Yasser A. Nour

Does laryngopharyngeal reflux affect healing and recovery after tonsillectomy

INTRODUCTION Laryngopharyngeal reflux is increasingly being implicated in several otolaryngological disorders. AIMS To study a potential correlation between pre-operative laryngopharyngeal reflux and wound healing and recovery after tonsillectomy, based on subjective and objective findings. MATERIALS AND METHODS A prospective, blinded study was undertaken, including 60 patients scheduled for tonsillectomy, divided into two equal groups: a study group (group A) with pre-operative laryngopharyngeal reflux documented using ambulatory 24-hour pH monitoring; and a control group (group B) without laryngopharyngeal reflux. RESULTS Group A had significantly higher pain scores on the seventh and 14th post-operative days (p = 0.022 and p = 0.000, respectively) and took a significantly longer time to return to normal eating (p = 0.013), compared with group B. Group A also showed significantly slower healing on the seventh and 14th post-operative days, as estimated by assessing the grade of post-operative slough formation (p = 0.016 and p = 0.029, respectively). A significant correlation between the number of pharyngeal reflux episodes and the degree of post-operative slough was also found. CONCLUSIONS Laryngopharyngeal reflux can significantly decrease wound healing following tonsillectomy. Therefore, pre-operative recognition and management of this condition is desirable in order to eliminate its negative post-operative effect.

Rhinoscleroma: An updated experience through the last 10 years

Abstract Conclusion: Rhinoscleroma is a chronic, specific, granuloma of the nose and other parts of the respiratory system. The disease is endemic in Egypt and many other countries. The causative organism is Klebsiella rhinoscleromatis bacillus, proved by fulfilling Kochs postulates. The mode of infection is not known and its worldwide irregular geographical distribution is not understood. Lines of treatment are unsatisfactory and a tendency for recurrence is the rule. Objectives: Our aim was to study the clinical presentation, microbiology, pathological staging, follow-up, and lines of treatment of new rhinoscleroma patients admitted or seen at Alexandria Main University Hospital from January 1999 until January 2009. Methods: Demographic data and the results of clinical, bacteriological, and histological examinations were reviewed. Medical and surgical treatments were evaluated. Follow-up as regards the results of treatment and incidence of recurrence was assessed. Results: Fifty-six patients were included in the study. There were 26 males and 30 females, and 85% of patients presented in the third and fourth decades of life. The nose was affected in 100% of patients. Other regions affected were the nasopharynx in 13 patients, palate in 7 patients, skin in 2 patients, larynx in 3 patients, trachea in 17 patients, nasolacrimal duct in 2 patients, and premaxilla in 1 patient. No lymph node affection was reported. Klebsiella rhinoscleromatis strain III was isolated from 100% of patients. Antibiotics used were a combination of trimethoprim-sulfamethoxazole 400 mg and rifampicin 300 mg twice daily for 3 months. Since 2003, this was replaced by ciprofloxacin 500 mg twice daily for 3 months. Surgical procedures performed were removal of nasal granulations, bronchoscopic dilatation, bipolar coagulation of skin lesions, tracheostomy, and repair of pharyngeal stenosis. Results were disappointing, as a large number of patients did not attend for follow-up. A high incidence of recurrence was found, reaching up to 25% within 10 years.

Temporalis Myofascial Flap for Primary Cranial Base Reconstruction after Tumor Resection

OBJECTIVE To evaluate the use of the temporalis myofascial flap in primary cranial base reconstruction following surgical tumor ablation and to explain technical issues, potential complications, and donor site consequences along with their management. DESIGN Retrospective case series. SETTING Tertiary referral center. PARTICIPANTS Forty-one consecutive patients receiving primary temporalis myofascial flap reconstructions following cranial base tumor resections in a 4-year period. MAIN OUTCOME MEASURES Flap survival, postoperative complications, and donor site morbidity. RESULTS Patients included 37 males and 4 females ranging in age from 10 to 65 years. Two patients received preoperative and 18 postoperative radiation therapy. Patient follow-up ranged from 4 to 39 months. The whole temporalis muscle was used in 26 patients (63.4%) and only part of a coronally split muscle was used in 15 patients (36.6%). Nine patients had primary donor site reconstruction using a Medpor((R)) (Porex Surgical, Inc., Newnan, GA) temporal fossa implant; these had excellent aesthetic results. There were no cases of complete flap loss. Partial flap dehiscence was seen in six patients (14.6%); only two required surgical débridement. None of the patients developed cerebrospinal leaks or meningitis. One patient was left with complete paralysis of the temporal branch of the facial nerve. Three patients (all had received postoperative irradiation) developed permanent trismus. CONCLUSIONS The temporalis myofascial flap was found to be an excellent reconstructive alternative for a wide variety of skull base defects following tumor ablation. It is a very reliable, versatile flap that is usually available in the operative field with relatively low donor site aesthetic and functional morbidity.

Deep Neck Infections of Congenital Causes

Objectives. To review cases of deep neck infections with underlying congenital etiology with special emphasis on their clinical presentations and the computed tomographic findings and to discuss the various therapeutic modalities employed for such lesions. Study Design. Case series with chart review. Settings. Alexandria University Hospital, Egypt. Subjects and Methods. The authors retrospectively reviewed the clinical, imaging, and operative records of deep neck infection cases presented to their department in the past 10 years. Deep neck infection cases due to congenital causes were included in the study. Results. Of the 249 cases of deep neck infections admitted to the authors’ department in the past 10 years, 39 patients were diagnosed with deep neck infections due to congenital causes. Patients were classified into 2 groups. In group 1 (29 patients), computed tomography revealed the presence of infected cystic swelling in the neck that was classified as second branchial cyst (16 patients), third and fourth branchial cysts (8 patients), and thyroglossal cyst (5 patients). Group 2 (10 patients) presented with recurrent attacks of deep neck infection with a history of incision and drainage several times. Radiological and operative findings revealed the presence of congenital pyriform fossa sinus. Conclusion. Computed tomography is helpful in diagnosing infected congenital cysts and its types. Infected congenital cysts could be excised completely under an umbrella of antibiotics. Recurrence of deep neck infections should alert the physician to the possibility of underlying congenital lesions. Thorough clinical and radiological assessment is mandatory to rule out the possibility of a congenital pyriform fossa sinus.

Helicobacter pylori infection and chronic, persistent cough: is there an association?

INTRODUCTION Chronic, persistent cough is a common clinical problem, the cause of which sometimes remains unidentifiable. AIMS To study a potential association between Helicobacter pylori infection and chronic, persistent cough. MATERIALS AND METHODS A clinical observational study with symptom analysis, including 162 patients whose main presenting complaint was chronic, persistent cough of unidentifiable cause (study group) and 42 patients with chronic, non-specific laryngopharyngeal manifestations not including chronic cough (control group). RESULTS Active H pylori infection was present in 86.4 per cent (140/162) of patients in the chronic cough group, as opposed to 45.2 per cent (19/42) of the control group, as confirmed by detection of H pylori antigen in stool specimens. This difference was statistically significant (p<0.001). There was a significant improvement of the chronic cough of 75.4 per cent (98/130) of patients after successful H pylori eradication using appropriate medical therapy (p<0.001). CONCLUSIONS Helicobacter pylori infection may lead to laryngopharyngeal irritation, with several clinical manifestations including chronic, persistent cough. However, the exact mechanism of this requires further research.

Endoscopic radical antrectomy: a permanent replacement for the Caldwell–Luc operation

INTRODUCTION Chronic inflammation of sinus mucosa is a multifactorial condition which sometimes results in irreversible pathological mucosal changes. AIMS To evaluate the efficacy of endoscopic radical antrectomy in treating chronic, hyperplastic, eosinophilic sinusitis, and to compare this procedure with classical endoscopic middle meatal antrostomy. MATERIALS AND METHODS A randomised, controlled trial with parallel design was conducted between July 2000 and December 2004, including 119 patients who fulfilled the clinical, radiological and histopathological criteria for chronic, hyperplastic, eosinophilic sinusitis. Patients were randomly allocated to two treatment groups: classical endoscopic middle meatal antrostomy and endoscopic radical antrectomy. The main outcome measures were recorded in each subgroup at the time of the patients last clinic visit. In each subgroup, these included subjective improvement and evaluation of the endoscopic appearance of the maxillary sinus. RESULTS Thirty-two per cent of patients in the endoscopic middle meatal antrostomy group were considered surgical failures, compared with 14.5 per cent of the endoscopic radical antrectomy group. This was statistically significant (p = 0.023). Unhealthy maxillary sinuses were significantly more prevalent in the endoscopic middle meatal antrostomy group (p = 0.029). CONCLUSIONS In those patients fulfilling the criteria suggestive of chronic, irreversible sinonasal pathology, primary endoscopic radical antrectomy was significantly better than endoscopic middle meatal antrostomy, based on subjective and objective findings.

Radical Resection of Fibrous Dysplasia Involving the Anterior Cranial Base

Background:Fibrous dysplasia (FD) is a non-neoplastic developmental disease of bone characterized by replacement of normal bone by immature bone and osteoid in a cellular fibrous matrix. FD affecting the cranial base is often challenging to treat because of the proximity to neurovascular and ocular structures. Methods:This is a retrospective study comprising 32 patients diagnosed with FD involving the anterior cranial base during a 9-year period. From these cases, 26 patients were surgically treated at the Department of Otorhinolaryngology, Alexandria University. The remaining 6 patients refused surgical treatment and were followed up. The follow-up period ranged from 1.5 to 9 years (mean, 4.6±2.1 y). Results:The most common symptoms were headache (75%), nasal obstruction (65.6%), and proptosis (59.4%). The most frequently involved bone was the ethmoid (93.8%), followed by the sphenoid (68.8%). Out of the 32 patients, 6 patients refused surgical treatment and were followed up. Among the 26 patients who underwent surgery, 15 underwent radical excision, and in the remaining 11 cases the resection was considered subtotal. None of the patients who had radical resection developed any regrowth of their lesions. Three of the 11 patients who had subtotal resection demonstrated radiologic evidence of regrowth. Conclusions:In most cases of FD involving the anterior cranial base, accurate preoperative radiologic planning and modern surgical techniques with immediate reconstruction allow an aggressive but definitive treatment with good functional and aesthetic results.