Objective Perilymph leak is considered a major complication of cochlear implantation (CI) surgery and can lead to surgical difficulties and postoperative morbidities. This study is aimed to formulate an algorithm for better management of perilymph leak in cases of CI.Methods This is a retrospective study conducted in our tertiary institute on pediatric patients with perilymph leak during CI surgery from January 2017 to January 2023. Standard facial recess approach and round window cochleostomy were used in all cases. The clinical data, imaging, details of surgery, management of perilymph leak, and outcome were revised.Results One hundred and fourteen cases of perilymph leak out of 1035 cases of CI surgery (11.1%) were collected. In 108 cases, an oozer was encountered, while in 6 cases a severe gusher occurred. Their ages ranged between 2 and 15 years, with 74 male patients. Our algorithm for control of the leak during surgery included elevation of the head, hyperventilation, mannitol, steroids, and wait until the flow of the gusher decreases. Widening of the cochleostomy, use of an electrode with cork, and muscle packing were also helpful in control of the leak. In severe cases, subtotal petrosectomy was adopted with fat obliteration. All cases were managed properly with our algorithm. Only two cases had persistent leak postoperatively and were managed conservatively without need for revision surgery nor lumbar drain.Conclusion In CI surgery, proper prediction, diagnosis, and systematic management of perilymph leak including nonsurgical and surgical methods are crucial for better and safe outcomes.Level of Evidence Level III.

Vestibular compensation (VC) represents a remarkable aspect of neuroplasticity, showcasing the brain’s ability to adapt to disruptions in balance and spatial orientation caused by various vestibular disorders. This extended review provides a comprehensive overview of the mechanisms underlying VC, focusing on the distinct challenges posed by unilateral and bilateral vestibular disease. By examining the pathophysiological processes associated with these conditions, we gain critical insights into how the central nervous system employs adaptive strategies to restore functional balance. Additionally, this review underlines the multifaceted nature of VC, which emphasizes the necessity for personalized approaches in treatment, as not all patients will respond similarly to therapeutic interventions. Advancing our understanding of VC enriches the field of neurorehabilitation and holds significant promise for improving the quality of life for patients affected by vestibular disorders. By continuing to explore the intricate mechanisms of compensation and the factors that influence recovery, we can enhance our approaches to diagnosis, treatment, and rehabilitation. This will ultimately lead to better patient outcomes and a deeper comprehension of the brain’s remarkable adaptability in the face of vestibular challenges. The journey toward improved care for individuals with vestibular disorders is ongoing, and it is imperative that we remain committed to research, education, and innovation in this vital area of medical science.

Tracheostomy in pediatric age group is associated with many challenges, difficulties and complications which are in inverse proportion with child age at time of tracheostomy. We conducted this study to assess pediatric tracheostomy in the first year of life in terms of indications, complications and outcomes. This retrospective study was conducted from January 2011 to January 2021 on pediatric patients undergoing tracheostomy in the first year of life and followed up for 36 months. We reviewed their clinical data, age, sex, indication of tracheostomy, intraoperative and postoperative complications and decannulation. 112 patients were included. Their ages ranged first day to 12 months and 45

Background: Laryngeal carcinoma is not uncommon worldwide. We conducted this study to comprehensively compare the outcome of stapler versus conventional suturing in total laryngectomy primary or salvage.Patients and Methods: This is a retrospective study conducted in our tertiary institute from 2015 to 2022 involving patients diagnosed with laryngeal carcinoma who underwent total laryngectomy either primary or salvage. We divided patients into 4 groups: primary or salvage laryngectomy, closed with stapler or manual suturing. The reported outcomes included : operative time, length of hospital stay, start of oral feeding, incidence of pharyngocutaneous fistula, positivity of surgical margins, and surgical site infection. Patients with multiple comorbidities and those requiring a flap for pharyngeal closure were excluded .Results: A total of 91 patients were included in our study. Pharyngocutaneous fistula rate was 19% in conventional patient group in comparison to 6.7% in stapler group for primary total laryngectomy while it was 12.5% for salvage with stapler and 25% for salvage with conventional. Hospital stay was 6 +/- 1.5 days for stapler and 11.4 +/- 2.9 days for conventional suturing in primary laryngectomy. It was 8.8 +/- 1.3 days for stapler and 13.1 +/- 1.8 for conventional suturing in salvage laryngectomy. There was highly significant difference found as regard mean operative time, start of oral feeding and hospital stay in favor of stapler use.Conclusion: Stapler use in total laryngectomy is is a simple, fast, and effective technique with tension free watertight closure, better hemostasis, less contamination of surgical field than manual suturing

OBJECTIVE:This study is to evaluate the results obtained in a group of implanted otosclerotic patients and compare them with a matching group of non- otosclerosis cochlear implant patients. METHODS:Pre-operative computed tomographic scans, intra-operative findings, type of electrode used and difficulties of 17 patients with otosclerosis were documented. Post-operative complications, facial nerve stimulation, electrode dislocation and audiological and speech outcomes were documented and the data analysed. RESULTS:Surgical difficulties were directly related to the advanced stage of the disease. No major complications were reported in this cohort. No significant difference was found between both groups one year after surgery; the mean pure tone average was 35 dB ± 4.43, speech reception threshold was 40 ± 4.96 and speech discrimination score was 80 per cent ± 12.55 in the otosclerotic group. CONCLUSION:Cochlear implantation is a safe and effective management for advanced otosclerosis patients even after stapes surgery.

Surgery for cochlear implantation is becoming increasingly common. It is a precise surgery and carries with it a number of very specific complications. Although uncommon, they can profoundly affect the recipients’ quality of life. We report on our patients’ population and compare with different series. This is a retrospective analysis of patients who underwent cochlear implant surgery in our center or who were referred for management of complications between November 2012 and November 2022. There were 2126 patients aged 9 months-68 years [mean 3.2 yrs] with 147 adults > 18 yrs. The male: female ratio was nearly 1. We are reporting on late complications excluding device failures. There were 186 complications [8.7

The objective of this consensus is to provide otolaryngologists with appropriate strategies in the management of external auditory canal (EAC) carcinoma. In the absence of randomized controlled trials, the consensus is based on expert opinions utilizing the Rand/UCLA appropriateness method [Fitch and Aguilar in The RAND/UCLA appropriateness method user's manual, RAND Corporation, Santa Monica, CA, 2001], drawing from existing literature and clinical experience. The management recommendations are structured around 12 key areas, including: definition and pathology, pathogenesis, clinical manifestations, work-up, tumor staging system, surgical management of primary tumor, surgical management of the parotid gland and the temporomandibular joint, lymph node metastasis, radiotherapy, chemotherapy, reconstruction, and follow-up. Management strategies for EAC carcinoma rely on tumor extension and histopathological features. Surgical removal with free surgical margins or combination with radiotherapy, chemotherapy are most often the best options. Given the rarity of the disease, prospective, randomized, multi-institutional clinical trials should be designed to enable reliable comparisons of the outcomes of EAC carcinoma treatments, thereby providing evidence-based clinical data to establish widely accepted guidelines. It emphasizes the need for a multidisciplinary team to be involved in the management of EAC carcinoma, and regular follow-up should be implemented postoperatively.

BACKGROUND:The aim of this study was to survey the knowledge and treatment management practices for single-sided deafness (SSD) among different subspecialties of otolaryngology. METHODS:A questionnaire was sent via Google Sheets to members of the Turkish and Egyptian Otorhinolaryngology Societies between December 2021 and February 2022. For the statistical analysis, the respondents were divided into 3 groups as otologists, non-otologists, and residents at the department of otolaryngology-head and neck department. RESULTS:There were no statistically significant differences between otologists and non-otologists in radiological imaging (child P = .469, adult P = .140) and preferred treatment method (child P = .546, adult P = .106). However, otolaryngologists showed significant differences in radiological evaluation (P <.001), vestibular evaluation (P = .000), and frequency of treatment options recommended for pediatric and adult SSD patients (P = .000). CONCLUSION:There were no significant differences in SSD diagnosis, treatment, and rehabilitation between otologists and non-otologists. However, when comparing pediatric and adult patients, there was a difference in the treatment management of SSD patients.

OBJECTIVE:Identify the prevalence of syndromes in a cohort of patients who underwent cochlear implantation, to report on the presence of inner and middle ear malformations and highlight the surgical difficulties encountered. STUDY DESIGN:Observational, retrospective study. SETTING:Tertiary referral children's hospital pediatric cochlear implant program. MATERIAL & METHODS:An IRB-approved retrospective chart review of children undergoing cochlear implantation at a tertiary academic medical center, from 2018 to 2023. Preoperative imaging data of syndromic patients in that cohort with special attention to the presence of inner ear or middle ear malformations were collected. Abnormal intraoperative findings and difficulties reported by the surgeons were also noted. RESULTS:1024 children were unilaterally implanted for bilateral profound hearing loss. There were 45 cases diagnosed with associated syndromes (4.3%). The commonest syndromes were Jervell and Lange Nielsen (JLN) syndrome followed by Waardenberg syndrome (WS), in a prevalence of 34% and 32% respectively. These syndromes had no associated inner ear malformations (IEM). Less common syndromes included Branchio-oto-renal (BOR) syndrome, CHARGE association and Treacher Collins syndrome, 3 cases each, and keratosis icthyosis deafness syndrome (KID), Usher syndrome and Albino, 2 cases each and an H syndrome case. There were 9 cases (20%) with IEM, with 6 cases of perilymph gusher. Two cases had middle ear anomalies and one case had a facial nerve course abnormality. The outcome of these cases was similar to non-syndromic cases. CONCLUSION:Children with syndromic HL should be dealt with on a case by case scenario to diagnose inner and middle ear malformations. Additional disabilities can affect the rehabilitation procedures. All children with congenital hearing loss should undergo pediatric, cardiologic, ophthalmologic and nephrologic examination in order to exclude the syndromic etiology of hearing loss.

BACKGROUND:Conventional radiological evaluation does not evaluate the functional status of the auditory pathway in patients scheduled for cochlear implantation (CI).OBJECTIVES:Determine the value of diffusion tensor imaging [DTI] in the preoperative evaluation of some patients scheduled for CI.MATERIAL AND METHODS:Patients with profound SNHL and inner ear and/or cochlear nerve anomalies or long standing SNHL were selected. They underwent conventional MRI images of the brain in three orthogonal planes, MR arterial spin labelling (ASL), perfusion, and DTI auditory tractography to determine functional status of the auditory pathways.RESULTS:Ten patients were included. Seven with bilateral SNHL, one with fluctuating hearing loss and one with long standing single sided deafness. In 8 patients the auditory pathway could be traced and functional maps could determine the side of possible better function. In the patient with progressive hearing loss DTI revealed major central pathway problems and CI was discouraged. In the patient with SSD, DTI revealed a robust intact pathway and CI was advised.CONCLUSIONS:DTI and auditory tractography can help in outlining the functional integrity of the 33auditory pathway and assist in decision making before CI.

BACKGROUND:This study aimed to evaluate the role of landmarks for proper round window electrode insertion in cochlear implantation surgery.METHODS:This is a case series study. We included 150 patients undergoing cochlear implantation in a tertiary medical center during the period from January to December 2019. Patients with inner ear malformations or ossification or revision surgery were excluded. Three surgeons partici- pated in the study. During surgery, the round window electrode insertion was marked using 5 surgical landmarks: oval window, pyramid, fustis, round window membrane, and arborization of intracochlear blood vessels. Each surgeon reported on the identification of each landmark and its reliability for round window electrode insertion.RESULTS:Oval window and round window membrane were clearly seen by the 3 surgeons in all cases. Pyramid was seen in 94% of cases, fustis in 85%, and intracochlear wall in 90% of cases. The postoperative transorbital x-ray confirmed the intracochlear position of electrodes in all cases.CONCLUSION:Round window electrode insertion can be precisely performed using these 5 surgical landmarks in straight forwards cases as well as in difficult cases. These landmarks can also assist in teaching young surgeons, in a step-wise manner, how to properly do round window electrode insertion in cochlear implantation surgery.

Hypothesis To characterize transcanal endoscopic landmarks of the medial labyrinthine wall and correlate these with anatomical features of the fundus of the internal auditory canal (IAC). Background The transcanal transpromontorial approach (TTA) enables minimally invasive access to the IAC. The establishment of a landmark-based dissection technique for the approach is crucial to avoid injury to the facial nerve. Methods Twenty temporal bones were dissected endoscopically through the TTA. Furthermore, high-resolution computed tomography (CT) scans from ten adult normal temporal bones were analyzed and three-dimensionally reconstructed. Results A stepwise dissection technique for the TTA was demonstrated depending on a newly described landmark used in the identification of the facial nerve. The proposed landmark, which was named the intervestibulocochlear crest (IVCC), is an integrated part of the otic capsule. It can be differentiated after the excision of the lateral labyrinthine wall as a laterally based bony pyramid between the cochlea and the vestibule. Its medially directed apex blends with the central part of the falcifrom crest and points to the distal part of the meatal facial nerve. The IVCC is best detected on axial CT images at the level of the tympanic facial nerve. The union between the IVCC and the falciform crest appears radiologically as a short stem or mini-martini glass. Conclusion The proposed IVCC is a novel landmark with a consistent relationship to the IAC fundus and the facial nerve. It may be utilized in conjunction with the falciform crest to identify the facial nerve during minimally invasive transcanal surgeries.

Purpose Gestational SARS-Cov-2 infection can impact maternal and neonatal health. The virus has also been reported of causing sensorineural hearing loss. The objective of this study was to determine the possible effect of maternal SARS-COV-2 infection on neonatal hearing as identified during universal hearing screening. Methods Retrospective cohort study in two tertiary referral centers including all neonates born from November 2020 through April 1st, 2021 and undergoing the universal hearing screening program. Maternal Covid-19 infection was recorded (timing and severity) and the results of hearing screening of their neonates compared to the incidence of neonatal hearing loss results of the national universal screening program during the same period. Results A total of 984 neonates were included (508 males and 476 females). Sixty-three neonates were excluded due to comorbidities which could cause hearing loss. The incidence of failed responses in the community at large was 2.3%. Twenty-seven failed both steps of screening (2.9%; p < 0.2). There were 34 Covid-19 positive mothers (17 in the first trimester, 8 in the second and 9 in the third). Twenty-nine neonates failed the first screening ( p < 0.00001) but on further testing only one neonate failed (2.9%). Conclusion In this study, neonates born to Covid-19 positive mothers do not seem to have an increased risk of hearing loss. However longer follow-up of these neonates is mandatory to detect any possible delayed effects of the virus.

Introduction Epistaxis is a common presentation among children. Objective To investigate the suitability of a simple tool of assessment for patients with epistaxis that could guide in subgrouping those with possible bleeding tendencies who may need further assessment. Methods Children who presented to a tertiary outpatient clinic with epistaxis of an unknown cause were recruited. They underwent thorough clinical assessment and answered the pediatric bleeding questionnaire and the epistaxis severity score. All patients underwent complete blood count as well as coagulation profile, and confirmatory diagnostic tests were performed as needed. Results Among the 30,043 patients who presented to the outpatient clinic over a year, 100 children had epistaxis, with an estimated annual frequency of 1 in 300. A total of 84% of the patients were younger than 12, and nearly half of these were younger than 6 years. Seventy-six patients had recurrent epistaxis, and 12 had systemic comorbidities. A significant higher percentage of patients presented with epistaxis in the hot months of the year. A total of 90% of the patients presented anterior bleeding, and the majority were treated with nasal compression only. Forty-three patients presented with epistaxis only; 37 of them were diagnosed as idiopathic epistaxis, and 6 had local causes. Fifty-seven patients presented with other bleeding manifestations, 47 of whom had a definite bleeding disorder and the other 10 had undiagnosed bleeding tendency. Those with other bleeding manifestations showed a higher frequency of positive family history of epistaxis; of being referred from a primary care physician; of having alarming low platelet count, and of presenting less seasonal variability. A bleeding score ≥ 2 showed significant value in suspecting an underlying systemic pathology as a cause of epistaxis. Conclusion The pediatric bleeding questionnaire is a useful and simple tool in the identification of pediatric patients who need further diagnostic testing to detect any underlying bleeding tendency.

Objectives: The aim of this work was to assess the type and site of the 35delG gene mutation in patients presenting with profound SNHL and scheduled for cochlear implantation. The secondary objectives were to determine their geographical distribution throughout Egypt, screening of the parents for the mutation, and to correlate the type of mutation with clinical severity and outcomes after surgery. Methods: The study was carried out on 100 consecutive patients scheduled for cochlear implantation. Patients with syndromic hearing loss or noncongenital hearing loss (trauma, infections, and ototoxicity) were excluded. All patients were subjected to detailed history taking including geographic tagging for their origins in Egypt, imaging (CT and MRI cochlear implantation protocols), full audiological evaluation (PTA, ABR, and TEOAE), and genetic screening for GJB2 mutation using Invitrogen PCR mix and ApaI restriction enzyme (North America, CA, 10572-014). The parents of mutation-positive patients were also subjected to audiological and genetic analysis. All patients were subjected to postimplantation evaluation of hearing after 6 and 12 months. Results: There were 64 males and 36 females from 98 families. Ages ranged between 1.9 and 7 years (mean 3.72 years). They originated from all over Egypt but the majority came from the Giza and Cairo areas. The 35delG mutations were found in exon 2 in 31% of the cases and all were heterozygous. In the parents, 18 mothers and 13 fathers were positive but only 8 had mild to moderate SNHL. Hearing evaluation by pure tone and speech discrimination scores at 6 and 12 months showed that the 35delG children had a statistically better result compared to the children without this mutation. Conclusion: The prevalence of the 35delG mutation in nonsyndromic children in this sample was 31% which is different from previous studies in the Egyptian population but close to the values found in other populations in the Mediterranean basin.

Background: Preoperative radiological prediction of the round window niche configuration. Methods: Fifty patients were evaluated. A single-axial high-resolution computed tomography image at the level of the cochlear aqueduct was compared to the intraoperative surgical images. Radiological configuration was classified as open, hooded, or covered depending on the extent of bony overhang. Surgical images were processed using Image J software to determine the amount of drilling required before the round window membrane is exposed. These images were classified according to the St. Thomas classification into 3 grades. Results: In all patients, the axial cut showing the cochlear aqueduct was obtained. There were 12 cases in the open category, 17 in the hooded category, and 21 in the covered one. Intraoperatively, the actual findings were type I 12, type II 18, and type III 20. The correspondence between the expected and actual classification was correct in 8, 12, and 18 cases, respectively. Comparing the intraoperative findings with the expected radiological configuration, there was a good concordance with a statistically non-significant difference ( χ2 = 0.2613; P = .87751). Conclusion: It is possible to predict the configuration of the round window niche on a single-axial computed tomography cut and plan the most suitable axis of approach and predict the amount of drilling expected to expose the round window membrane.

Allergic fungal rhinosinusitis (AFRS) is a common disorder with a high prevalence and a very high incidence of recurrence. Management includes surgery and medical treatment in the form of local and/or systemic steroids. However, some cases are resistant to the action of steroids and further treatment is warranted. Being an immune-mediated disorder, targeting IgE seems a logical step. Immunotherapy drugs acting on the IgE (e.g. omalizumab) can modify the clinical course of the disease. This study aimed at evaluating the effect of omalizumab on the clinical course of patients undergoing surgery for AFRS. This is a two-arm prospective, randomized, single blind clinical trial among patients with AFRS. Twenty patients were included and randomly divided into two groups: Group A; 10 patients received a single subcutaneous injection of omalizumab (Xolair ‘ Novartis) (150 mg) 2 weeks postoperatively. Group B: 10 patients received local steroids nasal sprays (budesonide or mometasone furoate, 100 μg twice daily for 6 months, starting 2 weeks postoperatively. All patients underwent history, examination, CT scan and IgE level estimation and were submitted to endoscopic sinus surgery. They were evaluated at 4 weeks interval for 6 months. In both groups there were highly significant differences between pre/post-operative SNOT-20 scores, TNSS scores, total IgE level and Philpott–Javer staging scores. Comparison between the two study groups at 24 weeks showed a highly significant difference (p = 0.001) between post-operative SNOT 20 and TNSS scores in favour of group A. There was no statistically significant difference between the two study groups as regarding postoperative total IgE or Philpott–Javer scores. There were two recurrences in both arms, but no significant side effects. We compared a single post operative injection of omalizumab with twice daily intranasal steroid spray for 6 months. Both treatments were effective, but the omalizumab group showed a more significant clinical and endoscopic response. There were no significant side effects in both arms. This novel approach used a single low dose injection of omalizumab increased the compliance of the patients with minimal complications. Longer follow-up of the patients is ongoing to determine the optimal time for re-injection. The only downside was the higher cost of omalizumab compared to that of local steroids.

Cerebrospinal fluid (CSF) rhinorrhea is not an uncommon condition, and it may lead to recurrent attacks of meningitis. The detection of the leakage site is an essential part of the investigations performed for the patient. In some cases, an anterior skull base site cannot be detected despite continuous leakage. In these cases, a more distal site must be sought. Furthermore, in some cases, the leakage occurs in the temporal bone. In such patients, a history of hearing loss or previous ear complaints indicates a hidden CSF otorhinorrhea. We present two adult cases of congenital hearing loss due to unilateral inner ear anomalies who presented later in life with repeated meningitis attacks and CSF otorhinorrhea.

Background: Allergic fungal rhinosinusitis (AFRS) is due to the continuous exposure of fungal antigens to an atopic individual. It is caused by type I, IgE mediated (and possibly type III) hypersensitivity reaction to an extramucosal fungal antigen. Medical treatment following the surgery is the standard protocol of management. Steroids (systemic/topical) have been considered as the standard medical treatment for control of the disease despite high recurrence rate and their serious side effects. Instead, omalizumab, a humanized monoclonal anti-IgE antibody, can be tried as a new treatmentmodality with less side effects to control symptoms and decrease the recurrence rate in AFRS patients. It acts by aborting the immunological reaction to sinonasal fungi through preventing the release of inflammatory mediators that cause allergic signs and symptoms. Aim: To evaluate the role of omalizumab for postoperative management of AFRS patients in comparison to topical steroids as regarding symptom free interval and side effects. Patients and methods: A total of 20 patients with AFRS were included in the study. Patients were divided randomly into two equal groups: group A used local steroid and group B used single dose of subcutaneous omalizumab. Clinical parameters were compared at 4,8,12 and 24 weeks. Results: Although there was no statistical significant difference between both groups as regards endoscopic nasal examination posttreatment, patients of group B were statistically better as regards clinical and subjective parameters.Conclusion: We suggest that omalizumab has more superior effect than local steroids in controlling nasal symptoms in AFRS patients despite the same endoscopic scores post-treatment. More well-designed large prospective randomized controlled trials to determine the effects and optimal dosage and duration of omalizumab therapy in patients with AFRS will be necessary.