Predictive role of facial nerve palsy improvement in malignant external otitis

PURPOSE

To evaluate the effects of different factors on facial nerve palsy improvement in patients with malignant external otitis (MEO) and the predictive role of improvement on MEO.

METHODS

Data were collected from all MEO patients with facial paralysis who were hospitalized between 2012 and 2017 at a tertiary referral center. We contacted patients at least 6 months after their admission to evaluate their facial nerve function and survival rate.

RESULTS

In a study of 19 samples with a mean age of 69.1 years, 9 patients (47.7%) had some or complete improvement, while 10 (52.6%) had no or very minimal improvement. In this study, there was no statistically significant difference between patients with and without facial nerve palsy improvement in terms of age, sex, usage of antifungal treatment alongside antibiotics, duration of hospital stays, HbA1c level, presentation of hearing loss and vertigo, the severity of facial palsy, comorbidity score, mean of fasting blood sugar, leukocytosis, first ESR and ESR drop, CRP and physiotherapy. We found a positive correlation between improving facial palsy and patients' survival rates.

CONCLUSION

Considering the possible influence of facial paralysis improvement prognosis on MEO patients' survival, it could affect our approach to the disease.

Determination of the radioanatomical factors related to the position of facial nerve in accessing jugular foramen and carotid artery in temporal bone

Introduction

Preservation of the facial nerve is of great importance in temporal bone surgeries. We intend to investigate the measurements of the radioanatomical factors related to the position of the facial nerve in accessing jugular foramen and internal carotid artery (ICA) in temporal bone of patients who were candidates for temporal high resolution computed tomography (HRCT) scan.

Methods

In this correlation cross-sectional study, samples were selected from patients referred to Amir Alam Hospital who were previously candidates for temporal HRCT. Radioanatomic factors were evaluated in three axial, coronal and sagittal views. Analyzes were performed using descriptive statistics, correlation analysis and factor analysis.

Results

A total of 173 samples were investigated. The most reliable radioanatomical factor based on coefficient of variation (CV) was the distance of the 7th nerve to the temporomandibular joint (TMJ) in the inferior to the cochlea in the sagittal view (variable name S2) (CV = 8.1%) and then the distance from the 7th nerve to the TMJ in the inferior section of the cochlea in the axial view (variable name AI3) (CV = 8.4%). Based on correlation analysis and then confirmatory factor analysis, three common latent factors were identified (overall R2 = 0.999).

Conclusion

The results of this study can be used for two purposes. First, the direct use of the estimated measures in surgical operations, and the second is more advanced modeling to choose the approach in the surgical operation and how to implement that approach. For the first aim, the two factors AI3 and S2 were the most reliable radioanatomical factors in different people. For the second aim, the three-dimensional understanding of the obtained measurements and the further identification of the anatomical nature of the latent factors can help in choosing the approach in surgery.

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.

Evaluation of Sudden Sensory-Neural Hearing Loss Patients Treated with Systemic Steroids with Additional Intratympanic Dexamethasone Injection in Different Intervals; a Clinical Trial Study

Sudden Sensory-Neural Hearing Loss (SSNHL) is one of the most important otologic emergency. Although adding intratympanic (IT) steroids to systematic steroid may be beneficial, the exact timing of the IT injections to provide the best response needs further investigations. To compare different protocols in treting sudden sensorineural hearing loss. We performed a clinical trial study on 120 patients from October 2021 to February 2022. All patients were prescribed 1 mg/Kg daily oral prednisolone. After randomization to three groups, the control group received standard twice a week IT steroid injections in 12 days (four total injections) while intervention groups 1 and 2 received once and twice a day IT injections for ten days. Audiometric study repeated 10-14 days after the last injection and assessed based on the Siegel criteria. We used the Chi-Square, Analysis of Variance (ANOVA), Kruskal-Wallis's tests where appropriate. The most clinical improvement was found in the standard treatment group, and group-2 had the greatest number of patients with no improvement; however, no overall significant difference was observed among the three groups (p-value: 0.066; Pearson Chi-Square). Less frequent IT injections in patients already on systemic steroids provide similar results to more frequent injections.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03641-4.

Enhancing Medical Students' Knowledge and Performance in Otolaryngology Rotation through Combining Microlearning and Task-Based Learning Strategies

Microlearning is recommended to be implemented within the context of a wider teaching-learning ecosystem, especially in real working environments. Task-based learning is used in clinical education setting. This study aims at assessing the effect of an integrated approach of microlearning with task-based learning on medical students' knowledge and performance in Ear, Nose and Throat clerkship rotation. A total of 59 final-year medical students participated in this quasi-experimental study which included two control groups (routine teaching and task-based learning methods) and one intervention group (combined microlearning and task-based learning method). Pre- and post-tests of students' knowledge and performance were assessed through a multiple-choice question test and a Direct Observation Procedural Skills (DOPS) instrument, respectively. Performing Analysis of Covariance for knowledge post-test scores among three groups revealed significant differences (F = 3.423, p-value = 0.040) and the intervention group had the highest score. Analyzing DOPS results showed that the intervention group achieved significantly higher scores compared to the control ones for all the expected tasks (p-values = 0.001). The findings of the present study show that the combined strategy of microlearning with task-based learning is an effective clinical teaching method for enhancing medical students' knowledge and performance in a real working environment.

Cranial nerve palsy prevalence and associated factors in patients with malignant otitis externa

Objective

To identify the prevalence of cranial nerve (CN) palsy and its associated factors in malignant otitis externa (MOE).

Methods

In a retrospective study, records of MOE patients from 2011 to 2014 were reviewed. MOE and CN involvement were evaluated based on patient demographics, clinical, and paraclinical data.

Results

Overall, 119 MOE patients with a mean age of 65.9 ± 11.3 were included. 69.7% were male, and 63.0% had a history of diabetes. The most common symptoms and signs were otalgia (97.5%), otorrhea (44.5%), and ear canal erythema/edema (24.4%). Thirty-three patients (27.7%) had CN involvement. The facial nerve was mostly involved (26.1%). Skull base osteomyelitis (SBO) was present in 59 patients. When excluding patients younger than 30 and older than 80, age decade was correlated with CN palsy. 66.9% of patients with CN palsy and 65.6% without CN palsy were male, which was significantly different. The following factors were not significantly different between patients with and without CN palsy: Comorbidities, signs and symptoms, diagnostic delay, erythrocyte sedimentation rate level, fasting blood sugar, hemoglobin A1c level, antifungal therapy, hospitalization duration, and SBO on imaging. Tinnitus was correlated with SBO evidence on imaging (specificity: 96.7%).

Conclusion

CN involvement occurs in about three out of 10 MOE patients. Male gender and advanced age may be related to a higher incidence rate of CN palsy. Tinnitus can be a specific indicator of SBO. These findings could help in better decision-making for early interventions.

Level of Evidence

4.

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.

Effectiveness of vestibular rehabilitation therapy in patients with idiopathic Cerebellar Ataxia with Bilateral Vestibulopathy (iCABV)

OBJECTIVE

To evaluate the benefit of vestibular rehabilitation therapy (VRT) in the management of patients with idiopathic cerebellar ataxia with bilateral vestibulopathy (iCABV).

BACKGROUND

iCABV is a hindbrain degenerative disorder with impairment of both central and peripheral vestibular pathways. There is combined failure of four compensatory eye movement systems including the vestibulo-ocular reflex (VOR), optokinetic reflex, smooth pursuit and the visually enhanced vestibulo-ocular reflex (VVOR). Phenotypic presentation includes postural and gait instability, oscillopsia and dizziness with active head movement. The benefit of VRT in iCABV patients has not been established.

METHODS

A retrospective review was performed on a cohort of twelve patients diagnosed with iCABV in a multidisciplinary neuro-otology clinic. All participated in VRT and completed their suggested course of VRT. The following clinical measures were assessed before starting and after finishing VRT: 1) Dizziness Handicap Inventory (DHI), 2) Activities-Specific Balance Confidence (ABC) Scale, 3) Catastrophization scale, 4) Positive Affective Negative Affective Score (PANAS), 5) Dynamic Gait Index (DGI) and 6) Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). The number of falls historically was recorded in addition to gait speed (ft./sec).

RESULTS

Following VRT, patients were found to have improved balance on mCTSIB (condition 4 : 7 vs 18 seconds, P = 0.04) and a better postural stability with a reduced number of falls (p = 0.01). No statistically significant improvement was seen in the DHI, ABC, Catastrophization scale, DGI, PANAS and gait speed (p > 0.05).

CONCLUSIONS

iCABV patients who underwent VRT were found to have a better postural stability and reduced risk of falls. VRT was not found to significantly improve patients' overall subjective perception of their symptoms or their psychological status.

Iatrogenic facial nerve injury in mastoidectomy: The impact of variables on the outcome

OBJECTIVE

To evaluate iatrogenic facial nerve injury in mastoidectomy and its paralysis improvement result after nerve injury management.

METHODS

A retrospective review of medical records of 21 patients with iatrogenic facial nerve injury following mastoidectomy who underwent nerve injury management in a tertiary referral center.

RESULTS

There were nine males and 12 females, with a mean age of 40.4 ± 15.1 years. Cholesteatoma was the most common primary pathology (76.2%). Mastoidectomy was canal wall up in 8 patients and canal wall down in 13. Nerve injury was due to drilling in 10 patients and sharp tools in 11. The tympanic segment of the facial nerve was the most common injured site (50.0%). Decompression was the most common nerve injury management method (52.4%). Other injury management methods were end-to-end anastomosis (14.3%), great auricular nerve graft (23.8%), and facial-hypoglossal nerve transfer (9.5%). No statistically significant correlation was found between facial nerve function 3-6 months after injury management and the following factors: age, gender, primary pathology, type of mastoidectomy, surgeon's experience, nerve injury site, mechanism of trauma, and nerve injury management method and timing.

CONCLUSION

Regardless of the surgeon's experience or technique applied, a meticulous approach may be more valuable in decreasing the chance of iatrogenic facial nerve injury.

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.

The anti-inflammatory effect of dapsone on ovalbumin-induced allergic rhinitis in balb/c mice

AIMS

Allergic rhinitis (AR), a major chronic inflammatory disease of the respiratory system, is a public health issue because of its substantial negative impact on quality of life and work efficiency alongside its high prevalence and costs. Dapsone is a sulfone chemical with reported anti-inflammatory and antibacterial properties. Accordingly, we investigated the anti-inflammatory impact of dapsone on ovalbumin-induced allergic rhinitis in balb/c mice.

MAIN METHODS

Intraperitoneal ovalbumin and hydroxide aluminum injection followed by intranasal ovalbumin administration sensitized female Balb/c mice. Mice received intraperitoneal dapsone either acute (5, 10, 20 mg/kg) 30 min before the last ovalbumin challenge, or chronic (20 mg/kg) on days 21 to 35.

KEY FINDINGS

Both acute and chronic intraperitoneal usage of dapsone showed a considerable decrease in the nasal scratching behavior, the number of sneezing, serum IL-4 and IgE levels of ovalbumin-induced AR in balb/c mice, but there was a significant increase in serum IFNγ level. Histopathological analysis demonstrated a significant reduction of eosinophil numbers, following dapsone injection. Goblet cell hyperplasia and respiratory epithelial-thickness decreased significantly in the acute and chronic 20 mg/kg dapsone groups compared to the ovalbumin-induced controls.

SIGNIFICANCE

This study shows that there is an association between acute and chronic dapsone treatment and some anti-allergic effects through an inflammation cascade.

Post-traumatic peripheral vestibular disorders (excluding positional vertigo) in workers following head injury

Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience. The UHN WSIB Neurotology database (n = 4291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI. Based on a database of 4291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere's disease in the post-traumatic setting did not appear greater than found in the general population. The clinical spectrum pertaining to recurrent vestibulopathy, Meniere's disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

The Relationship Between Sudden Sensorineural Hearing Loss, Vestibular Neuritis, and Infection With COVID-19

Introduction: This study aimed to investigate the relationship between sudden sensorineural hearing loss, vestibular neuritis, and infection with COVID-19. Materials and Methods: In this study, a total of 56 Iranians (32 females and 24 males) with a Mean±SD age of 45.12±14 years were studied in Tehran City, Iran. Individuals diagnosed with Sudden Sensorineural Hearing Loss (SSNHL) or vestibular neuritis based on definitive diagnostic criteria were included in the study. The methodology comprised four sections of underlying Sudden Hearing Loss,, auditory and vestibular inspection, SARS-CoV-2 Reverse Transcription-Polymerase Chain Reaction (RT-PCR) test, and statistical analysis. Also, the videonystagmography test was used in participants with vertigo to diagnose vestibular neuritis. Pure tone audiometry confirmed SSNHL in some patients with a complaint of hearing loss. Furthermore, tuning fork, Rinne and Weber tests were also performed. Results: The results of SARS-CoV-2 RT-PCR in 56 subjects showed that eight subjects (22.2%) with vestibular neuritis and two with SSNHL (10%) had a positive RT-PCR test. The Chi- square and Fisher exact-tests with a 95% confidence interval revealed no statistically significant (P>0.05) relationship between COVID-19 infection and vestibular neuritis or SSNHL. Conclusion: The present study showed no statistically significant relationship between audiovestibular disorders and positive SARS-CoV-2 RT-PCR test. However, the possibility of this relationship cannot be ruled out, and there is a need for studies with larger sample sizes.

The Effects of Resveratrol on Oxidative Stress Markers: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

Recent trial studies have found that resveratrol supplementation beneficially reduces oxidative stress marker, but, there is no definitive consensus on this context. The present systematic review and meta-analysis aimed to investigate the effect of resveratrol supplementation on oxidative stress parameters.

METHODS

We searched databases of Pubmed, Scopus and Cochrane Library up to December 2018 with no language restriction. Studies were reviewed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) and Cochrane handbook. To compare the effects of resveratrol with placebo, weighted mean difference (WMD) with 95% confidence intervals (CI) were pooled based on the random-effects model.

RESULTS

Among sixteen clinical trials, we found that resveratrol supplementation increased GPx serum levels significantly (WMD: 18.61; 95% CI: 8.70 to 28.52; P<0.001) but had no significant effect on SOD concentrations (WMD: 1.01; 95% CI: -0.72 to 2.74; P= 0.25), MDA serum levels (WMD: -1.43; 95% CI: -3.46 to 0.61; P = 0.17) and TAC (WMD: -0.09; 95% CI: -0.29 to 0.11; P = 0.36) compared to placebo. Finally, we observed that resveratrol supplementation may not have a clinically significant effect on oxidative stress.

CONCLUSION

However, the number of human trials is limited in this context, and further large prospective clinical trials are needed to confirm the effect of resveratrol supplement on oxidative stress markers.

Evaluation of Patients with Delayed Endolymphatic Hydrops by Videonystagmography, Vestibular-Evoked Myogenic Potentials, and Electrocochleography

INTRODUCTION

The categorization of delayed endolymphatic hydrops (DEH) based on the ear which produces vertigo may sometimes cause misdiagnosis.

OBJECTIVES

The aim of this study was investigating the vestibular-evoked myogenic potentials (VEMPs), electrocochleography (ECoG), and videonystagmography (VNG) in cases with DEH to determine the ear that originates symptoms.

METHODS

In this cross-sectional study, 34 patients - 20 males and 14 females - with profound unilateral sensorineural deafness and vertigo attacks were recruited and evaluated by the ECoG, VNG, and VEMPs tests.

RESULTS

The average age was around 43; the summating potential/action potential was abnormal in 29.4% of patients in their normal auditive ear. In 32.4, 17.6, and 50% of cases with a deaf ear, absent, normal, and abnormal VEMPs results were sequentially observed, respectively. In normal-hearing ears, absent, normal, and abnormal VEMPs were observed in 23.5, 50, and 26.5%, respectively. In the normal-hearing ear, the distribution of abnormal VEMPs was 26.5%, and in the deaf ear, this parameter was abnormal in 50% of the opposite ear (p value = 0.00021). In the VNG test, among patients with a normal-hearing ear, results in 27 and 7 patients were sequentially normal and hypofunction.

CONCLUSION AND SIGNIFICANCE

The probability of a hypofunction VNG test in a normal-hearing ear might be greater when the VEMPs results of the contralateral deaf ear are normal. In patients with a normal-hearing ear, the distribution of abnormal VEMPs in the contralateral deaf ear is greater, although the intact side may also manifest abnormality in VEMPs tests. The initial evaluation should begin in a deaf ear as well as for the normal-hearing ear ere utilizing ablation surgery.

Current Understanding and Unknown Aspects of the Treatment of Granulomatosis with Polyangiitis (Wegener's Granulomatosis): Opportunities for Future Studies

Granulomatosis with polyangiitis (GPA) is a rare and systemic autoimmune disease, causing necrotizing vasculitis of small arteries and veins. The majority of diagnosed patients with GPA have circulating anti-neutrophil cytoplasmic antibodies (ANCA) directed against proteinase 3 (PR3). Here, we have reviewed the last findings and uncertainties regarding the treatment of GPA. Between the available treatments, in addition to corticosteroids, cyclophosphamide (CYP) is effective for remission-induction, while it is associated with some serious side effects, such as infertility and increased risk of malignancies. On the other side, rituximab (RTX) seems a safer alternative option and as effective as CYP. It could be used as both remission-induction and maintenance therapy in GPA patients, especially in women of childbearing age. Pregnant patients, who must not be exposed to the CYP and RTX could be well-managed with intravenous immunoglobulin (IVIg). Co-trimoxazole, which is widely used to treat certain bacterial infections or as prophylaxis in immunosuppressed patients, could be effective in preventing disease relapse. In the meantime, 15- deoxyspergualin, plasma exchange are other therapeutic options with a low level of evidence. Regarding potential treatments, ofatumumab, ocrelizumab, belimumab, atacicept, tabalumab, abatacept (CTLA4-Ig), and Janus kinase inhibitors seem to be effective. Renal involvement, older age, the presence of baseline organ damage, delayed-diagnosis of disease, rising in creatinine level, and higher neutrophil/lymphocyte ratio is associated with poor outcomes. Optimum doses of medications, prediction of treatment response and disease relapse, explaining lack of response in some patients, treating children with GPA, and management of GPA during the pregnancy are controversial issues, which need further studies.

Facial nerve paralysis in malignant otitis externa: comparison of the clinical and paraclinical findings

BACKGROUND

Malignant otitis externa is an uncommon but critical challenging disease with some degree of cranial nerve involvement.

AIM/OBJECTIVE

to examine the factors leading to facial paralysis in these patients and clarify indications for aggressive treatment in the group most at risk.

MATERIAL AND METHODS

In a case-control study, demographic, clinical, laboratory, audiometric, imaging, and treatment characteristics of 139 patients in groups with and without facial paralysis were analysed.

RESULTS

45 patients (32.4%) had facial paralysis. Compared to patients without facial nerve involvement, patients with facial palsy had a higher rate of inflammatory markers (mean erythrocyte sedimentation rate on admission [67.71 vs 51.16 mm/h], and the average of total ESR [64.27 vs 54.46 mm/h], as well as the mean C-reactive protein [38.96 vs 27.53 mg/L]). Also, the involvement of the facial canal (p < .01) and nasopharyngeal space (p < .05) were related to the incidence of facial paralysis.

CONCLUSION

Nasopharyngeal extension of the inflammation and facial nerve canal erosion might be useful as predictors of facial nerve dysfunction. The elevated erythrocyte sedimentation rate is correlated with the increased risk of facial paralysis, and aggressive medical management is more crucial.

SIGNIFICANCE

Improvement in predicting the outcome of patients with malignant otitis externa.

The Effects of Omega-3 Supplementation on the Expanded Disability Status Scale and Inflammatory Cytokines in Multiple Sclerosis Patients: A Systematic Review and Meta-Analysis

Recent trial studies have shown that omega-3 supplementation can beneficially improve scores on the Expanded Disability Status Scale (EDSS), which is considered a gold standard for measuring disability and disease severity in Multiple Sclerosis (MS) patients, as well as reducing neuroinflammation. The present systematic review and meta-analysis aimed to evaluate the effect of omega-3 supplementation on EDSS and cytokines in MS. A systematic search was performed on Pubmed, Scopus and Cochrane Library up to October 2018. Studies were reviewed based on the Cochrane handbook, and the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Weighted Mean Difference (WMD) with 95% Confidence Intervals (CI) were pooled using a random effects model in order to compare the effects of omega-3 with placebos. Among 4 trials, omega-3 supplementation had no significant effect on EDSS scale (WMD: -0.07; 95% CI: -0.27 to 0.13; P=0.50), as well as serum levels of IL-1β (WMD: -7.67; 95% CI: -23.31 to 7.97; P=0.34) and IL-6 (WMD: -153.57; 95% CI: -455.36 to 148.23; P=0.32). However, omega-3 significantly reduced TNF-α concentration (WMD: -16.76; 95% CI: -18.63 to -14.88; P < 0.00001) compared to placebo. Overall, omega-3 supplementation may not have a clinically considerable impact on EDSS or proinflammatory markers. However, the existing trials are limited in this context, and further clinical trials are required to confirm the potential effects of the omega-3 supplement on MS disease management.

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.

The effect of test-enhanced spaced learning on the otolaryngology board and annual examination results: A quasi-experimental study

INTRODUCTION

In the test-enhanced spaced learning, educational contents are presented in small packages of well-developed test questions with a defined frequency to the learners. It is not clear that applying this educational style might have a positive impact on the summative assessment. Therefore, in this study, we assessed the effect of the test-enhanced spaced learning on the otolaryngology board and annual examinations of residency training.

METHODS

In a quasi-experimental study with consecutive sampling, all forty-four residents of otolaryngology in four levels of training in 2016 at Tehran University of Medical Sciences (TUMS) received daily-standardized multiple-choice questions with a twice-repeated frequency of 10 days. Individual feedback according to one's response to each test was provided. The results of national board and annual exam were compared with the same results of all residents of other universities and previous year TUMS' residents for whom spaced learning were not applied and they were considered as the control groups. The board exam had two parts, multiple-choice questions, and computer-based clinical examination. The annual exam format was multiple choice questions. The total score for each one was 150. Student's t-test and Mann-Whitney U test were used for comparative analyses.

RESULTS

The mean of the board exam results showed statistically significant improvement compared to other medical schools (113.6±10.7 vs. 102.9±13.4 in multiple-choice questions, p-value= 0.048, 118.7±12.5 vs. 54.1±60.0 in the computer-based clinical examination, p-value<0.001), while similar comparison results in the previous year did not show any significant difference.

CONCLUSION

Spaced learning with testing effect may be useful in the clinical education setting to improve the learning outcomes.

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.

Comparative analysis of proteinase, phospholipase, hydrophobicity and biofilm forming ability in Candida species isolated from clinical specimens

Candida species are the commensal organisms of human and animal mucosa that cause a wide range of debilitating diseases in immunocompromised patients and other susceptible individuals. The present study aimed to investigate the ability of clinical isolates of various Candida species to produce proteinase and phospholipase, hydrophobicity and biofilm forming ability that assumed to have a vital role in Candida pathogenicity. Eighty-four Candida strains belonged to Candida albicans (44.1%), C. glabrata (5.9%), C. guilliermondii (5.9%), C. krusei (10.8%), C. parapsilosis (26.2%), and C. tropicalis (7.1%) were examined for proteinase and phospholipase production, cell surface hydrophobicity and biofilm forming ability. The production of proteinase and phospholipase was detected in 81 (96.4%) and 79 (94.1%) of the strains, respectively. C. albicans showed the highest proteinase and phospholipase activity (mean Pz values of 0.42±0.25 and 0.72±0.28) and biofilm formation ability (0.66±0.22). C. parapsilosis had the highest hydrophobicity (42.97±16.1), which showed a good correlation with biofilm formation ability. A considerable percentage of non-albicans Candida strains produced significant amounts of proteinase and phospholipase with a good ability of biofilm formation in vitro. Taken together, our results further substantiated that enzymatic activity, hydrophobicity and the ability for biofilm formation are important virulence factors which may be account for pathogenicity of various Candida species distributed in albicans and non-albicans groups.

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.

The Follow-Up Role of the Vestibular Evoked Myogenic Potential Test in Meniere's Disease

Despite some proposed roles for the diagnostic impact of the cervical vestibular evoked myogenic potential test in the patients with Meniere's disease, the role of this test as an objective instrument in following up the patients with Meniere's disease who underwent. Intratympanic steroid injection is not cleared. In a prospective study, thirty-one adult patients with definite one-sided Meniere's disease with vertigo as main complaint refractory to medical treatments for three months, were selected. Patients underwent three times of intratympanic dexamethasone injection with one-week intervals. We performed cervical vestibular evoked myogenic potential test at first and four weeks after the last injection for all participants. We followed the patients for one year. The study results were analyzed with the chi-square test. Cervical vestibular evoked myogenic potential test could not be recorded in 26 patients (83.9%), and the test results were abnormal in the remaining 5 patients. The results were abnormal in the healthy ear of 32.3% of the patients. Despite the clinical improvement of the symptoms after intratympanic injection, the test results were not changed. Cervical vestibular evoked myogenic potential test could not be recorded in the majority of the patients with Meniere's disease; while it is usually recorded in normal ears. On the other hand, results of the cervical vestibular evoked myogenic potential test do not change during the early phase after treatment and could not be a good option for follow up and evaluating the response in this situation.

Efficacy of systemic and intratympanic corticosteroid combination therapy versus intratympanic or systemic therapy in patients with idiopathic sudden sensorineural hearing loss: a randomized controlled trial

OBJECTIVE

The present study was conducted to compare the rates of recovery from idiopathic sudden deafness after the treatment with oral and intratympanic corticosteroids in both mono and combination therapies.

STUDY DESIGN

Triple-blind randomized clinical trial.

SETTINGS

Tertiary referral hospital.

SUBJECTS AND METHODS

A total of 112 patients who were admitted to the ENT emergency department randomly divided into three groups: an oral corticosteroid plus intratympanic placebo (systemic corticosteroid monotherapy group); an intratympanic corticosteroid plus oral placebo group (IT monotherapy group); and a combination therapy group (IT plus systemic combination group). All patients were treated additionally with antiviral and proton pomp inhibitor. An audiometry was performed once before beginning the therapies and again at the end of the therapy.

RESULTS

Of the total of 112 patients, 32 received intratympanic (IT) corticosteroids, 45 were receiving systemic corticosteroids, and 35 were receiving a combination of the two. A total of 74 patients (66.1%) responded positively [response to treatment was calculated as gain of at least 10 dB in 10 dB in average threshold or with the minimum improvement of 15% in speech discrimination scores (SDS)] to corticosteroid therapy. No significant differences were observed between the three groups (IT, systemic group, and combination therapy group) in their overall response to treatment (p = 0.5). Patients who suffered from concomitant tinnitus and dizziness responded less positively to the treatment (p < 0.002). Positive family history of SSNHL seems to be negative prognostic factors in the response to treatment (p < 0.001). The response to treatment was not related to the pattern (p = 0.04) and initial severity of hearing loss (p = 0.9).

CONCLUSION

This study did not find any difference in the rate of hearing improvement between systemic, intratympanic, and combined corticosteroid therapy for sudden hearing loss.

LEVEL OF EVIDENCE

1b.

Methylprednisolone versus Dexamethasone for Control of Vertigo in Patients with Definite Meniere's disease

INTRODUCTION

Definite Meniere's disease is associated with two or more definitive periods of vertigo along with hearing loss, plus tinnitus or aural fullness or both. This study aimed to compare the effect of intratympanic dexamethasone and methylprednisolone on the functional-level scale of pure-tone audiometry (PTA), and class outcome measures of vertigo.

MATERIALS AND METHODS

In this clinical study, 69 patients with definite Meniere's disease, referred to the tertiary otolaryngology center, were randomly assigned to two groups: 36 patients were treated with intratympanic dexamethasone (4mg/dl) and 33 patients were treated with intratympanicmethylprednisolone (40mg/dl). Each group received three weekly injections. After a follow-up of 1 and 6 months, PTA changes and vertigo control were evaluated.

RESULTS

There was no statistically significant difference between the two groups with regard to control of vertigo (P=0.866, P=0.879 for 1 and 6 months post injection, respectively). PTA improvement was statistically significantly higher in the methylprednisolone group (P=0.006).

CONCLUSION

In summary, intratympanic corticosteroid is an effective treatment for Meniere's disease and can prevent other invasive treatments. Intratympanic methylprednisolone can improve hearing level to a greater extent than intratympanic dexamethasone, but the two groups were similarly beneficial in controlling vertigo. However, there was a trend toward a more sustained benefit with methylprednisolone.

A Treatment Protocol for Management of Bacterial and Fungal Malignant External Otitis: A Large Cohort in Tehran, Iran

AIMS

High rates of negative microbiologic test results highlight the potential role of empiric antimicrobial agents in management of malignant otitis externa (MOE). This study investigates the clinical presentation, laboratory findings, and response to empiric treatment in a large group of patients admitted to a tertiary academic hospital in Tehran, Iran.

METHODS AND MATERIALS

We recruited 224 patients diagnosed with MOE in a prospective observation from 2009 through 2015. All patients received a 2-agent antibacterial regimen at baseline (phase I). Patients with no improvement within 10 days and/or nonresponders to a second course of antibacterials were switched to antifungals (phase II). Response to treatment was observed and documented in both groups.

RESULTS

All patients had physical symptoms for more than 12 weeks before admission. In total, 127 patients responded well to antibacterials. Eighty-seven out of 97 patients who were switched to antifungals had complete response to treatment; patients in the latter group had significantly higher A1C levels at baseline.

CONCLUSION

Our findings provide evidence to develop clinical guidelines that accelerate diagnosis and treatment of MOE to improve patient outcomes.

Analysis of Saccular Function With Vestibular Evoked Myogenic Potential Test in Meniere's Disease

Meniere's disease is the disorder of inner ear characterized by vertigo, tinnitus and sensorineural hearing loss. The vestibular evoked myogenic potential (VEMP) test could be useful in the analysis of saccular function, and diagnosis of Meniere's disease. In this study, we've analyzed the saccular function, using VEMP test in different groups of Meniere's disease. Patients were categorized as possible, probable or definite Meniere's disease groups according to the guideline of American Academy of Otolaryngology-Head and Neck Surgery. The exclusion criteria were neuromuscular system diseases, diseases of central nervous system, inner ear disorders, conductive hearing loss, a history of ototoxic drug consumption, being a drug abuser and a positive history of inner ear surgery or manipulations. The VEMP test is the recording of positive and negative waves from sternocleidomastoid muscle that is made by an auditory click to the ear. From the total of 100 patients, the waves of VEMP test was seen in 59 patients which 19 patients had abnormal amplitude, and latency and 40 patients were with normally recorded waves. There was a significant relationship between the severity of hearing loss and a VEMP test without any recorded waves. Most of the cases with 'no wave recorded' VEMP test, were patients with severe hearing loss. However, there wasn't any relation between the pattern of hearing loss and 'no wave recorded' VEMP test. VEMP test could be a valuable diagnostic clue especially in patients with definite Meniere's disease.

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.

Induction of apoptosis by opium in some tumor cell lines

The current study is aimed at investigation of the opium effects on the apoptosis of different cell lines in culture medium and compares such effects with one another. The study is carried out on over 8 cell lines (AA8, AGS, Hela, HepG2, MCF7, N2a, PC12, WEHI). A 2.86 x 10-4 g/ml opium concentration was prepared and added to the culture medium of the cell lines for 48 hours. Cytotoxicity was tested by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay. The apoptotic effect of opium on the cell lines was analyzed by Annexin-PI test. Opium with concentration of 2.86 x 10-4 g/ml in 48 hours significantly induces apoptosis in certain cell lines (i.e. AA8, N2a, WEHI), apoptosis and necrosis in some others (i.e. Hela, HepG2, MCF7, and PC12), and also solely necrosis in the AGS cell line. One could infer that the usage of opium with different levels in different tissues leads to certain disorders in some tissues and may have therapeutic effects under distinctive conditions (i.e. unchecked growth of cells) as confirmed by the results.

HLA-Cw Allele Frequency in Definite Meniere's Disease Compared to Probable Meniere's Disease and Healthy Controls in an Iranian Sample

INTRODUCTION

Several lines of evidence support the contribution of autoimmune mechanisms in the pathogenesis of Meniere's disease. The aim of this study was determining the association between HLA-Cw Alleles in patients with definite Meniere's disease and patients with probable Meniere's disease and a control group.

MATERIALS AND METHODS

HLA-Cw genotyping was performed in 23 patients with definite Meniere's disease, 24 with probable Meniere's disease, and 91 healthy normal subjects, using sequence specific primers polymerase chain reaction technique. The statistical analysis was performed using stata 8 software.

RESULTS

There was a significant association between HLA-Cw*04 and HLA-Cw*16 in both definite and probable Meniere's disease compared to normal healthy controls. We observed a significant difference in HLA-Cw*12 frequencies between patients with definite Meniere's disease compared to patients with probable Meniere's disease (P=0.04). The frequency of HLA-Cw*18 is significantly higher in healthy controls (P=0.002).

CONCLUSION

Our findings support the rule of HLA-Cw Alleles in both definite and probable Meniere's disease. In addition, differences in HLA-Cw*12 frequency in definite and probable Meniere's disease in our study's population might indicate distinct immune and inflammatory mechanisms involved in each condition.

CXCL9 expression and polyomavirus BK infectivity in renal transplant patients with nephropathy

Polyomavirus BK is an important risk factor for nephropathy and renal lose after kidney transplantation. CXCL9 is a key immunoregulatory molecule which participates in stimulation and migration of immune cells to the infected sites. Thus, the main aim of this study was to evaluate the expression levels of CXCL9 mRNA and serum levels in the infected polyomavirus BK infected renal transplant patients with and without nephropathy compared with healthy controls. This cross sectional study was performed on three studied groups including: polyomavirus BK infected vs. non-infected renal transplant patients with nephropathy and healthy controls. The mRNA and serum levels of CXCL9 were evaluated on the studied patient and control samples using an in-house comparative real time PCR and ELISA methods, respectively. The mRNA expression and serum levels of CXCL9 were both increased in polyomavirus BK infected compared with non-infected renal transplant patients and also in comparing with healthy controls. This upregulation was significant in the serum level in polyomavirus BK infected vs. non-infected patients and also in comparing with controls. According to these results, polyomavirus BK can induce renal complications via stimulation of inflammatory biomarkers like chemokine. Confirmation of the increasing of the expression and production of CXCL9 as a pro-inflammatory chemokine in renal transplanted polyomavirus BK infected patients with nephropathy need to confirm in further completed studies with longer follow-up.

Preventive effect of ginger (Zingiber officinale) pretreatment on renal ischemia-reperfusion in rats

BACKGROUND/AIMS

The present study examined the preventive effect of ginger against renal ischemia-reperfusion (I-R) injury.

METHODS

30 adult male rats were used. The animals were allocated to five groups of 6 rats: (1) normal (N), (2) normal + ginger (N+G), (3) right nephrectomy (Sham), (4) I-R, and (5) I-R + ginger (I-R+G). To induce renal ischemia, animals were unilaterally nephrectomized and subjected to 45 min of left renal pedicle occlusion with 24 h reperfusion. Ginger was administered orally 24 h and just before ischemia. At the end of the experiment, blood samples and urine were collected. The following renal functional parameters were studied: serum and urinary levels of creatinine and urea, fractional excretion of sodium, and creatinine clearance. Histopathological examination of the kidney was also performed.

RESULTS

Rats with renal I-R showed a significant increase in creatinine and urea concentration in serum and also a significant decrease in creatinine clearance compared with the other groups. In addition, renal histopathology in the I-R group showed severe alterations such as tubular dilatation and tubular epithelial necrosis. However, these changes were significantly reduced in the I-R+G group.

CONCLUSION

This study suggests that ginger is a useful agent for the prevention of renal ischemia reperfusion-induced injury.

A description of parasite-harbouring cells in localized lymphadenitis in dry type cutaneous leishmaniasis

Lymphadenitis with or without dry-type cutaneous leishmaniasis is rare. The lesion might self heal or show excellent response to antimonial therapy. Routine histopathological changes of localized leishmaniasis lymphadenitis are non-caseating to suppurative granulomata mostly in paracortical areas, some with extension to germinal centres, medullary cords and/or pericapsular spaces which have to be distinguished from other causes of lymphadenitis such as tuberculosis, cat-scratch disease and toxoplasmosis. Dense lymphoplasmocytic infiltrate was observed surrounding the necrotizing granuloma together with dense capsular fibrosis with multiple granulomata in subcapsular and pericapsular areas. Immunostaining of lymph nodes showed that a few macrophages were harbouring Leishman bodies. Dispersed Langerhans cells were also harbouring Leishman bodies in the parasitophorous vacuoles between their cytoplasmic pseudopods. In conclusion multiple noncaseating to suppurative granulomata with dense pericapsular and capsular granulomo-sclerotic changes should be considered in the differential diagnosis of leishmaniasis lymphadenitis.

Intralesional autotherapy of cutaneous leishmaniasis with buffy coat cells: cytological findings

The skin lesions of five patient volunteers with dry-type cutaneous leishmaniasis were treated by intralesional injection of auto-leukocytes prepared from buffy coat of the patient's own blood. Giemsa stained, air-dried cytological smear preparations were prepared from scrapings taken from the margins of the lesions. The cellular interaction between the organism and the inflammatory response of the host was studied. All lesions showed clinical evidence of regression. The cytological findings suggested progressive degradation of the Leishman donovan (LD) bodies within the parasitophorous vacuoles of the activated macrophages. The parasiticidal effect appeared to be induced by synergistic action of the injected neutrophils and lymphocytes. Due to lack of placebo controls in this study the possibility that, healing might not be related to therapy can not be excluded. This study illustrates the potential for intralesional autotherapy with buffy coat in dry-type cutaneous leishmaniasis.

Cytologic features of "dry-type" cutaneous leishmaniasis

Exfoliative cytology smears from the lesions of 179 patients with cutaneous leishmaniasis due to Leishmania tropica were studied with specific reference to cellular reactions and their effect on the parasite. Aggregates of the parasite (so-called Leishmania Donovan bodies) were present within macrophages and in some fibroblasts. The nature of the inflammatory reaction to the disease was studied by performing differential counts of the inflammatory cells present in the smears. These were correlated with the number of Leishman Donovan bodies. There was an inverse relationship between the number of Leishman Donovan bodies and the percentage of small lymphocytes, neutrophils, and type I macrophages. It is postulated that aggregates of activated macrophages (designated types II and III) and the Leishmanian milieu (sticky matrix) protect the amastigote Leishmania parasites from being eradicated by the inflammatory and immune reaction. The cytoplasmic blebbing of the parasitophorous vacuoles and cell to cell connection of the activated histiocytes could be shown by the CD-68 immunostaining of the tissue biopsy.