Tamer Ali Youssef

Congenital glottic web: Management and anatomical observation

Introduction:  Congenital anterior glottis web is a rare congenital laryngeal anomaly presenting usually by either dysphonia or airway obstruction. Several ways for managing this condition have been proposed including endoscopic, as well as external techniques.

The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study.

The objective of this article is to verify the role of postural restrictions after repositioning maneuvers in treating patients with benign paroxysmal positional vertigo (BPPV). The study included published articles yielded by a Pubmed search concerning post-maneuver postural restriction in treating BPPV. The search was limited to articles published in English language in the last three decades. The search was done on 1/11/2011. For the 18 relevant articles, we applied our inclusion and exclusion criteria and only 9 articles were included. The data collected from each article were statistically analyzed utilizing meta-analytic Review Manager (RevMan 5.1) software. (Version: 5.1.0.0). There were no significant differences between patients instructed with postural restriction after undergoing repositioning maneuver and patients left free to move after undergoing repositioning maneuver with regard to the presence or absence of post-maneuver symptoms. In conclusion, post-maneuver restrictions do not add to the success of the treatment of BPPV and there is no reason to submit patients to these impractical instructions.

Intraoperative parathyroid hormone as an indicator for parathyroid gland preservation in thyroid surgery

BACKGROUND Intra-operative parathyroid hormone (PTH) levels have successfully been used to assess surgical ablation of parathyroid adenomas, the use of this same test to predict preservation of viable gland has not been widely used. AIM to test the sensitivity and specificity of intraoperative rapid PTH assay test in predicting permanent postoperative hypoparathyroidism, and applicability to guide the search for inadvertently removed parathyroid glands for possible auto transplantation. PATIENTS AND METHODS 52 patients undergoing total thyroidectomy for non-malignant thyroid diseases were included. Intraoperative rapid PTH assay test was performed. If levels were reduced, or less than 3 parathyroid glands were detected, removed thyroid gland was examined for unintentionally removed parathyroid tissue for possible auto transplantation. RESULTS There was a strong correlation between intraoperative rapid PTH assays and those taken 24 hours after surgery, 16 out of 52 patients had reduction of the PTH intraoperatively to levels below 25 pg/ml, of them, 11 patients (who had values between 15-24 pg/ml) recovered to normal PTH levels within 4 weeks, while the 5 patients with intraoperative PTH levels below 15 pg/ml failed to regain normal PTH levels up to 12 weeks postoperatively, even in those patients where parathyroid tissue was auto transplantated. The 4 patients who had parathyroid tissue reimplanted intraoperatively restored some of their parathyroid function as indicated by relative rise of their PTH levels, but did not reach even the low normal levels. (ROC) curve for prediction of early hypoparathyroidism using intraoperative rapid PTH assay was statistically highly significant with optimal cutoff value for predicting early hypocalcaemia level <27 pg/ml, (sensitivity 100%, specificity 68.2%). (ROC) curves for predicting permanent hypoparathyroidism using intraoperative rapid PTH assay or standard PTH assay taken 24 hours after surgery were statistically significant with optimal cutoff value PTH level <12 pg/ml on the intraoperative PTH curve or <15 pg/ml on the postoperative PTH curve (sensitivity 100%, specificity 100%). CONCLUSION Intraoperative PTH assay may allow intraoperative monitoring of parathyroid function, predicting postoperative outcomes, may identify patients at risk of developing postoperative hypoparathyroidism, guiding surgeons to re-examine removed specimens for inadvertently removed parathyroid tissue with possible auto transplantation, or more practically a guide to early replacement therapy to prevent hypocalcaemia, leading to safe and early hospital discharge. Limitations in our study to be reconsidered in further studies, are relative small sample size, inability for randomisation, and the variable values reported for the cut off value of PTH causing hypocalcaemic symptoms needing intervention.

Benefit of combined endoscopic sinus surgery and aesthetic rhinoplasty.

INTRODUCTION Rhinoplasty is one of the most commonly performed aesthetic procedures today. Although nasal airway obstruction is frequently treated concomitantly with the aesthetic procedure, chronic sinusitis has typically postponed until full resolution of inflammatory symptoms. AIM OF THE STUDY To investigate the feasibility of combining FESS with septorhinoplasty by measuring different outcomes including operative time, blood loss, post-operative edema of the upper and lower eyelids, periorbital ecchymosis, patient discomfort and complication rates. PATIENTS AND METHODS The study included 20 patients with deformed nose associated with chronic rhinosinusitis (CRS) not responding to medical treatment for at least 3 continuous months, irrespective to sex, of ages 20-60, and without any systemic diseases (study group), and 20 patients with deformed nose without any sinus problems (control group). RESULTS There was no significant difference between the two groups in the different measured outcomes (P>0.05) except for the operative time which was significantly less in the control group (P<0.05). CONCLUSION Concurrent rhinoplasty and endoscopic sinus surgery may be performed safely and effectively with minimal risks. Proper patient selection and sound intraoperative judgment can avoid potential complications.

Allergic Rhinitis and its Impact on Asthma scores in asthmatic patients with and without allergic rhinitis

Background Allergic rhinitis and allergic asthma are chronic inflammatory conditions that frequently coexist, both with hallmark eosinophilia. Immunotherapy is an established treatment for allergic diseases. Noninjective routes for immunotherapy, such as the sublingual route, are thought to be valuable therapeutic options for respiratory allergy. Aim of the study In the present study, sublingual immunotherapy (SLIT) using multiple allergens was administered to allergic asthmatic patients with and without allergic rhinitis aiming to evaluate the clinical efficacy of and changes in allergen-specific antibodies during SLIT and its effect on control of asthma severity and nasal allergy scores. Patients and methods The study included 40 patients in two groups: group I included 20 asthmatic patients and group II included 20 patients with both proven bronchial asthma and allergic rhinitis. All patients were subjected to assessment of the status of asthma and hence its degree of control using the Global Initiative for Asthma (GINA) guidelines; patients received SLIT according to the results over a period of 1 year and were clinically reassessed monthly. In addition, for the recruited candidates, the initial total immunoglobulin E (IgE) levels were measured and pulmonary function tests were performed at the time of recruitment and repeated after 6 months and 1 year of the initiation of the course of SLIT. SLIT was stopped for asthmatic patients during acute exacerbation and resumed after complete asthma control. Results There was a statistically significant decrease in blood eosinophils but a statistically insignificant decrease in total IgE 1 year after SLIT in both groups. Results of specific IgE to food and inhalants revealed that there was statistically significant reduction in the number of allergens in both groups 1 year after SLIT. Results of the skin prick test revealed similar results. Our results revealed that the scores of, both Allergic Rhinitis and its Impact on Asthma and GINA had improved in all patients after 1 year of continuous therapy. Conclusion SLIT is a safe treatment strategy that significantly reduces symptoms and medication requirements and improves asthma control in both asthmatic patients with and without allergic rhinitis. SLIT using multiple allergens lowered the allergen burden in both asthmatic patients with and those without allergic rhinitis. Level of evidence 1b (Clinical Decision Rule tested within one clinical center).

Role of virtual bronchoscopy in foreign body inhalation in children

Objective To investigate the usefulness of three-dimensional images on the basis of multidetector computer tomography (MDCT) in the evaluation of suspected foreign body (FB) aspiration in children. Patients and methods A total of 28 children presented to Ain Shams University hospital with suspected FB inhalation. All patients underwent chest radiographs. Of the patients, eight with inconclusive history, physical examination, and negative radiograph findings for FB inhalation underwent MDCT. All patients underwent rigid bronchoscopy (RB) and the results were compared with the findings of chest radiographs and virtual bronchoscopy images. Results Four patients were negative by radiography and MDCT scan, and were subjected to RB, with no FB found. The other four patients who were negative by radiography turned out to be positive by MDCT and were subjected to RB, which was positive for FB in only 3 patients. MDCT had a negative predictive value of 100%, whereas its positive predictive value was 75%. Conclusion RB should always be performed as a first-line procedure in the presence of a combination of characteristic clinical and radiographic signs. In the other patients, the presence of FB can be confirmed by MDCT in order to reduce the negative RB rate.

Arterial Blood Supply of the Nose: An Angiographic Study

Objective: To define anatomical variations associated with arterial blood supply of the nose which has clinical implications on the management of different disorders, especially intractable posterior epistaxis. Study Design: Case series. Methods: Selective angiography of external and internal carotid arteries of 100 patients scheduled for routine angiography was done. Results: Different anatomical variations were documented. The ophthalmic artery can arise from the middle meningeal artery in 1% while ethmoidal arteries can be absent in 5%. The maxillary artery courses as 2 loops in the pterygopalatine fossa in 64% of cases where the descending palatine artery originates before the first loop or on its top so that caution is needed in controlling epistaxis. The sphenopalatine artery has different patterns of branching and may have more than 2 branches in 18% of cases. In 19% of cases, there is cross-circulation between both sides through the nasal blood supply. Conclusion: Angiographic study of the nose is a very helpful tool for accurate knowledge of anatomical variations of the arteries with a tremendous effect on our surgical approaches and techniques for the management of different diseases in the nasal region, especially intractable posterior epistaxis.

The transnasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhea from the lateral recess of the sphenoid sinus

Background Spontaneous cerebrospinal fluid (CSF) rhinorrhea from the lateral recess of the sphenoid sinus is surgically challenging. Sternberg′s canal has stirred great controversy as the potential source. The aim of this study was to present our experience with endonasal endoscopic repair, the possible etiopathology, and the outcomes. Study design This prospective study comprised 10 patients (seven female and three male) with spontaneous CSF rhinorrhea from the lateral recess of the sphenoid sinus, which was not related to trauma, previous surgery, tumors, irradiation, or meningitis. CSF rhinorrhea was confirmed with β2 transferrin test and high resolution CT scan (HRCT) and MRI cisternography. All patients were treated with the endonasal endoscopic conservative retrograde trans-sphenoidal approach. Results The mean BMI was 35.55 ± 2.84 kg/m 2 . Elevated intracranial pressure was present in all cases confirmed directly (with a mean intraoperative lumbar drain pressure of 27.5 ± 3.84 cm H 2 O), and indirectly [with the presence of primary empty sella (100%), arachnoid pits (30%), and attenuated skull base (40%)]. Osteodural defect was constantly present in the superior wall of the lateral recess, lateral to the foramen rotundum, none above the foramen rotundum or below the vidian canal orifice. The mean follow-up was 46.9 ± 8.26 months. Conclusion The endonasal endoscopic repair is a safe and effective method. The etiopathology is multifactorial. The management of elevated intracranial pressure is crucial. The potential source is not Sternberg′s canal but persistent cartilaginous vascular channels at the ossification center of the alisphenoid, cartilaginous precursor of the greater wing of the sphenoid bone.