for ABI surgery.

METHOD

Study was done at Auditory implant centre in Madras ENT research foundation, which includes 24 children who had undergone ABI surgery and are being followed up for 1 year, post operatively. Aims were to study the anatomical variants and the outcomes of ABI implantation. To determine if different anatomical variants effect placement of ABI electrode. To assess the patient outcomes by Categories of auditory Performance (CAP) scores and Speech Intelligibility Ratings (SIR) scores.

RESULTS

All the candidates showed gradual improvement in audiological and verbal outcomes after the ABI. The mean CAP and SIR scores after 6 months of AVHT were 2.07 and 1.37 respectively. After 1 year of auditory verbal rehabilitation therapy CAP was 3.42 and SIR was 2.33. Flocculus of the cerebellum can be of different grades. Though, there was difficulty in insertion of the electrode in subjects with anatomical variants, the outcomes were comparable with other subjects.

CONCLUSION

ABI surgery involves frequent anatomical variations surrounding the lateral recess which makes the positioning of the auditory prosthesis difficult. Variants during the surgery can make the placement of ABI electrodes difficult, but promising results were seen all the implantees.

Knowledge, Attitudes and Practices Relating to Vertigo among Newly Diagnosed Patients: Findings of a Prospective, Observational Registry in India

OBJECTIVE

Vertigo is a common complaint in clinical practice, with multi-causative etiology, substantially impacting individual's overall lifestyle and behavior. However, so far no much data is available to understand the knowledge, attitude and practices (KAP) about vertigo in newly diagnosed Indian patients. Hence, the objective of this prospective, non-interventional, observational registry was to evaluate KAP towards vertigo and assessment of their awareness through a questionnaire-based survey.

METHODS

Newly diagnosed patients with vertigo (aged ≥18 years), visiting the physicians, were provided with a self-administered validated questionnaire with domains namely knowledge (18 questions), attitude (7 questions), and practices (8 questions). Primary objective was to analyze the percentage of patients with high, average and low level of knowledge; percentage of patients who were little, quiet and extremely concerned about vertigo and its treatment; percentage of patients taking high, moderate and poor level of precaution towards vertigo. All variables were subjected to statistical analysis.

RESULTS

Overall, 1167 (76.8%) patients completed the KAP questionnaire (women: 52.9%; men: 47.1%). A total of 17.3% patients had low level of knowledge, 73.9% had average and 8.74% patients had high level of knowledge regarding vertigo. Attitude domain revealed that majority of the patients (86.20%) had little concerned attitude towards vertigo; 9.85% patients were extremely concerned and 3.94% patients were not concerned regarding vertigo. Practice domain revealed that none of the patients took high level of precautions, 79.8% patients took moderate precautions and 20.2% took less precaution for disease prevention.

CONCLUSIONS

This study revealed that the knowledge, attitude and practice patterns amongst Indian vertigo patients are inadequate, highlighting the need for awareness and scientific education amongst these patients in India. Moreover, health care providers should be trained to provide counseling to these patients effectively.

Towards a consensus on a hearing preservation classification system

CONCLUSION

The comprehensive Hearing Preservation classification system presented in this paper is suitable for use for all cochlear implant users with measurable pre-operative residual hearing. If adopted as a universal reporting standard, as it was designed to be, it should prove highly beneficial by enabling future studies to quickly and easily compare the results of previous studies and meta-analyze their data.

OBJECTIVES

To develop a comprehensive Hearing Preservation classification system suitable for use for all cochlear implant users with measurable pre-operative residual hearing.

METHODS

The HEARRING group discussed and reviewed a number of different propositions of a HP classification systems and reviewed critical appraisals to develop a qualitative system in accordance with the prerequisites.

RESULTS

The Hearing Preservation Classification System proposed herein fulfills the following necessary criteria: 1) classification is independent from users' initial hearing, 2) it is appropriate for all cochlear implant users with measurable pre-operative residual hearing, 3) it covers the whole range of pure tone average from 0 to 120 dB; 4) it is easy to use and easy to understand.

Evaluation of an in-house-developed radioassay kit for antibody detection in cases of pulmonary tuberculosis and tuberculous meningitis

A radioassay for the detection of antitubercular antibody has been developed. The technique involves the addition of (125)I-labeled Mycobacterium tuberculosis antigen as a tracer, diluted clinical sample (serum or cerebrospinal fluid [CSF]), and heat-inactivated Staphylococcus aureus to capture the antibody, incubation for 4 h, and quantitation of the amount of antibody present in the sample. A total of 330 serum samples from patients with pulmonary tuberculosis and 138 control serum samples from individuals who were vaccinated with M. bovis BCG and from patients with pulmonary disorders of nontubercular origin were analyzed. Also, 26 CSF samples from patients with tuberculous meningitis and 24 CSF samples as controls from patients with central nervous system disorders of nontuberculous origin were analyzed. Sensitivities of 80 and 73% were observed for patients with pulmonary tuberculosis and tuberculous meningitis, respectively, and specificities of 90 and 88% were seen for the two groups of patients, respectively. The sensitivity was lower, however, for human immunodeficiency virus-infected patients coinfected with M. tuberculosis. The control population could be differentiated from the patient population. This assay is rapid and user friendly and, with its good sensitivity and specificity, should benefit the population by providing diagnoses early in the course of disease and, hence, permit the early administration of appropriate chemotherapy.

Olive oil aspiration pneumonia (lipoid) in children

In the Asir region of south-western Saudi Arabia, nasal instillation of olive oil to infants and children in the recumbent position is practised to relieve nasal congestion. Aspiration of olive oil results in lipoid pneumonia resistant to antimicrobial treatment. A series of 5 children, aged 4-72 months, with olive oil-induced lipoid pneumonia is presented. Clinical presentation included persistent coughing, tachypnoea, recurrent febrile illness and chest infections. The pulmonary radiological picture was mainly right middle lobar and perihilar infiltrates. Bronchial lavage and microscopic examination of the aspirate confirmed the presence of fat globules. The pneumonia resolved on treatment with steroids and physiotherapy in the form of clapping and vibrations. For infants and children in this area who present with persistent pulmonary infiltrates which are not responsive to antimicrobials, the differential diagnosis of not only animal fat (ghee, clarified butter) but also of olive oil lipoid pneumonia must be considered.

Bronchiectasis due to lipid aspiration in childhood: clinical and pathological correlates

We report the clinical and pathological features in six Arab children with bronchiectasis caused by ghee lipid aspiration. They all had a history of ghee administration followed by a history of chronic cough dating from early childhood. Chest radiographs showed consolidation/collapse of the right middle and left lower lobes in the majority, and bronchography and chest CT scan confirmed bronchiectasis. The children were treated medically, without any improvement, and five required surgery. The histology of the lung revealed dilated bronchi filled with vacuolated granular eosinophilic material and the peripheral lung tissue was mostly atelectatic with patchy lymphocytic bronchiolitis. Frozen sections of the lung tissue showed scattered lipogranulomas with fat-laden macrophages and fat droplets within peripheral and perivascular lymphatics. In communities where the traditional practice of force-feeding infants and children with ghee exists, it may be an important predisposing cause of bronchiectasis.

Is fine needle aspiration of the tonsil superior to a surface swab for isolating its core flora in recurrent tonsillitis?

This prospective study was designed to explore the possible role of fine needle aspiration of recurrently inflamed tonsils in determining their core flora. Seventy-seven patients undergoing tosillectomy for recurrent tonsillitis were included. Colonies grown from fine needle aspirate and surface swab were compared with tonsillar core culture obtained after tosillectomy. The pathogens isolated by fine needle aspiration culture were not greatly different from surface swab results in comparison to core isolates. The results of fine needle aspirate do not appear to confer any advantage over surface swab in representing core flora. These findings would seem to indicate no clinical use for fine needle aspiration in the management of recurrent tonsillitis.

Study of anti-idiotype antibodies to the monoclonal antibody HGT3a and its relation to the 38 kDa antigen of Mycobacterium tuberculosis

The hypervariable regions of the immunoglobulins which function as the antigen binding sites are capable of provoking an antibody response and are referred to as anti-idiotypic antibodies. Antisera were raised in rabbits against the idiotypes of a mouse monoclonal antibody HGT3a which binds only to the 38 kDa antigen of the M. tuberculosis complex group of organisms. Idiotype specificity in these antisera was determined by dot ELISA, Western blot and solid phase inhibition assays. In vivo administration of this rabbit anti-idiotypic antibody to Swiss mice evoked an anti-anti-idiotypic antibody response, further confirming the internal antigen mimicry by the anti-idiotypic antibodies of the 38 kDa antigenic epitope and its potential use as a surrogate antigen. Antibody response to the anti-idiotypic antibodies in the sera of patients with pulmonary tuberculosis showed significant correlation with the antibody response to the 38 kDa antigen studied in the same clinical samples indicating a close similarity of the 38 kDa antigen of M. tuberculosis and the rabbit anti-idiotypic antibody produced against MoAb HGT3a.

Reaction of human lungs to aspirated animal fat (ghee): a clinicopathological study

We report the clinical findings and pathological lung changes in four children following a cultural practice of forced feeding with animal fat (ghee) during infancy. The clinical presentation was of acute or chronic chest infection which failed to respond to antimicrobial therapy. The radiographic features ranged from extensive bronchopneumonia to collapse/consolidation and bronchiectasis. The light microscopy findings included diffuse mononuclear interstitial pneumonia, intraalveolar desquamation of pneumocytes, lipid granuloma formation, lung atelectasis and bronchiectasis. In the two children with longstanding reactions, the striking feature was the minimal lipid engulfment by the macrophages, the continuation of the mononuclear interstitial pneumonia, bronchiectasis and minimal lung fibrosis. In these two older children, the lung lymphatics were probably the main channels for drainage of the aspirated ghee.

Post intubation laryngeal sequelae in an intensive care unit

The incidence, severity and pattern of post-intubation laryngotracheal sequelae in a 12 bed multidisciplinary intensive care unit (ICU) were assessed in this prospective study. One-hundred and fifty consecutive patients requiring intubation for more than 24 hours for various indications were studied. Evaluation of the larynx and trachea was done using a fibreoptic bronchoscope introduced through the endotracheal tube prior to elective extubation. Rigid bronchoscopy and direct laryngoscopy were performed in very small children and adults requiring tracheostomy. One-hundred and thirty-one (87.6 per cent) patients had visible laryngeal pathology in the immediate post-extubation period. Thirteen (8.6 per cent) had long term sequelae. A high incidence of long term sequelae was noted in patients with seizures (25 per cent) followed by patients with head injury (19 per cent). Steroid therapy failed to offer any significant protection but resulted in doubling of pulmonary sepsis. A grading system was adopted to classify acute laryngotracheal injury and a significant correlation was found between the presence of slough in the immediate post-extubation period and subsequent development of long term sequelae. There was also a significant correlation between a deeper insertion of the endotracheal tube and development subsequently of long term sequelae. The significance of these findings is discussed.

Actinomycosis of the vallecula: report of a case and review of the literature

A rare case of actinomycosis presenting primarily as a mass in the vallecula is described. The patient was a healthy, 65-year-old Saudi, lady who was not immunocompromised and had no other primary pathology in the oral cavity. The clinical presentation and management of the case are discussed and the relevant literature reviewed.

Head and neck cancer in a referral center in Asir region

This study looks at the incidence of head and neck cancer in the Southwest Region of the Kingdom of Saudi Arabia (Asir Region). There were a total of 204 newly diagnosed patients seen at Asir Central Hospital between 1987 and 1992; 113 males and 91 females. All were Saudi patients. Frequency at various sites with reference to sex and age was determined and comparison with local and international published reports was made. To the best of our knowledge, this is the first paper in the Kingdom to look at head and neck cancer as a distinct entity. In this study, skin cancer was the most common among males followed by oral and pharyngeal cancers. Among females, thyroid cancer was the most common followed by skin and oral cancers. Some preventive measures are discussed.

Detection of antibodies to defined M. tuberculosis antigen (38 kDa) in cerebrospinal fluids of patients with tuberculous meningitis

Antibodies to the 38 kDa antigen of M. tuberculosis which is serospecific to the tuberculosis complex group of organisms was studied in CSF samples of patients with tuberculosis meningitis. Patients were classified into four groups, viz. post-mortem-proved, culture-proved, clinically suspected and tuberculoma. Anti-38 kDa antibody was detected by ELISA and was positive in 60%, 80% 62.5% and 0%, respectively in the four groups. Controls showed a false-positive detection of 5%. Follow-up of patients was done up to 6 weeks and antibody levels dropped in all the patient groups.

Sensorineural hearing loss in neurobrucellosis

A case of neurobrucellosis presenting to the otologist with sensorineural hearing loss (SNHL) as the predominant clinical feature is reported. The diagnostic features and treatment options are discussed and the need for prolonged combination treatment to prevent relapse and further deterioration of hearing stressed. SNHL in neurobrucellosis has hitherto been reported principally in neurology literature as something of an incidental finding and so escapes the attention of otologists. It is hoped that this report will alert otologists in areas where brucellosis is endemic to the need to include tests for brucellosis in the routine diagnostic screening for SNHL. Practitioners in other locations should also consider this possibility when dealing with patients who have visited or lived in endemic regions.

Bronchoscopy in lipoid pneumonia

Forcible administration of rendered animal fat to infants is a tradition in south western Saudi Arabia. Accidental inhalation may result in a resistant form of lipoid pneumonia. A series of 24 cases of lipoid pneumonia, 22 of which were diagnosed by bronchoscopy with bronchial lavage and microscopic examination of the aspirate, are reported. The technique is described briefly and the results analysed. A high index of suspicion together with bronchoscopy and bronchial lavage of all cases of resistant or recurrent pneumonia is essential in areas such as ours for diagnosis of this condition.

Rhinocerebral aspergillosis

Aspergillosis is increasingly being recognised as a common fungal infection of the paranasal sinuses. Although the disease is almost endemic in neighbouring Sudan, there are few reported cases from the Kingdom of Saudi Arabia. We report four cases of sinus aspergillosis with involvement of the skull bases and/or intracranial spread; a condition we have termed rhinocerebral aspergillosis. Invasive aspergillosis in our subgroup of patients occurs in otherwise healthy patients with normal immune status, quite unlike most reported cases in the western literature. The causative agent in all our patients was identified as aspergillus flavus, similar to patients reported from Sudan. This is again at variance with the case reports from other geographical locations, where aspergillus fumigatus is the commonest causative agent. Saudi Arabia would appear to represent a distinct geographical enclave, together with Sudan, where rhinocerebral aspergillosis of the sinuses and skull base may be more common than has previously been realised.

Otological manifestations of thalassaemia intermedia: evidence of temporal bone involvement and report of a unique cholesteatoma-like lesion

Thalassaemia intermedia should be considered in any chronically anaemic patient presenting from the Middle East with hearing impairment. We report here three Saudi siblings with thalassaemia intermedia and features of severe bone marrow expansion, particularly invading the temporal bone. They were seen first for their otological problems before they had access to proper haematological evaluation. One member was admitted for surgical exploration of a cholesteatoma, which was then found to be marrow expansion of the temporal bone. Screening of the family revealed two more anaemic siblings with thalassaemia intermedia. Audiological examination of all the family members showed that only the two affected members had a high frequency sensori-neural hearing loss. Bone marrow expansion into the temporal bone is a rare feature of thalassaemia intermedia. Cholesteatoma-like lesion has not been previously described. It has to be considered in all cases of symptomatic thalassaemia intermedia manifesting with cavitation and lytic lesions in the mastoid system. The likelihood that sensorineural hearing loss may complicate the thalassaemias is raised and the possible mechanism for such involvement discussed. The proper management for different otological manifestations of the thalassaemias is suggested. These cases would suggest a more extensive involvement of the temporal bone in the thalassaemias than has been previously recognized. Further large scale studies are required to illuminate the subject.

A study of tubercular antigen and antibody in childhood tuberculosis

A radioimmunoassay for the detection of tubercular (TB) antigen (Ag) and antitubercular antibody (Ab) was evaluated for the serodiagnosis of childhood tuberculosis. Children with primary complex, progressive primary complex, miliary tuberculosis, and calcified lung lesions without clinical evidence of active tuberculosis were studied. Significantly elevated levels of TB Ag and TB Ab isolated from the circulating immune complexes were obtained in primary, progressive primary, and miliary tuberculosis patients as compared to controls (P less than 0.01). The majority of patients with calcified lung lesions and without active tuberculosis demonstrated high levels of antibody. It was observed that elevated levels of TB Ag and/or antibodies were present in 54 per cent of patients with primary complex, 94 per cent of patients with progressive disease and 69 per cent of patients with miliary tuberculosis. It is possible that is suspected patients with the above mentioned diseases, a diagnosis can be established by using these techniques.

Fibre-optic endoscopy in atrophic rhinitis

Primary atrophic rhinitis seems to have a high prevalence in the arid regions bordering the great deserts of Saudi-Arabia. Fibre-optic endoscopy was performed on 42 patients treated surgically. Fibre-optic endoscopy demonstrated the presence of crusts in the nasal cavities and their subsequent reduction following surgery. It also demonstrated ulceration of the cartilaginous nasal septum in some cases and this may explain the pathogenesis of septal perforation noted in a high number of our patients. Fibre-optic nasendoscopy was also helpful in demonstrating the reappearance of free mucus in the nasal cavity and helped to determine the optimal time for reversing Young's procedure. Fibre-optic nasendoscopy is a reliable tool for verifying the results of surgery and comparing the efficacy of various treatment modalities.

Facial palsy following fine needle aspiration biopsy of parotid hemangioma: a case report and review of the literature

We present here a case of cavernous hemangioma of the parotid which presented as an acute emergency with sudden pain, trismus and swelling. The patient subsequently developed a complete lower motor neuron facial palsy a few hours after a fine needle aspiration biopsy was performed. Total parotidectomy with preservation of the facial nerve relieved the patient of all his symptoms with complete recovery of facial function in six weeks.

Khat and oral cancer

Oral cancers in the Asir region of Saudi Arabia have been observed to occur mostly among patients who have been long-term khat users. In a survey that reviewed cancers for the past two years there were 28 head and neck cancer patients, 10 of whom presented with a history of having chewed khat. One of these was a case of metastatic cervical lymph node and unknown primary, one was a parotid tumour, and the remaining eight presented with oral cancers. All were non-smoking khat chewers and all of them had used it over a period of 25 years or longer. We conclude that this strong correlation between khat chewing and oral cancer warrants attention.

Lipoid pneumonia in children following aspiration of animal fat (ghee)

Exogenous lipoid pneumonia induced by modified animal fat (ghee) in 10 children is described. The initial presentation was of an acute or chronic pneumonia which proved refractory to anti-microbial chemotherapy. The radiological presentation varied from mild perihilar consolidation to diffuse and extensive bilateral involvement, particularly of the posterior lung segments. A history of administration of ghee provided the initial clue to the diagnosis, which was confirmed by demonstration of fat by bronchoalveolar lavage or by open lung biopsy. Eight of the 10 patients improved with either steroid therapy alone or steroids with resection of the most involved lung segments. One patient, who had extensive superinfection with Mycobacterium fortuitum, died. Lipoid pneumonia should be considered in the differential diagnosis of 'non-resolving' pneumonias in communities where the cultural practice of infant feeding with ghee is prevalent. Public awareness through health education about the potential hazards of this practice to infants and children can contribute to reduce the incidence of the problem.