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   Table of Contents - Current issue
April-June 2022
Volume 28 | Issue 2
Page Nos. 103-188

Online since Wednesday, September 21, 2022

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Whisper test – Mass hearing screening programme Highly accessed article p. 103
MK Taneja, Megha Jain, Vivek Taneja, Sandip M Parmar
Aims and Objectives: To screen the school going mass for hearing loss and study its relationship with their academic performance and aptitude and compare it with pure tone audiometry and validate whisper test. Material and Methods: Procedure- Examiner stands arm distance (60cm) behind the patient. Mask the non-test ear by occluding the external auditory canal by continuously generating rubbing sound. The patient is explained to repeat the words. Test always started with consonants followed by vowels. If more than 80% were correct it was treated as passed. Results: In our study out of 86 students, 8 children failed in whisper test, but all passed in conversation test. In the present study performance was poor in failed students. The incidence of day dream, learning difficulty, inattentiveness was high with hearing impaired children. Conclusion: The whisper test is a simple effective diagnostic and mass hearing screening test which can predict an early hearing loss and if performed by a trained paramedical or social worker can differentiate in conductive, sensorineural, cochlear, and retrocochlear lesion. Since the whisper test does not require a qualified audiologist or otolaryngologist, it should be be a part of annual health check-up and national programme of prevention and control of deafness specifically hearing care in the elderly.
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Evaluation of the rate of tympanic membrane perforation in otomycosis Highly accessed article p. 107
Rajendra Kumar Teharia, Vikram Singh Rathore
Introduction: Otomycosis (OM) is an external ear infection of fungi and sometimes associated with tympanic membrane perforation (TMP). In this study, we analyzed and discussed the rate of TMP in otomycotic patients with no other associated pathology. Materials and Methods: In this prospective observational study, a total of 120 cases of OM were seen from August 2017 to April 2018 and microscopy with local cleaning was done. Fungal material was collected from all patients individually and sent for Gram staining and histopathological confirmation of fungus species and looked for TMP. Topical clotrimazole (1%) drops were given as empirical treatment with weekly microscopy and follow up to 12 weeks. Results: Eleven cases (9%) had tympanic perforation at the time of the first examination. In all cases with the TMPs, the causative organism was the Aspergillus species. Persistent TMP was present in 6 cases (5%). A total of three persistent TMPs required surgical intervention after 12 weeks. Conclusion: In OM, TMP is not infrequent and it requires careful examination especially under a microscope to identify it.
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Traumatic perforation of tympanic membrane: A prospective study in a tertiary care institute Highly accessed article p. 111
GM Puttamadaiah, PN Bhanuprakash, B Viswanatha, Kartik Irappa Patil, P Architha Menon
Introduction: Traumatic perforation of tympanic membrane (TM) is caused by increase in air pressure due to slapping, road traffic accident, blast injury, syringing, trauma by ear buds, etc., The incidence has been increased in recent times due to increased domestic violence and road traffic accidents. Hence, there is a need for early identification, evaluation, and management to reduce the morbidity. Objectives: The objective of the study was to describe etiologies of traumatic perforation of TM, to assess the findings of pure tone audiometry (PTA) among patients with traumatic perforation of TM, and to determine the outcome. Materials and Methods: This study was done between November 2017 and May 2019 in the department of ENT at Bangalore Medical College and Research Institute on 88 patients with traumatic perforation of TM who were subjected to otoscopic examination, tuning fork tests, and PTA. Patients were followed up on weekly basis. Results: Out of 88 patients, 33 patients (37.5%) were in the age group of 21–30 years. Fifty-four were males (61.36%) and 34 were females (38.63%). Slapping is the most common mode of injury with 50 (56.8%) patients. Left ear 55 (62.5%) was more commonly involved than right ear 33 (37.5%). Small perforation 55 (62.5%) was more common followed by medium-sized perforation 25 (28.4%) and large perforations were the least 8 (9.1%). Multiple quadrants were involved in 33 patients (37.5%). Posteroinferior quadrant was most commonly involved. Deafness (75%) was the most common symptom involving 66 patients. Average time taken for spontaneous healing was 37 days. Mean hearing improvement compared between hearing loss at the time of trauma and after 3 months was 13.18 ± 7.05 dB, which is statistically significant (P = 0.0001). Conclusion: Traumatic perforation of TM spontaneously healed in 80 participants (90.90%), whereas eight participants (9.09%) underwent surgery, i.e., tympanoplasty.
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The frenotomy efficacy in gaining weight of exclusively breastfed infant with ankyloglossia p. 116
Trimartani Koento, Susyana Tamin, Syahrial Marsinta Hutahuruk, Asti Praborini, Ervin Amouzegar
Background: Ankyloglossia, or tongue-tie, is a condition in which the tongue is attached to the floor of the mouth through the frenulum, causing limited tongue movement. Short frenulum variations cause reduced anterior tongue movement resulting in breastfeeding, swallowing, articulation, and orthodontics problems. These abnormalities in infants cause breastfeeding problems that affect infants' weight gain, malocclusion, and speech disorders. Frenotomy in infant ankyloglossia is performed if there are problems with breastfeeding, poor sucking, slow weight gain, and recurrent mastitis. With this indication, we need to observed the efficacy of frenotomy done before the age of 1 month, and the frenotomy done at 1-3 months old in gaining weight of exclusively breastfed infants with ankyloglossia. Materials and Methods: A observational retrospective cohort method from patient medical records in a private hospital in Jakarta, Indonesia. The research subject is a total sampling patient medical records secondary data and collected 68 subjects. The Subjects are divided into two groups, the first group was patients whose frenotomy was done before the age of 1 month, and the second group was patients whose frenotomy was done at 1-3 months old. We assessed the weight gain between the two groups. The data were analyzed and compared the percentage of weight gain before and after frenotomy. Results: The percentage of weight gain before and after frenotomy shows that in the first group, there was a percentage gain of 11.4% in body weight of the subjects and during post-frenotomy control, the percentage of weight gain in this group increased to 111, 4%. In the second group, the percentage of weight gain before the frenotomy was 70.6%, while the post-frenotomy control was only 57.7%. Conclusion: The study demonstrated the efficacy of frenotomy in gaining weight of exclusively breastfed infants with ankyloglossia. There was a significant difference in the weight gain of infants with ankyloglossia who underwent frenotomy at the age of exclusive breastfeeding, before the age of 1 month and between the ages of 1 to 3 months.
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Cone-Beam Computed Tomography Evaluation of Morphology and Orientation of Styloid Process and Prevalence of its Elongation in Age and Gender: An Institutional-Based Retrospective Study - A Dentist Perspective p. 119
S Priyadharshini, K Saraswathi Gopal, Srividhya Srinivasan
Background: Styloid process (SP) is a cylindrical, cartilaginous bone that projects downward, medially from petrous part of the temporal bone on right and left sides. There are variations noted in the SP which results in impingement on nearby vital structures and can cause annoying orofacial pain. Cone-beam computed tomography (CBCT) gives an accurate image without superimposition of adjacent structure. Aim: This study aims to investigate the three-dimensional orientation, length, and morphological variations of the SP using CBCT. Materials and Methods: One hundred and twenty CBCT images from the age of 20–60 years were retrieved and further divided into three groups (Group I, II, III). The length, anteroposterior angulation (APA), and mediolateral angulation (MLA) of styloid were measured along with its type of classification of elongation and calcification pattern were recorded. Statistical analysis was done using SPSS version 28. Results: In our study, the mean length, APA, and MLA of both right and left SPs were found to be 3.05 ± 1.1 cm, 31.7° ± 6.2°, and 67.3° ± 5.8°, respectively. 41.7% was the prevalence of elongation. No significant difference in prevalence, among age group observed. Type I and Type II classification of elongation was predominantly seen. Type B pattern of calcification was found to be statistically highly significant (P = 0.000) on both right and left sides. Conclusion: Diversity of SP in length, angle, and morphology can occur within individuals across populations and among gender; these variations need to be considered in symptomatic patients.
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Q10 and Tip Frequencies in Individuals with Normal-Hearing Sensitivity and Sensorineural Hearing Loss p. 126
N Devi, K Sreeraj, S Anuroopa, S Ankitha, V Namitha
Context: Cochlear plays a major role in providing fine-tuned frequency resolution of the sounds that were perceived. However, in the impaired auditory systems, this frequency resolution is affected, which indirectly leads to distortion in the perception of the sounds. However, the sharpness of tuning of a filter can be obtained from Q10 values and the shift in the tip frequencies of the psychophysical tuning curve can provide an estimate for the frequency resolution of the cochlea. Aim: This study aimed to estimate and compare the Q10 values and tip frequency between individuals with normal hearing and hearing loss. Subjects and Methods: A total of 92 ears were included for the study which was divided into two groups based on the hearing sensitivity. The psychophysical turning curves were obtained for 500 Hz, 1 kHz, 2 kHz, 4 kHz, and 6 kHz. The data on Q10 and the tip frequencies were statistically analyzed. Results: The results reveal that individuals with hearing loss have lesser Q10 values compared to individuals with normal hearing and this increased with increase in the test frequencies. Comparing the shift in the tip frequency between the two groups of individuals, the shift was toward the lower frequency which indicates it is an involvement of the outer hair cells. However, this study was limited only to those with mild flat sensory neural hearing loss. Conclusion: It could be concluded that Q10 and tip frequency measurement would be a valid measure for frequency resolution of the cochlea.
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Patient-Related long-term outcome measures after mastoid surgery at a tertiary care center of North India: A retrospective analysis p. 130
Sourabha Kumar Patro, Naresh K Panda, Ramya Rathod
Background: Long-term postsurgical follow-up in chronic otitis media (COM) is crucial in otologic practice for outcome assessment. Validated questionnaires for the same are robust alternatives when physical visits are not feasible such as the current COVID-19 pandemic and we present our findings of outcome assessment using COM outcome test (COMOT)-15 questionnaire through nonphysical mode. Materials and Methods: A retrospective analysis of a cohort of 112 patients of COM who underwent surgery by the single senior otology surgeon between 2009 and 2019 was done using COMOT 15 questionnaire through telephonic methods to circumvent the need of office visits. Results: Fifty out of 112 patients could be contacted and consented for the assessment and their COMOT-15 scores were obtained. The numbers of patients with any otologic symptoms and their need for consultations, except hearing loss were significantly less. One-third of the patients had mild to moderate residual hearing loss and its quality of life impacts, although the same neither was statistically significant nor required increased numbers of consultations. Conclusion: Bothering symptoms and the need for a frequent visit to the doctor is significantly less with adequate clearance of disease and mastoid obliteration in cases of canal wall down procedures. The residual mild-to-moderate hearing loss are not significant and manageable with day-to-day activities. Successful outcome of COM surgery needs long-term follow-up and evaluation by all practicing otologic departments and surgeons which can well be done through nonphysical modes in unprecedented situations like the current times.
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Preoperative and intraoperative evaluation of round window configuration during cochlear implant in children p. 135
Jyoti Singh, Jayant Prakash, Sarita Kumari Mishra, Shruti Jha, Rakesh Kumar Singh
Context: To establish a reliable factor for predicting the anticipated difficulty and adequacy of niche drilling without damaging the intracochlear structures during cochlear implant (CI) surgery. Aims: This study aimed to access the correlation of the distance from round window-to-vertical facial canal and round window to pyramid with the visibility of round window intraoperatively. Settings and Design: A prospective observational study of CI surgeries was conducted in the E.N.T. Department of Indira Gandhi Institute of Medical Sciences, Patna, from December 2019 to December 2021. The study included 30 children aged <5 years who presented to the E.N.T. OPD with prelingual deafness and were diagnosed with bilateral severe-to-profound hearing loss. Subjects and Methods: The preoperative high-resolution computed tomography images in the axial cut bone window setting at round window level were used to calculate the distance of round window-to-vertical facial canal and round window to pyramid on the RadiAnt DICOM Viewer. The intraoperative visibility was assessed through the recordings of the operation. Statistical Analysis Used: The data were analyzed using the MS Office 2019 Excel spreadsheet (Microsoft Corp., Redmond, WA, USA) and the program IBM SPSS 28.0.0 (SPSS Inc., Chicago, IL, USA). One-way analysis of variance was used. Results: A significant difference existed between round window and vertical facial canal distance measured preoperatively with the three categories of visibility of round window intraoperatively (P = 0.033), but a weak significant difference was found with the distance of round window to the pyramid with the visibility of round window (P > 0.05). Conclusions: Preoperative computed tomography measurement of the round window and vertical facial canal is a reliable predictor of a round window configuration that may aid in predicting the round window visibility.
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Ischemia-Modified Albumin Levels in Patients with Bell's palsy p. 139
Ahmet Adnan Cirik, Muhammed Fatih Evcimik, Gözde Ülfer, Türkan Yiğitbaşi, Öztürk Aktaş
Background: Although several causes have been regarded as possible including viral, autoimmune, inflammatory, and vascular ischemia, the accurate etiology and pathophysiology of Bell's palsy (BP) remain unclear. The aim of the present article was to determine whether serum levels of ischemia-modified albumin (IMA) are associated with BP and if there is a posttreatment change in IMA levels. Materials and Methods: This was a prospective study enrolling 23 patients (10 males and 13 females; mean age: 44.71 ± 16.72 years; and range, 20–57 years) and 23 healthy individuals (12 males and 11 females; mean age: 37.91 ± 9.16 years; and range, 9–73 years) as the control group. Blood samples were obtained from the antecubital vein from all of the volunteers. Albumin cobalt binding test was used to obtain the IMA levels. Results: The mean IMA level was 0.38 ± 0.06 absorbance units in the study group at the time of diagnosis, 0.35 ± 0.07 absorbance units at the posttreatment period, and 0.35 ± 0.06 absorbance units in the control group. IMA levels of patients in posttreatment period were lower than the onset of illness. The result was statistically significant (P = 0.01). Conclusion: The data demonstrate that IMA decreased in BP with treatment. This is a preliminary study and we could not obtain results that clearly support the ischemic hypothesis of pathogenesis of BP; we think it gives an idea for further studies.
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Correlation of eustachian tube dimension and chronic otitis media p. 144
Sherin Varghese, MK Goutham, Marina Saldanha, Rajeshwary Aroor, Raghuraj Uppoor, Vadisha Srinivas Bhat
Background: Eustachian tube (ET) is a dynamically intricate and poorly accessible structure connecting the nose and the middle ear. Although chronic otitis media (COM) is multifactorial disease, ET dysfunction is an important but overlooked predisposing factor. With newer evidence into the dynamics and prognostic factor in outcome of middle ear surgeries, it has become a focus of research. Our study aims to evaluate the various ET parameters using high-resolution computed tomography (HRCT) scan with multiplanar reconstruction technique. These parameters were compared between the diseased and normal ears to evaluate any association between the ET parameters and middle ear disease. Materials and Methods: It is a retrospective study of 66 HRCTs, with 47 HRCTs of COM and rest were controls. ET parameters including (a) ET-angle, (b) length, (c) pretympanic diameter, and (d) diameter at isthmus are measured accurately using HRCT temporal bone. Results: ET angle was significantly obtuse in COM group (154.81° ± 6.33°) when compared with the controls (149.99° ± 6.24°) with P < 0.001. Similar observation in ET angle was noted in diseased ear (154.54° ± 5.79°) in unilateral COM when compared with contralateral ear (149.56° ± 6.87°) (P = 0.001). ET was longer in COM group (3.44 ± 0.31) when compared with controls (3.4 ± 0.35). Pretympanic diameter and diameter at isthmus were greater in control group. Conclusion: The obtuse ET angle and narrow pretympanic diameter may contribute to the pathogenesis of COM. These measurements may be useful in the assessment of ET function preoperatively and might help in determining the surgical outcome. HRCT of temporal bone with multiplanar reconstruction is an effective tool to measure ET dimensions accurately.
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Congenital mastoid cholesteatoma of adult patient masquerading as complicated otitis media – A case report and literature review p. 149
Balaji Ramamourthy, Anurag Snehi Ramavat, Neemu Hage, Arun Govind
The study highlights the management protocol of a large mastoid cholesteatoma presenting with sudden-onset facial palsy mimicking a complicated otitis media and literature review. Congenital cholesteatoma may affect various regions of the temporal bone, the mastoid process being the least frequently involved. The diagnosis is often missed, specifically when the patient presents with features of mastoiditis. Radiology plays an important role in clenching the diagnosis. Congenital (mastoid) cholesteatoma manifesting with features of complicated otitis media is a rare occurrence and needs familiarity to facilitate early diagnosis and appropriate management.
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The importance of considering the minimum interaural attenuation value in the masking procedure of pure-tone audiometry p. 153
Mohd Normani Zakaria
In pure-tone audiometry (PTA) testing, air conduction (AC) and bone conduction (BC) thresholds are documented accordingly to obtain complete information on the hearing status. Nevertheless, due to the cross-hearing phenomenon, a masking procedure is typically implemented in PTA as an effort to obtain the exact (masked) AC and BC thresholds. As indicated by the respective masking rules, the decision to carry out the masking procedure is based on the “suggested” minimum interaural attenuation (IAA), which is 40 dB (for headphones), regardless of frequency. In this case report, the importance of considering the minimum IAA value based on research findings is highlighted. In particular, to produce more reliable PTA results, the masking procedure can be conducted by considering a lower IAA value (<40 dB).
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Palatal tic disorder causing objective clicking tinnitus in an 8 years old p. 156
N Manoj Kumar, Rajiv Ranganath Sanji, Srirangaprasad Krishnaswamy
Palatal tremors including myoclonus are well-known causes of objective tinnitus. Essential palatal tremors and tic disorders are recognized but rarer causes of objective pulsatile tinnitus. An 8-year-old boy presented with a chief complaint of clicking sounds in both the ears for 1 month, intermittent, occurs frequently in episodes, wherein intraoral examination revealed bilateral rhythmic, low frequency, symmetrical contractions of the soft palate muscles accompanied by clicking sounds audible to physician as well (objective tinnitus). The child's mother stated that the clicking sounds were not present when he was asleep. When the child was distracted by tuning fork sound, the palatal movements stopped. CNS examination, developmental history, birth, and growth history were all normal. Magnetic resonance imaging study with contrast enhancement was normal. The child was started on clonazepam and clonidine and follow-up was done after 1st and 2nd months. The tinnitus reduced but did not resolve completely. Clinical features of a patient with palatal tremor should be carefully assessed with prior knowledge of possible etiopathologies to guide the investigations and management. We highlight a case of palatal tic disorder to bring the possibilities quickly to the reader's mind.
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External ear canal osteoma presented as multilobulated mass with peripheral calcifications p. 160
Abdul Azim Al-Abrar Ahmad Kailani, Nik Adilah Nik Othman, Mohd Khairi Md Daud
External auditory canal (EAC) osteoma is a slow-growing benign tumor. It appears as a single, pedunculated hyperdense lesion. Most osteomas are asymptomatic and treated conservatively while surgery is reserved for symptomatic osteomas. Surgical excision of EAC osteoma is approached either endoscopically or microscopically by postauricular, endaural, or transcanal approaches depending on the site and size of osteomas. We report a case of external auditory osteoma presented with an atypical finding of multilobulated mass with peripheral calcification on computed tomography scan.
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Absent Stapedius Muscle and other Rare Congenital Ossicular Anomalies: A Case Series p. 163
Madhukar Upadhyay, Sunil Goyal
Conductive hearing loss due to ossicular anomalies is generally associated with external auditory canal dysplasia. Congenital ossicular anomalies in isolation are rare and often have a delayed diagnosis, particularly if unilateral. In such cases, the predominant symptom is conductive hearing loss and otosclerosis is usually the major differential diagnosis. We present a series of three cases of congenital ossicular chain anomaly. These patients were initially diagnosed as a case of otosclerosis. However, the diagnosis was revised based on intraoperative findings and managed accordingly.
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The presence of atypical auditory brainstem response waveforms in a child with normal hearing p. 167
Mohd Fadzil Nor Rashid, Mohd Normani Zakaria, Maziah Romli, Wan Najibah Mohamad, Mahamad Almyzan Awang
Auditory brainstem response (ABR) is an objective test typically carried out to estimate behavioral hearing thresholds among difficult-to-test children. The latencies of ABR waveforms are commonly used for hearing diagnosis. The available ABR normative data are utilized as guidelines by clinicians to identify the prominent peaks of ABR. In this paper, atypical ABR waveforms of a normal child were reported. Several useful points were highlighted from the present case report to guide clinicians to appropriately interpret the ABR results.
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“Itch” gratification-Insect polyembolokoilamania of the ear p. 171
Venkatesha Belur Keshavamurthy, K Ramya, Spoorthi Manjunath
Foreign body in the ear is one of the most common conditions encountered at the otorhinolaryngology outpatient clinic. Insects, especially live insects present as painful foreign bodies of the external ear. Insects that are most frequently recovered from the ear canal include ticks, bees, beetles, and cockroaches. We present the case report of a 17-year-old girl with recurrent right ear foreign body (live insect) five times in a span of 6 months. This recurrent presentation of the patient on the same side (right) led us to suspect behavioral abnormality. She was diagnosed to have mild intellectual developmental disorder with obsessive compulsive disorder and was treated accordingly. Behavioral problems must be ruled out in recurrent cases of unilateral foreign body ear.
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Facial nerve palsy - A rare and underrecognized neurological manifestation of rhino-orbito-cerebral mucormycosis with potential for misdiagnosis p. 174
Tarun Ojha, Priyanshi Gupta, Vaishali Kataria, Kanika Sharma
Rhino-orbito-cerebral Mucormycosis is a rapidly aggressive disease having various clinical presentation like facial pain, nasal stuffiness, headache, retro-orbital pain, orbital swelling, ophthalmoplegia and visual loss. Multiple cranial nerves can be involved, however facial nerve palsy has been rarely reported. We aim to highlight the involvement of facial nerve as a presenting symptom. Mucormycosis should be kept as a differential in these cases for rapid diagnosis and treatment initiation to provide a good overall outcome.
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A case of mastoiditis complicated with bezold abscess in the only hearing ear p. 178
Siang Poon Goh, Noor Dina Hashim, Faizah Mohd Zaki, Asma Abdullah
Bezold abscess (BZ) is defined as a deep neck abscess as the result of mastoiditis with mastoid tip erosion after otitis media (OM). Despite its rare occurrence due to the early intervention of ear infection with antibiotics, diligently looking for this complication is important, especially in the immunodeficient population. The utilization of radio imaging remains crucial in the management of acute OM with complications. The contrast-enhanced computed tomography facilitates the diagnosis and provides a glimpse of the disease extension. Early recognition and intervention are vital for a good outcome. The authors present a case report of a mastoiditis complicated with a BZ in the only hearing ear. The risk factors, presentations, and treatment options are discussed, along with the review of the literature.
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Otogenic cerebellar abscess with cholesteatoma p. 181
MK Vybhavi, V Srinivas, V Prashanth, Dechu Muddaiah, M Lavanya
Otogenic brain abscesses are the second-most common intracranial complication observed in patients of chronic otitis media, more frequently occurring with cholesteatoma. Due to the availability of antibiotics and advanced imaging techniques, the incidence and mortality of otogenic brain abscesses has reduced. Nevertheless, we still come across cases of otogenic brain abscess in modern times. Here, we report a case of the left ear chronic otitis media, squamosal type with intracranial complication of the left cerebellar abscess in a 14-year-old girl. Magnetic resonance imaging of the brain showed a thick-walled cystic lesion in the left cerebellar hemisphere measuring 41 mm × 28 mm × 26 mm suggestive of brain abscess. High-resolution computed tomography of the temporal bone showed soft-tissue density in the left mastoid air cells, in epitympanum, and mesotympanum encasing the left middle ear ossicular chain, suggestive of chronic otomastoiditis with possible underlying cholesteatoma. The patient underwent left retromastoid suboccipital craniotomy and excision of brain abscess followed by the left modified radical mastoidectomy 1 month later. Follow-up scan at 6 months showed no recurrence or any residual disease. Hence, timely surgical intervention for complicated chronic otitis media gives satisfactory results.
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Sudden sensorineural hearing loss in coronavirus disease-2019: Our experience p. 186
Meng Hon Lye, Carren Teh Sui Lin, Nik Adilah Binti Nik Othman
Coronavirus disease-2019 (COVID-19) is an ongoing global pandemic exerting considerable strain on the health-care system. Sudden-onset sensorineural hearing loss (SSNHL) among patients with COVID-19 had been reported sparingly in the literature. Hearing loss can be easily overlooked in intensive care settings and establishing diagnosis can also be challenging. Proposed causes include injury to inner ear structures, cochlear nerve, or auditory brainstem. Prompt diagnosis and treatment is recommended to avoid long-term morbidity. All patients presenting with sudden-onset hearing loss should be screened for COVID-19. Here, we report a case of COVID-19 patient with SSNHL and how the hearing level is determined.
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