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Introduction: A common childhood disease known as otitis media with effusion (OME) is described as the presence of fluids in the middle ear without any features of an acute ear infection. OME in the pediatric age group often leads to manifestations of hearing loss and speech delay. Methods: The search for recent research articles on managment of otitis media with effusion was done with databases scopus, pubMed, medline, and google scholar. This review article discusses the epidemiology, etiopathogenesis, clinical features, and current management of OME in children. Results: Nasal balloon auto-inflation appears to be a promising technique with some benefits in selected cases of OME. Insertion of grommets or ventilation tubes in pediatric patients with OME and hearing impairment is helpful in case of failed watchful waiting. Grommet insertion is usually effective in restoring hearing thresholds. Adenoidectomy can be performed in addition to grommet insertion in children of OME with adenoid hypertrophy. A combination of ventilation tubes and adenoidectomy is broadly helpful to normalize the hearing and increasing nasal patency. Early treatment of OME is helpful to improve the quality of life and social and educational performance. Neither medical treatment nor complementary or alternative treatment has been proven for giving effective treatment of OME. In children of OME with hearing impairment benefit through the effective restoration of hearing by insertion of ventilation tubes (grommets). Adenoidectomy is helpful in the case of persistent OME. Conclusion: The combination of ventilation tubes and adenoidectomy in children with OME is beneficial in terms of hearing, respiratory, and development of the children.

Background: Otitis media with effusion, a typical condition characterized by fluid in the middle ear area, has a significant negative influence on both the health and economy of the entire world. In children, hearing loss brought on by otitis media with effusion can hinder the development of language and conduct. This study aimed to assess how local dexamethasone affects human tympanic membranes' ability to resist myringosclerosis brought on by ventilation tubes. Patients and Methods: This prospective case-control study was conducted at Benha University Hospital, on 50 patients of both sexes and different ages complained of hearing loss due to persistent otitis media with effusion that has been resistant to therapy for nearly three months. The patients were subdivided into two equal groups: 25 patients were participants in group (A), which underwent myringotomy with breathing tube insertion only. 25 patients were participants in group (B), who had myringotomy, breathing tube insertion, and local dexamethasone instillation. Results: As far as myringosclerosis was concerned, there was no statistically significant variation between the two groups (P-value > 0.05). As determined by the quadrants under otomicroscopic examination, there was a significant variation between the two groups (P-value < 0.01) in relation to myringosclerosis findings. The histopathological assessment of myringosclerosis revealed a significant variation between the two groups with regard to the condition's symptoms (P-value < 0.01). Conclusion: Topical dexamethasone use may be helpful in avoiding the development of myringosclerosis. Dexamethasone's anti-inflammatory and immunosuppressive properties may be responsible for this impact. [ABSTRACT FROM AUTHOR]

Background: Otitis media with effusion is a collection of fluid inside the middle ear cleft, treatment of this condition include medical and surgical methods. This research goal is to focus and specify the clinical features of OME and the association between the new staging and the postoperative findings after surgery of insertion of ventilation tubes (VTs). Objectives: The objective of the study was to assess postoperative sequelae after VT insertion in children. Patients and Methods: Thirty two children with OME with surgical insertion of short term ventilation tubes were included in this study and followed up for one year. Results: In 22 patients, the fluid aspirated surgically after myringotomy was serous, whereas 10 patients were mucinous; for the patients, 53.12% had recurrence, whereas 46.88% showed no recurrence of OME. Only 6.25% of cases included in this study developed myringosclerosis; no otorrhea was reported during the period of the presence of VT in the tympanic membrane, no persistent tympanic membrane perforation after VT auto-extrusion. Conclusion: Even though VT have shown to be very useful in solving conductive hearing loss, its efficacy is a matter of debate in preventing long-term poor effects of the tympanic membrane and delayed onset of hearing loss. Even though ventilation tubes have shown to be very useful in solving the problem of conductive hearing loss.

Otitis media with effusion is one of the most commonly encountered diseases by otolaryngologists. Hearing loss is the most common symptom, particularly affecting academic performance in school-age children. Therefore, establishing an accurate diagnosis is crucial. The primary diagnostic method is an otoscopic ear examination. Tympanometry is the most frequently used technique for diagnosis. In this study, we aimed to compare the results of tympanometric examinations with intraoperative findings. Our study included a total of 126 patients with a diagnosis of chronic otitis media with effusion and a decision for surgery, comprising 224 ears that were followed by our clinic. All patients underwent at least one myringotomy. Ventilation tubes were inserted in cases of glue ear. Preoperative physical examination and tympanometry results were compared with intraoperative findings. Of the 126 patients, 81 were male. The mean age was 5.3 years (range: 2-15). Preoperatively, 135 ears exhibited Type B tympanogram, and 89 ears exhibited Type C tympanogram. The rate of tube insertion was statistically significant in cases with type B tympanogram. Additionally, the tube insertion rate was determined to be 32.5% in cases with Type C tympanograms. In conclusion, diagnosing effusive otitis media is a crucial matter. While physical examination is the most important diagnostic tool, it may sometimes be insufficient. Tympanometry is a highly useful method for improving the diagnostic rate of this condition. [ABSTRACT FROM AUTHOR]

This study examined the effects of different types of tympanostomy tubes in pediatric patients undergoing cleft palate (CP) surgery in order to provide guidance for the proper insertion of tympanostomy tubes in the management of otitis media with effusion (OME). A total of 101 ears with middle ear effusion in 51 patients with CP were included in this study. Patients underwent palatoplasty and tympanostomy tube surgery at the same time. The type of tube inserted (Paparella type 1 or 2), the severity of CP, and types of palatoplasty surgeries were investigated. All patients were followed up for at least 6 months, and recurrence rates, complications, and reinsertion surgery were evaluated. The rate of OME recurrence after spontaneous tube extrusion was significantly higher in the type 1 group than in the type 2 group (44.3% vs. 19.4%, respectively, p = 0.016). Persistent eardrum perforation was more common in the type 2 group than in the type 1 group (41.9% vs. 12.9%, respectively, p = 0.001). The tube reinsertion rate was higher in the type 1 group than in the type 2 group (22.9% vs. 3.2%, respectively, p = 0.015). The tube reinsertion rate decreased to 8.6% in cases of palatoplasty with Sommerlad's technique, even with type 1 tube insertion, which was not significantly different from the reinsertion rate in the type 2 group (3.7%, p = 0.439). The Paparella type 1 tube would be a better choice in cases of palatoplasty performed using Sommerlad's technique, particularly considering the higher rate of persistent eardrum perforation after extrusion associated with the Paparella type 2 tube. Alternatively, a larger size type 2 tube may be considered in other surgeries to decrease the frequency of recurrence and tube reinsertion. [ABSTRACT FROM AUTHOR]

Background: Ventilation tube (VT) insertion is the most common treatment for otitis media with effusion (OME). However, OME recurrence and persistent tympanic membrane (TM) perforation after VT removal are encountered in a certain percentage of such children. Methods: This study was performed to determine the outcomes of children who underwent long-term VT insertion. A total of 326 ears from 192 patients were analyzed. The associations among the patient age, sex, history of OME, history of repeated acute otitis media, placement duration, whether the VT had been removed intentionally or spontaneously, and the outcome (persistent TM perforation or OME recurrence) were analyzed. The outcomes of multiple VT tube insertions were also reviewed. We also analyzed whether or not local or general anesthesia was associated with the early spontaneous extrusion of the VT. Result: The OME recurrence and TM perforation rates were 29% (96/326 sides) and 17% (57/326 sides), respectively, for first insertions. In addition, 96 (29%) sides underwent ≥2 insertions. The shorter the duration for which the VT was retained in the middle ear, the more significant the rate of increase in OME recurrence. The OME recurrence was observed more often when VT was spontaneously removed than when intentionally removed. The rate of persistent TM perforation was significantly associated with male sex. Persistent TM perforation was not observed in patients who underwent 4 or 5 insertions. The anesthesia method did not significantly influence the timing of spontaneous extrusion of VT. Conclusion: The retention period of VT should be at least 2 years, and VT removal at the age of 7 might be a viable strategy. Multiple VT insertions are recommended for patients with recurrent OME. Ventilation tube under local anesthesia is an effective option for tolerable children. [ABSTRACT FROM AUTHOR]

Abstract Objective(s) This clinical study was performed to analyze the characteristics of cholesterol granuloma (CG) and evaluate our results in children. Methods The clinical records of children diagnosed with CG were retrospectively reviewed. Results The total of 17 children (20 ears) with CGs were included in this study. Endoscopy revealed pars flaccida retractions and lipoid tissue deposition behind the intact blue tympanic membrane (TM). CT scan revealed bony erosion and extensive soft tissue in the middle ear and mastoid. No ossicular chain destruction was found. All 20 ears underwent canal wall-up mastoidectomy and ventilation tube (VT) insertion, 3 sets of VT were performed in 5 ear and 2 sets in one. The residual perforation was seen in 2 ears following VT. The CT revealed well-pneumatized antra and tympanic cavities at postoperative 12–24 months. Conclusion(s) The CG should be suspected for the patients with yellow lipoid deposition behind the blue TM. CT of CG usually revealed bony erosion and extensive soft tissue in the middle ear and mastoid. Mastoidectomy combined with VT insertion and etiological treatment have a favorable prognosis for CG in children.

The objective was to determine the range of hearing improvement (in dB) post ventilation tube insertion in children with chronic otitis media with effusion (COME), and whether there was a difference in hearing improvement between age groups and genders. This study also investigated whether there was a difference in the mean hearing improvement between the left and right ear, how many months passed before recovery of eustachian tube function, and how long the aeration of the middle ear lasted. The children included in the study were between six and twelve years of age, diagnosed with COME by audiological processing (type B tympanometric recording and conductive hearing loss up to 40 dB on pure tone audiometry) and underwent surgical insertion of ventilation tubes in both ears. Patient data included preoperative tympanometric records, preoperative and postoperative tone audiometry findings, tubometry findings 6 and 10 months after insertion of ventilation tubes, age and gender data, and length of time during which the tubes were in place. The mean hearing improvement of the included patients was 24.2 dB on the right ear and 24.5 dB on the left ear. There was no statistically significant difference between the left and right ear or between the genders. Older age groups had a higher mean hearing improvement compared with the younger age group. Younger age groups had a longer expected period of eustachian tube function recovery, and were expected to have ventilation tubes inserted for a longer period of time. Treatment with ventilation tube insertion resulted in significant improvement in hearing in children where previous conservative therapy failed to recover eustachian tube function and improve hearing. Although children of older age groups had greater preoperative hearing impairment, the recovery of both eustachian tube function and hearing improvement was faster, and the mean length of time that the ventilation tubes had to be inserted was shorter.

Objective(s): This clinical study was performed to analyze the characteristics of cholesterol granuloma (CG) and evaluate our results in children. Methods: The clinical records of children diagnosed with CG were retrospectively reviewed. Results: The total of 17 children (20 ears) with CGs were included in this study. Endoscopy revealed pars flaccida retractions and lipoid tissue deposition behind the intact blue tympanic membrane (TM). CT scan revealed bony erosion and extensive soft tissue in the middle ear and mastoid. No ossicular chain destruction was found. All 20 ears underwent canal wall-up mastoidectomy and ventilation tube (VT) insertion, 3 sets of VT were performed in 5 ear and 2 sets in one. The residual perforation was seen in 2 ears following VT. The CT revealed well-pneumatized antra and tympanic cavities at postoperative 12–24 months. Conclusion(s): The CG should be suspected for the patients with yellow lipoid deposition behind the blue TM. CT of CG usually revealed bony erosion and extensive soft tissue in the middle ear and mastoid. Mastoidectomy combined with VT insertion and etiological treatment have a favorable prognosis for CG in children. [ABSTRACT FROM AUTHOR]

Background: Otitis Media with Effusion (OME) is frequently caused by adenoiditis in children. OME is arguably one of the most common disorders that impairs hearing, speech development, and causes learning issues as a result. However, treatment options are debatable. Aim: This study aims to evaluate if inserting a ventilation tube in conjunction with adenoidectomy is significantly superior to adenoidectomy in conjunction with myringotomy alone in terms of hearing outcome in 6-12 years old children with OME. Patients and Methods: In this prospective controlled clinical study, 33 children; 66 ears, with ages ranging from 6-12 years (19 males and 14 females) diagnosed as cases of bilateral OME and varying degrees of adenoid hypertrophy were included. The patients were randomized into two groups; group I (17 patients; 34 ears) underwent adenoidectomy and endoscopic myringotomy alone, whereas the 16 patients;32 ears, in group II underwent adenoidectomy and endoscopic myringotomy together with ventilation tube insertion. Measurement of pure tone hearing threshold was achieved pre-operatively and at the end of 1st and 3rd postoperative months. The means of the pure tone hearing threshold averages of the patients in both groups were compared. Independent samples t-test was used to define the association between the two means. Results: Pre-operatively, the means of pure tone hearing threshold averages were 27.3 ± 2.670 dB in group I patients and 29.5 ± 2.865 dB in group II patients. At the end of 1st and 3rd post-operative months, the pure tone hearing threshold average means in group I patients were 18.2 ± 2.689dB and 14.8 ± 2.735 dB respectively, while the means in group II patients were 10.6 ± 1.742 dB and 3.5 ± 1.158 dB respectively. Independent samples t-test revealed a statistically significant difference between group I and group II patients regarding the means of pure tone hearing threshold averages at the end of the 1st and the 3rd post-operative months (P value=0.015 and 0.003 respectively). Conclusion: In terms of hearing level, ventilation tube insertion in conjunction with adenoidectomy is statistically superior to adenoidectomy with myringotomy alone in the treatment of OME. [ABSTRACT FROM AUTHOR]

Background and Objective: The aim of this study was to investigate the factors affecting extrusion time in both children and adults with ventilation tube (VT) insertion, providing useful information for clinicians for better decision-making, follow strategy, and potentially improve clinical outcomes for these patients. Methods: Data from patients receiving myringotomy with VT insertion from January 1, 2007, to June 30, 2012, were retrospectively collected and analyzed by the end of 2018. Various factors, including age, gender, history of VT insertion, tympanogram, size of VT used, local finding of tympanic membrane, hypertension, diabetes mellitus, hyperlipidemia, and postoperative ear infection, were included and analyzed to examine the effects of these factors on extrusion time. Results: A total of 447 patients were included in this study (Child group--Adult group ¼ 237:210). The overall average extrusion time was 225.85 days. In the subgroup analysis, the average time was 221.3 days and 231.0 days for children and adults, respectively. The results showed that the VT extrusion time was significantly longer in participants without a history of VT insertion and in those where larger sized VTs were inserted in both age-groups. Male gender had an influence on extrusion time in children. In addition, a history of VT insertion and VT size were determined to be factors related to extrusion before 12 months in children. Conclusion: History of VT insertion and VT size were significantly related to VT extrusion time in both children and adults and defined as factors associated with extrusion before 12 months in children. The findings suggest avoiding VT with a diameter < 1 mm and considering an appropriately larger size in patients with a history of VT insertion to optimize VT retention. [ABSTRACT FROM AUTHOR]

Introduction:The best strategy to treat otitis media with effusion in cleft lip/palate patients is still under debate. This research aimed to evaluate the otologic outcomes in children at least five years post-repair.Materials and Methods:A retrospective study was conducted on 40 children who underwent palatoplasty between January 1, 2012, and January 1, 2014, at Children’s Medical Center (Tehran, Iran). Patients had intervelar veloplasty under magnification (Sommerlad’s Technique). Based on patients’ charts, their age, gender, cleft type, date of palatoplasty, as well as the date and the frequency of ventilation tube (VT) insertion, were recorded. Furthermore, otomicroscopy, middle ear status, and tympanometry were assessed five years postoperatively. Results:There was no significant difference in middle ear status between children with complete and incomplete cleft palates. The mean age at the time of study and the mean follow-up duration were significantly higher in the normal middle ear group, compared to the abnormal middle ear group (7.7±1.6 vs. 6.8±0.9, P=0.03 and 6±1.15 vs. 5.42±0.9, P=0.04, respectively). Middle ear status was not significantly different between early or late palatoplasty patients. In addition, the frequency and timing of VT insertion were not significantly different between the two groups.Conclusions:Middle ear status improved as patients grew older; however, the age of palatoplasty and the frequency of VT insertion were not significant prognostic factors in patients who underwent intervelar veloplasty under magnification.

Background and Objectives: There is no consensus regarding the indications for and timing of ventilation tube (VT) insertion in cleft lip and palate (CLP) patients. Our aim was to search for clinical and surgical (i.e., VT insertion) characteristics that influence the hearing status in CLP. Materials and Methods: We reviewed the hearing outcome of consecutive CLP cases operated on at a single referral center. Univariate and multivariate analysis were applied as appropriate. Results: We included 285 consecutive CLP patients, 109 female and 176 male; the mean age at last follow-up was 16.2 years. Unilateral CLP was found in 249 cases and bilateral CLP in 36. Early VTs (i.e., at the time of hard palate surgery) were applied in 75 (26.3%) patients. Late VTs (i.e., after hard palate surgery during follow-up) were applied in 69 (24.2%) children, at a mean age of 6.7 years old. Hearing loss (pure-tone average > 20 dB) was found in 114 (40%) CLP patients at last available follow-up (mild hearing loss in 96 patients, moderate in 18). In univariate and multivariate analyses, we found that only the absence of early VT insertion (p = 0.0003; OR = 18.2) was an independent prognostic factor of hearing loss in CLP patients. Furthermore, when early VTs were not inserted, there was a high risk of late VT (p = 0.002; OR 13.6). Conclusions: According to our results, the absence of VT insertion at the time of hard palate surgery is an independent prognostic risk factor of hearing loss in CLP patients. Early VT placement in CLP patients may prevent hearing loss and related consequences. These findings should be tested in a large, randomized clinical trial. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of with tympanostomy tubes (TT) on infrared tympanic membrane thermometer (ITMT) results and to provide a systematic review of ITMT results in non-naïve tympanic membranes. Study design: Original prospective blinded case series and systematic literature review. Settings: A single tertiary university-affiliated medical center. Methods: ITMT measurements of patients with unilateral TT and contralateral naïve control ear were randomly conducted by a single investigator blinded to the TT side before and after cerumen was removed from the external auditory canals. A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Google Scholar" on comparable published cases was performed. Results: The mean paired differences (95% confidence interval [CI]) between ventilated and non-ventilated ears before and after cerumen removal were 0.08 ºC/0.14 ºF (−0.04 to 0.19 ºC/− 0.07º–0.34º) and 0.62 ºC/1.12 ºF (0.04–0.25 ºC/0.07–0.45 ºF), respectively (P < 0.001 and P = 0.01, respectively). Conclusion: These findings support the validity and accuracy of ITMT in the setting of ventilated ears. [ABSTRACT FROM AUTHOR]

Background: Otitis media with effusion is a collection of fluid inside the middle ear cleft, treatment of this condition include medical and surgical methods. This research goal is to focus and specify the clinical features of OME and the association between the new staging and the postoperative findings after surgery of insertion of ventilation tubes (VTs). Objectives: The objective of the study was to assess postoperative sequelae after VT insertion in children. Patients and Methods: Thirty two children with OME with surgical insertion of short term ventilation tubes were included in this study and followed up for one year. Results: In 22 patients, the fluid aspirated surgically after myringotomy was serous, whereas 10 patients were mucinous; for the patients, 53.12% had recurrence, whereas 46.88% showed no recurrence of OME. Only 6.25% of cases included in this study developed myringosclerosis; no otorrhea was reported during the period of the presence of VT in the tympanic membrane, no persistent tympanic membrane perforation after VT auto‑extrusion. Conclusion: Even though VT have shown to be very useful in solving conductive hearing loss, its efficacy is a matter of debate in preventing long‑term poor effects of the tympanic membrane and delayed onset of hearing loss. Even though ventilation tubes have shown to be very useful in solving the problem of conductive hearing loss. [ABSTRACT FROM AUTHOR]

Otitis media with effusion (OME) is the most common cause of acquired pediatric hearing loss. The treatment of persistent OME includes myringotomy with or without tube insertion, with a reported recurrence rate of 19.9–40%. This study aims to investigate the recurrence rate of OME and its predictors following myringotomy. A retrospective study that included 345 ears that underwent myringotomy for persistent OME in 179 pediatric patients during 2016–2018. Patients were followed for 36–48 months post myringotomy procedure to detect the recurrence rate. The study sample was divided into two groups based on recurrence status, and the groups were compared using chi-square test and independent T-test. Significant variables (p-value ≤ 0.05) were included in the logistic regression model to determine the predictors of OME recurrence after myringotomy. OME recurrence was detected in 85 ears (24.64%). The OME recurrence rate is higher in patients who underwent myringotomy alone compared to myringotomy with tube insertion (44.1% vs. 22.8%). The insertion of a tympanostomy tube decreases the recurrence rate of OME by 59.9% (OR 0.401; 95% CI 0.162–0.933). The other socio-demographic and clinical characteristics such as age, siblings, daycare attendance, passive smoking, previous acute otitis media, atopy, and adenoidectomy did not significantly influence OME recurrence (p-value > 0.05). The recurrence rate of OME following myringotomy is high. Myringotomy with tube insertion significantly decreases the recurrence rate and the need for further surgeries compared to myringotomy alone. Adenoidectomy and the patient's age have no impact on the recurrence rate of OME. [ABSTRACT FROM AUTHOR]

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This article reports a case of congenital choanal atresia with additional nostril and nasal deformities admitted to Henan Children's Hospital. A 43-day-old female patient was admitted to the hospital because of wheezing with mouth opening breathing and restricted feeding after birth'. The patient was diagnosis as bilateral congenital posterior nostril membranous atresia, congenital extra nostril nasal deformity and nasal stenosis by fiberoptic nasopharyngoscopy, CT, gene detection, and physical examination results. Under general anesthesia, endoscopic bilateral posterior nostril plasty and left anterior nostril plasty were performed. The child recovered well after operation., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Introduction: The best strategy to treat otitis media with effusion in cleft lip/palate patients is still under debate. This research aimed to evaluate the otologic outcomes in children at least five years post-repair. Materials and Methods: A retrospective study was conducted on 40 children who underwent palatoplasty between January 1, 2012, and January 1, 2014, at Children's Medical Center (Tehran, Iran). Patients had intervelar veloplasty under magnification (Sommerlad's Technique). Based on patients' charts, their age, gender, cleft type, date of palatoplasty, as well as the date and the frequency of ventilation tube (VT) insertion, were recorded. Furthermore, otomicroscopy, middle ear status, and tympanometry were assessed five years postoperatively. Results: There was no significant difference in middle ear status between children with complete and incomplete cleft palates. The mean age at the time of study and the mean follow-up duration were significantly higher in the normal middle ear group, compared to the abnormal middle ear group (7.7±1.6 vs. 6.8±0.9, P=0.03 and 6±1.15 vs. 5.42±0.9, P=0.04, respectively). Middle ear status was not significantly different between early or late palatoplasty patients. In addition, the frequency and timing of VT insertion were not significantly different between the two groups. Conclusions: Middle ear status improved as patients grew older; however, the age of palatoplasty and the frequency of VT insertion were not significant prognostic factors in patients who underwent intervelar veloplasty under magnification. [ABSTRACT FROM AUTHOR]

Copyright of Saudi Medical Journal is the property of Saudi Medical Journal and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Objective Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad’s Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients. Methods non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty. Results Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P

Background and purpose: Tympanostomy surgery and ventilation tube (VT) placement are reliable methods to reduce the complications of eustachian tube dysfunction and inadequate middle ear ventilation. However, tympanostomy is associated with some complications. This study aimed to investigate the frequency distribution of tympanostomy surgery, success rate, its complications and the demographic characteristics of patients during 2011-2017 in Sari, Iran. Materials and methods: This retrospective descriptive study was performed using data from the records of 512 patients who underwent VT surgery in Sari during 2011-2017. A checklist was used to collect the data and SPSS V24 was used for data analysis. Results: The most common complaint at the time of referral was hearing loss (38.3%). In 79%, bilateral VT was performed and 6.5% had complications after the operation. The most common complication was purulent otorrhea (4.1%). Postoperative success rate of VT was found to be 93%. Conclusion: Given the high success rate of VT surgery, this procedure could be a good method in treatment of hearing loss, acute recurrent middle ear infections, and the adverse effects of tonsillitis and allergy on middle ear.

Background: The surgeon and physician's decision-making may be influenced by many factors. The clinical practice guideline suggested that watchful waiting for 3 months should be the initial management for pediatric otitis media with effusion. The waiting time of ventilation tube insertion for pediatric patients is a proper measurement for physician decision-making. This study investigated factors influencing the waiting time for pediatric ventilation tube insertion and to explore factors influencing physician decision-making. Methods: Information associated with all patients under 18 years of age who received ventilation tube insertions from July 1, 2000 to December 31, 2009 were retrieved and analyzed from a nationwide, population-based administrative database. The waiting time before ventilation tube insertions from the time of diagnosis of otitis media with effusion was recorded. Certain factors that would influence the waiting time were identified. At the same time, how these factors influenced clinical decision-making were also identified. Results: The waiting time decreased as patient age increased (p < 0.001), and increased as the recent frequency of upper respiratory tract infection diagnosis increased (p < 0.001). Patients who received simultaneously bilateral ventilation tube insertions had shorter waiting time than those who had unilateral surgery (p < 0.01) and patients who had undergone ventilation tube insertions in a tertiary referral center generally had longer waiting times (p < 0.001). Conclusion: The waiting time of ventilation tube insertions for pediatric otitis media with effusion can be influenced by many factors. Patients with older age and undergone simultaneously bilateral ventilation tube insertion had shorter waiting time. Patients who had more upper respiratory tract infection episodes and who received ventilation tube insertions in a tertiary referral center setting were subject to longer waiting times. [ABSTRACT FROM AUTHOR]

Otitis media with effusion (OME) in children with cleft palate (CP) is known to be refractory to treatment and most of these patients undergo surgery for ventilation tube (VT) placement. To identify the outcomes of children with CP using long-term VT with a 'waiting until spontaneous extrusion' strategy. We retrospectively reviewed the medical records of all children with CP who visited our department from December 2016 to November 2017 and who received long-term VT placement in our department. Risk factors related to residual perforation and recurrence of OME were analyzed. A total of 106 children were included in this study. Our statistical analysis of 94 ears followed for more than three months after VT loss revealed that longer VT placement was associated with residual perforation, and shorter VT placement was associated with OME recurrence. Although a longer duration of VT placement was associated with an increased rate, extremely long-term VT placement was not associated with residual perforation, as expected. Half of the VTs were spontaneously extruded at 40 months after insertion. Long-term VT insertion using a waiting until spontaneous extrusion strategy is a potential option for children with CP. [ABSTRACT FROM AUTHOR]

Otitis and middle ear disease present high morbidity rates in spite of current medical treatment, especially in the younger population. Otitis media with effusion (OME) is a chronic disease that is often found in school age children. Its evolution, recurrence, complications and resolution still present a challenge to otologists. For some time, middle ear ventilation tubes were used for this pathology, thus assuring proper middle ear ventilation and higher disease resolution rates. In the current paper, we investigate the connection between ventilation tube usage, the materials out of which they are made, the techniques involved and how these factors may influence disease resolution rates. [ABSTRACT FROM AUTHOR]

Abstract Hydrodissection technique is a safe way to establish a fully functional tympanic membrane in cases of early stages of atelectatic ears.

Timpanik membrana ventilasyon tüpü tatbiki en sık uygulanan kulak cerrahilerinden bir tanesidir. Kronik seröz otit medianın cerrahi tedavisinde sıkça uygulanan bu yöntem hastada orta kulağın ventilasyonunu sağlayıp orta kulak basıncını düzenler. Ventilasyon tüpü tatbikine bağlı en sık karşılaşılan komplikasyonlar miringoskleroz, atrofi ve otoredir. Tüpün atılım sürecinde mediale doğru yönlenip orta kulağa atılmasıyla sağlam zarın medialinde görülmesi haline oldukça nadir rastlanan bir komplikasyondur. Ventilasyon tüpü tatbiki sonrası komplikasyon çok nadir gözlense de erken dönemde tanınıp tedavi edilmesi durumun daha kötüye gitmesini engelleyecektir.Bu vaka sunumunda rutin takiplerini bırakan geç dönem muayenesinde tüpü orta kulağa atılan ve çevresinde granülasyon dokusu oluşan hastanın literatür eşliğinde sunulması amaçlandı

Background: Otitis media with effusion is a prevalent disease of pediatrics. It is usually a self-limiting disease. However, it may be complicated by serious consequences. The early detection and the determination of actual prevalence could help in planning for preventive interventions. Aim of the work: To determine prevalence of otitis media with effusion and the risk factors associated with this disease. Patients and methods: The study included all patients younger than 16 years of age, who attended the outpatient clinic of otorhinolaryngology department (Al-Azhar Faculty of Medicine, New Dameitta), during the period from August 2016 to August 2018. In this work, 2338 patients were included (1351 males and 987 females). For each child, the demographic data were collected and documented. All attended children were submitted to an ear, nose and throat examination; both ears were examined by an otoscope (pneumatic) and tested with tympanometry by the same investigator. Results: The disease was diagnosed in 124 children (5.3%). The mean age of studied children was 9.13±2.83 years (range 4-15). The most common affected age was 4 years (15%) followed by 6 years (13.1%), then 15 years (6.3%). The condition was significantly associated with low socioeconomic class, smoking exposure and past frequent upper respiratory tract infection. Conclusion: The prevalence of OME in 4-15 years old children in Damietta Governorate was 5.3%, elevated to 15% at the age of 4 years. The low social state, exposure to smoking and frequent infections of upper airway were the most common associated risk factors.

Background and Objectives: There is no consensus regarding the indications for and timing of ventilation tube (VT) insertion in cleft lip and palate (CLP) patients. Our aim was to search for clinical and surgical (i.e., VT insertion) characteristics that influence the hearing status in CLP. Materials and Methods: We reviewed the hearing outcome of consecutive CLP cases operated on at a single referral center. Univariate and multivariate analysis were applied as appropriate. Results: We included 285 consecutive CLP patients, 109 female and 176 male; the mean age at last follow-up was 16.2 years. Unilateral CLP was found in 249 cases and bilateral CLP in 36. Early VTs (i.e., at the time of hard palate surgery) were applied in 75 (26.3%) patients. Late VTs (i.e., after hard palate surgery during follow-up) were applied in 69 (24.2%) children, at a mean age of 6.7 years old. Hearing loss (pure-tone average > 20 dB) was found in 114 (40%) CLP patients at last available follow-up (mild hearing loss in 96 patients, moderate in 18). In univariate and multivariate analyses, we found that only the absence of early VT insertion (p = 0.0003; OR = 18.2) was an independent prognostic factor of hearing loss in CLP patients. Furthermore, when early VTs were not inserted, there was a high risk of late VT (p = 0.002; OR 13.6). Conclusions: According to our results, the absence of VT insertion at the time of hard palate surgery is an independent prognostic risk factor of hearing loss in CLP patients. Early VT placement in CLP patients may prevent hearing loss and related consequences. These findings should be tested in a large, randomized clinical trial.

Objectives: Intratympanic steroid injection (ISI) for sudden sensorineural hearing loss (SSNHL) is a relatively popular and effective method, but there is no standardized method for intratympanic steroids for the treatment of SSNHL and no consensus on how to deliver steroids to the middle ear. The purpose of this study was to compare 2 means of intratympanic steroid delivery as therapy for SSNHL. Methods: A retrospective chart review was performed for the period from November 2018 to October 2022 at our Department of Otorhinolaryngology-Head and Neck Surgery. Sixty patients with profound SSNHL who have failed initial steroid therapy were divided into the continuously transtympanic steroid perfusion (TSP) therapy and the intermittent ISI therapy. Results: Posttreatment pure-tone average was 60.3 ± 18.2 dB in the TSP group and 67.5 ± 22.6 dB in the ISI group, 70.0% of subjects in the TSP group, and 46.7% of subjects in the ISI group had improved by 15 dB or more after the therapy. The increased hearing threshold of the TSP group (24.6 ± 14.1 dB) was better than the ISI group (16.6 ± 14.9 dB), and the hearing recovery was significantly different ( P < .05) in the 2 groups. Besides the hearing improvement was most obvious in low-frequency areas in the TSP group, the most significant hearing improvement was at 250 Hz, reaching 30.8 ± 3.3 dB. Conclusions: In SSNHL patients who have failed initial steroid therapy, TSP therapy via a ventilation tube can achieve good hearing outcomes and serve as a salvage therapy for patients with SSNHL., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To investigate the published time to extrusion of tympanostomy tubes inserted in the various quadrants of the tympanic membrane. Methods: Publications were selected by a search with 'PubMed', 'Embase' and 'Web of Science'. A meta‐analysis of time to extrusion as a function of tympanic membrane quadrant intubation was performed. Design, Setting, Participant‐Not relevant Main Outcome Measured: Extrusion rate of tympanostomy tubes inserted in the various quadrants of the tympanic membrane. Results: Eleven studies describing 2232 tympanostomy tubes were enrolled into the quantitative meta‐analysis. The extrusion rate was evaluated at 3‐month intervals up to 24 months post‐intubation, and it did not differ significantly at any of the time points tested for the superior and inferior anterior quadrants. The cumulative extrusion rates were as follows: 11 and 9%, 32 and 23%, 59 and 36%, 80 and 67%, 87 and 70%, 88 and 82%, and 96 and 89% in the superior and anterior quadrants, respectively, at 3, 6, 9, 15, 18, 21 and 24 months post‐intubation, respectively. Conclusion: Time to extrusion of tympanostomy tubes are similar for all 3 tympanic membrane quadrants. The anterior superior quadrant intubation has no superiority in terms of intubation time. [ABSTRACT FROM AUTHOR]

The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission to health care workers during myringotomy and tympanostomy tube (MT) insertion is unknown. To determine the need for enhanced precautions to prevent potential spread via aerosolized particles, we used an optical particle sizer to measure aerosol generation intraoperatively during a case series of MT insertion. We also discuss our institutional experience with safe pandemic-era perioperative practices. There was no measured increase in aerosol particle number during the procedure at a distance of 30 cm from the external auditory canal. These initial data are reassuring regarding the risk of SARS-CoV-2 transmission to the operating room team due to aerosol generation, but further study is necessary before making definitive recommendations. [ABSTRACT FROM AUTHOR]

Objective: Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad's Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients.Methods: non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty.Results: Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P < 0.005) to 12 cases in the left ear and 14 cases in the right ear after surgery. So, after surgery, 70 % of the tympanogram of left ears and 66.6 % of the tympanogram of Rt ears were in normal condition (type A tympanometry). ABR was done for 43 patients (86 ears) before surgery and six months after palatoplasty. Data were shown that 40 of the patients had mild to moderate hearing loss before surgery, which reduced significantly (P < 0.005) to 9 in the left ear and 11 in the right ear after palatoplasty. So, after surgery, 79 % of ABR of left ears and 73.8 % of ABR of right ears were in normal status (normal hearing threshold).Conclusions: Intervelar veloplasty under magnification (Sommerlad's technique) significantly improved the middle ear effusion without the need for tympanostomy tube insertion. [ABSTRACT FROM AUTHOR]

Background and purpose: Tympanostomy surgery and ventilation tube (VT) placement are reliable methods to reduce the complications of eustachian tube dysfunction and inadequate middle ear ventilation. However, tympanostomy is associated with some complications. This study aimed to investigate the frequency distribution of tympanostomy surgery, success rate, its complications and the demographic characteristics of patients during 2011-2017 in Sari, Iran. Materials and methods: This retrospective descriptive study was performed using data from the records of 512 patients who underwent VT surgery in Sari during 2011-2017. A checklist was used to collect the data and SPSS V24 was used for data analysis. Results: The most common complaint at the time of referral was hearing loss (38.3%). In 79%, bilateral VT was performed and 6.5% had complications after the operation. The most common complication was purulent otorrhea (4.1%). Postoperative success rate of VT was found to be 93%. Conclusion: Given the high success rate of VT surgery, this procedure could be a good method in treatment of hearing loss, acute recurrent middle ear infections, and the adverse effects of tonsillitis and allergy on middle ear. [ABSTRACT FROM AUTHOR]

Objective: To study the long-term outcome of otitis media with effusion in children with and without cleft palate treated with the same protocol of ventilation tube insertion. Materials and Methods: A retrospective cohort study was conducted in eighty-five children with cleft palate and 80 children without cleft palate who had otitis media with effusion and had follow-up between 2001 and 2019. Both groups were treated with ventilation tube insertion for longstanding middle ear effusion more than 90 days. The main outcome was the cumulative incidence of surgical management, time of the indwelling ventilation tubes, conditions of the tympanic membrane, and the hearing outcome. Results: At 24 months old, 63.5% of children with cleft palate and 11.3% of children without cleft palate had their first ventilation tube insertion. Repeated surgery was done in 81.2% of children with cleft palate and 50% of children without cleft palate (p < 0.001). The median duration of the indwelling tube was 11.3 months in the children with cleft palate and 12.4 months in the non-cleft children (p = 0.82). At the end of the study, 63.7% of children without cleft palate and 43.5% of children with cleft palate had normal tympanic membrane (p = 0.009). The hearing outcomes of children with and without cleft palate were 20.7 dB and 19.3 dB, respectively. Conclusion: Children with and without cleft palate were managed under the same guideline and the hearing outcome was favorable in both groups. [ABSTRACT FROM AUTHOR]

Objective: To study the long-term outcome of otitis media with effusion in children with and without cleft palate treated with the same protocol of ventilation tube insertion. Materials and Methods: A retrospective cohort study was conducted in eighty-five children with cleft palate and 80 children without cleft palate who had otitis media with effusion and had follow-up between 2001 and 2019. Both groups were treated with ventilation tube insertion for longstanding middle ear effusion more than 90 days. The main outcome was the cumulative incidence of surgical management, time of the indwelling ventilation tubes, conditions of the tympanic membrane, and the hearing outcome. Results: At 24 months old, 63.5% of children with cleft palate and 11.3% of children without cleft palate had their first ventilation tube insertion. Repeated surgery was done in 81.2% of children with cleft palate and 50% of children without cleft palate (p < 0.001). The median duration of the indwelling tube was 11.3 months in the children with cleft palate and 12.4 months in the non-cleft children (p = 0.82). At the end of the study, 63.7% of children without cleft palate and 43.5% of children with cleft palate had normal tympanic membrane (p = 0.009). The hearing outcomes of children with and without cleft palate were 20.7 dB and 19.3 dB, respectively. Conclusion: Children with and without cleft palate were managed under the same guideline and the hearing outcome was favorable in both groups.

Objective: To review guidelines for otologic procedures during the SARS-CoV-2 pandemic and to present a protocol for emergent or urgent mastoidectomy at our institution. Data sources: Guidelines regarding emergent and urgent otologic procedures from otolaryngologic societies are reviewed. We described a protocol for emergent or urgent mastoidectomy at our institution. Conclusion: Patients requiring urgent or emergent mastoidectomy during the COVID-19 pandemic require prompt treatment. We make the following recommendations: Emergent or urgent otologic procedures should be performed in a contained environment, such as a tent created by the microscope drape. The surgical team should practice using instruments in the tent setup to prepare for real cases. Otologic procedures should adhere to guidelines set for high-risk procedures.

Myringotomy with ventilation tube placement is a common surgical procedure performed in children and adults to remove fluid buildup behind the tympanic membrane. However, retention of tubes beyond achievement of therapeutic response increases risk for complications and additional intervention. This small feasibility study was conducted to demonstrate proof of concept of a novel bioabsorbable ventilation tube that provides the necessary duration of ventilation with absorption shortly thereafter. Tubes were placed in 15 ears of 14 patients meeting indications for short or intermediate duration of middle ear ventilation. Two independent examiners documented tube patency and tube absorption status at 3, 6, and 12 weeks or until absorption was complete. Results indicate that average ventilation time was 12 weeks (range, 3 weeks to 18 months). There was no observation of blockage. These findings support the feasibility of a novel bioabsorbable ventilation tube. [ABSTRACT FROM AUTHOR]

Long-term outcomes of children with and without cleft palate receiving early treatment for otitis media with effusion (OME) are unclear. To compare long-term otological and audiological outcomes between children with and without cleft palate treated with tympanostomy for OME before the age of 2 years. Ninety-five children (180 ears) with cleft palate (study group) and 97 children (185 ears) without (control group) were followed-up to a maximum age of 7 years. We retrospectively analyzed the audiological outcomes at the age of 7 years, and the otological outcomes at the last examination. The percentages of children with OME resolution before the age of 7 years were 47.4% and 60% in the study and control groups, respectively, and those of ears with healed tympanic membrane were 71.7% and 79.5% in the corresponding groups. Significantly more ears were subjected to retympanostomy in the study (31.1%) than in the control group (21.6%). Mean pure-tone average (0.5‒4 kHz) was 15.6 dB HL and 14.3 dB HL for the corresponding groups. Otological and audiological outcomes in both groups were similar. The audiological prognosis was favorable regardless of the cleft palate condition. [ABSTRACT FROM AUTHOR]

Hydrodissection technique is a safe way to establish a fully functional tympanic membrane in cases of early stages of atelectatic ears. [ABSTRACT FROM AUTHOR]

The application of ventilation tubes (VT) is one of the most frequently performed surgical ear. VT frequently applied in chronic serous otitis media surgery. VT, edits the middle ear pressure and provides ventilation of the midle ear. Altough the VT complications are rare, the most common complications associated with ventilation tube are myringosclerosis, atrophy and otorrhea. Thrown tube into the middle ear is an extremely rare complication. It is diagnosed and treated at an early stage of complications will prevent the situation from getting worse. In this study; the patient was presented,whose ventilation tube migrate to the middle ear and granulation tissue formed around. [ABSTRACT FROM AUTHOR]

The purpose of this study is to compare patient trends in otitis media with effusion (OME) symptoms and diagnoses before and after the COVID-19 pandemic in order to investigate the effects of the coronavirus disease of 2019 (COVID-19). A retrospective, multi-center, observational study was carried out between January 2018 and December 2022 at hospitals in the Iwate Prefecture with full-time doctors. All patients were initially separated into two groups, one for the pre-COVID-19 era (from January 2018 to June 2020), and the other for the COVID-19 era (from July 2020 to December 2022). In the pre-COVID-19 era, 132 patients had tympanostomy tubes (TT) placed, while 64 patients had them placed in the COVID-19 era. Between the pre-COVID-19 and COVID-19 eras, there were no statistically significant differences in terms of age, sex, side, craniofacial deformity, or adenoidectomy. Children in elementary school showed a greater decline than those in preschool (42–11 patients in elementary school (74%) and 49 to 32 patients in preschool school (35%); p = 0.025). The percentage of TT placements for OME dropped to roughly half during the COVID-19 epidemic. This was particularly obvious in elementary school students. [ABSTRACT FROM AUTHOR]

CIPROFLOXACIN OTIC DROPS FOR PREVENTION OF OTORRHOEA FOLLOWING MYRINGOTOMY AND VENTILATION TUBE INSERTION AMONG CHILDREN Ammar A Selman*, Ahmed A Alansary# & Abdulwahab B Abdulwahab@ *MB,ChB, Arab board candidate, ENT Dept., Basrah General Hospital. #MB,ChB, FICMS, Consultant Otolaryngologist, Head-ENT Dept, Basrah General Hospital. @MB,ChB, FICMS, ENT Specialist, ENT Dept, Basrah General Hospital. Abstract This study aimed to determine the effect of topical otic drops on the rates of postoperative ventilation tube otorrhoea and ventilation tube occlusion in children after myringotomy and ventilation tube insertion in children. A randomized comparative interventional study was carried out on 45 children (84 years) attending Basrah General Hospital, they were 32 males (71%) and 13 females (28.9%), 39 cases have bilateral otitis media with effusion and 6 with unilateral disease, the age range was 3-17 years old. After full assessment of patients, myringotomy and ventilation tube insertion was done for every one with or without adenoidectomy and tonsillectomy or both. They were divided into three groups: first group with no local intervention, second group with single application of ciprofloxacin otic drops at surgery, third group with continuous application of ciprofloxacin otic drops for four days after surgery. A follow-up visit was instructed after 14 days for all. The rates of postoperative ventilation tube otorrhoea and ventilation tube occlusion were recorded. With application of statistical analysis on the results, there was a statistically significant reduction in the rate of postoperative otorrhoea with using the ciprofloxacin otic drops for four days after surgery (P-value 0.043) with a reduction in the incidence of otorrhoea from 29.6% to 7.6% as compared to the group without using the drops. No significant results obtained with a single drops application at time of surgery. There were no statistically significant results in regard to the rates of postoperative ventilation tube occlusion among the study groups. In conclusion, ciprofloxacin otic drops application for few days after myringotomy and ventilation tube insertion appears to be effective to reduce the rate of postoperative ventilation tube otorrhoea. Neither the single nor the continuous otic drops applications could reduce the rates of postoperative ventilation tube occlusion

Background: Otitis media with effusion is one of the most common chronic otological conditions and the most common cause of conductive hearing loss in the pediatric population. Ventilation tubes insertion with or without adenoidectomy is considered as a standard surgical procedure. Objective: this study aimed to compare the efficacy and the complications of adenoidectomy with myringotomy in comparison with adenoidectomy and ventilation tube insertion in management of otitis media with effusion. Patients and Methods: this was a prospective study carried out between October 2017 to October 2018 (One year). The study included 60 cases diagnosed with persistent otitis media with effusion due to adenoid enlargement and they were categorized randomly into two groups (30 cases per each). Group I underwent myringotomy alone with adenoidectomy and group II underwent myringotomy with ventilation tube insertion with adenoidectomy. All patients were subjected to full ENT examination, tympanometry and hearing evaluation. Patients were followed up (After myringotomy healing, at one month and 3 months after healing) for 3 months after tube extrusion or myringotomy closure. Postoperative evaluation was done for all patients and complications were assessed. Results: the mean healing time was significantly longer in children who underwent adenoidectomy with ventilation tube (Group II) compared to patients of group I, (p<0.001) (28.5 vs. 2.2 weeks). The number of cases with OME recurrence after 3 months of healed myringotomy were significantly higher in group I (18 ears, 30.0%) compared to group II (6 ears, 10.0%), (p<0.006). Postoperative tympanogram was improved in both groups but, it was significantly improved in the group who underwent adenoidectomy with ventilation tube (Group II) compared to the group who underwent adenoidectomy with myringotomy only at all follow up intervals (p=0.015, 0.002, 0.022), respectively. The incidence of some postoperative complications such as otorrhea and tympanic sclerosis was significantly higher in group II (p=0.024 for otorrhea and p<0.001 for tympanic sclerosis). Conclusion: both used procedures were effective in the treatment of OME in children, but adenoidectomy with ventilation tube insertion was significantly better in improving tympanogram and reducing OME recurrence, while, it may increase incidence of some complications. Further studies are warranted with larger number of cases and longer follow-up period to confirm these results. [ABSTRACT FROM AUTHOR]