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1.  Cavernous hemangioma of the orbit: an unusual acute presentation 
We report an unusual presentation of an orbital cavernous hemangioma in a 26-year-old female, who noted sudden redness and swelling of the left eye (LE) on waking up. At presentation, upper eyelid edema with periorbital ecchymosis and subconjunctival hemorrhage were noted in the LE. Although there was transient symptomatic relief with topical medications, blurring of vision developed in the LE. When seen 10 days later, the patient’s LE showed axial proptosis. Magnetic resonance imaging revealed an intraconal soft tissue mass in the superomedial quadrant of the left orbit. Superior orbitotomy with mass excision was done; histopathological examination of the excised mass revealed a cavernous hemangioma. The patient had complete visual recovery following surgery. To our knowledge, an acute presentation of an orbital cavernous hemangioma with subconjunctival hemorrhage and periorbital ecchymosis has not previously been reported.
doi:10.2147/IMCRJ.S133284
PMCID: PMC5533564
subconjunctival hemorrhage; ecchymosis; cavernous hemangioma
2.  Chronic suppurative otitis media 
BMJ Clinical Evidence  2012;2012:0507.
Introduction
Chronic suppurative otitis media (CSOM) is a common cause of hearing impairment and disability. Occasionally it can lead to fatal intracranial infections and acute mastoiditis, especially in developing countries.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for chronic suppurative otitis media in adults and in children? What are the effects of treatments for cholesteatoma in adults and in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 51 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: topical ear cleansing, surgery for cholesteatoma, systemic antibiotics, topical antibiotics, topical antibiotics plus topical corticosteroids, topical antiseptics, topical corticosteroids, tympanoplasty (with or without mastoidectomy).
Key Points
Chronic suppurative otitis media (CSOM) causes recurrent or persistent discharge (otorrhoea) through a perforation in the tympanic membrane, and can lead to thickening of the middle-ear mucosa and mucosal polyps. It usually occurs as a complication of persistent acute otitis media with perforation in childhood. CSOM is a common cause of hearing impairment, disability, and poor scholastic performance. Occasionally it can lead to fatal intracranial infections and acute mastoiditis, especially in developing countries.
In children with CSOM, topical antibiotics may improve symptoms compared with antiseptics. The benefits of ear cleansing are unknown, although this treatment is usually recommended for children with ear discharge.
We don't know whether topical antiseptics, topical or systemic antibiotics, or topical corticosteroids, alone or in combination with antibiotics, improve symptoms in children with CSOM compared with placebo or other treatments.
In adults with CSOM, topical antibiotics either alone or in combination with topical corticosteroids may improve symptoms compared with placebo or either treatment alone, although we found few adequate studies. There is consensus that topical antibiotics should be combined with ear cleansing so that the antibiotics are able to reach the middle ear space. We don't know whether topical antiseptics, topical corticosteroids, or systemic antibiotics are beneficial in reducing symptoms.It is possible that antibiotics against gram-negative bacteria may reduce ear discharge more than other classes of antibiotics or placebo.
We don't know whether tympanoplasty with or without mastoidectomy improves symptoms compared with no surgery or other treatments in adults or children with CSOM.
Cholesteatoma is an abnormal accumulation of squamous epithelium usually found in the middle ear cavity and mastoid process of the temporal bone. Granulation tissue and ear discharge are often associated with secondary infection of the desquamating epithelium.
Cholesteatoma can be either congenital (behind an intact tympanic membrane) or acquired. If untreated, it may progressively enlarge and erode the surrounding structures. We don't know the beneficial effects of surgery, whether surgery can be delayed, or which surgical techniques are associated with the best outcomes in children or adults with cholesteatoma.
PMCID: PMC3412293  PMID: 23870746
3.  Testing the effects of long-acting steroids in edema and ecchymosis after closed rhinoplasty 
Plastic Surgery  2014;22(2):83-87.
Although rhinoplasty has proven functional and cosmetic benefits, postoperative periorbital edema and ecchymosis following the procedure remain a concern, even with the most experienced surgeons. Sequelae of the surgery can leave patients with socially unacceptabl e results, elevated anxiety and inconveniences. Managing the postoperative side effects of rhinoplasty with steroids was first advocated more than 35 years ago; since then, many regimens and different types of steroids have been used with varying degrees of success.
BACKGROUND:
Steroids have proven to be of some benefit in rhinoplasty edema and ecchymosis when administered at a high and repeated dose.
OBJECTIVE:
To evaluate the effects of single-dose, long-acting intramuscular steroids on postoperative edema and ecchymosis after closed rhinoplasty with osteotomies compared with placebo.
METHODS:
A randomized, double-blinded, placebo-controlled trial was performed. Fifty-four patients were randomly assigned to two groups: 28 received a single dose of long-acting dexamethasone (mean [± SD] dose 16±4 mg) immediately before anesthetic induction; the remaining 26 received an intramuscular injection of saline solution. The same surgeon performed all surgeries, with patients under general anesthesia. Acetaminophen was the only analgesic used to control postoperative pain. High-resolution digital photographs were taken on postoperative days 1, 3, 7 and 14. Scoring was performed separately for eyelid swelling and ecchymosis by an independent observer using a graded scale (0 to 5) for edema and a scoring system (0 to 13) for ecchymosis.
RESULTS:
No statistically significant differences in terms of age, sex or amount of bleeding during surgery were found between the two groups. No statistically significant difference was observed in the decrease of both ecchymosis and edema between placebo and high-dose, long-acting dexamethasone. A statistically significant difference in operation time was found, favouring the steroid group. No severe complications were observed due to steroid use.
DISCUSSION:
Osteotomies are basically a form of (controlled) trauma, with considerable disruption of the abundant blood vessels in this facial region and, therefore, are associated with with undesirable effects. A recent meta-analysis failed to show benefits of the use of steroids after postoperative day 3. Only a trend toward reduction in edema and ecchymosis with the use of long-acting steroids compared with placebo was demonstrated in the present study.
CONCLUSION:
There was no benefit in administering single-dose, long-acting steroids in patients undergoing closed rhinoplasty with osteotomies.
PMCID: PMC4116320  PMID: 25114618
Edema; Ecchymosis; Rhinoplasty; Steroids
4.  Chronic suppurative otitis media 
BMJ Clinical Evidence  2007;2007:0507.
Introduction
Chronic suppurative otitis media (CSOM) is a common cause of hearing impairment, disability, and poor scholastic performance, and can occasionally lead to fatal intracranial infections and acute mastoiditis, especially in resource-poor countries.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for chronic suppurative otitis media in adults; and in children? We searched: Medline, Embase, The Cochrane Library and other important databases up to January 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 48 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: ear cleansing, systemic antibiotics, topical antibiotics, topical antiseptics, topical corticosteroids, tympanoplasty (with or without mastoidectomy).
Key Points
Chronic suppurative otitis media (CSOM) causes recurrent or persistent discharge (otorrhoea) through a perforation in the tympanic membrane, and can lead to thickening of the middle ear mucosa, mucosal polyps, and cholesteatoma. CSOM is a common cause of hearing impairment, disability, and poor scholastic performance, and can occasionally lead to fatal intracranial infections and acute mastoiditis, especially in resource-poor countries.
Topical antibiotics either alone or in combination with topical corticosteroids may improve symptoms compared with placebo or either treatment alone in adults, although few adequate studies have been found. There is consensus that topical antibiotics should be combined with ear cleansing. We don't know whether topical antiseptics, topical corticosteroids or systemic antibiotics are beneficial in reducing symptoms.It is possible that antibiotics against gram negative bacteria may reduce ear discharge more than other classes of antibiotics or placebo.
We don't know whether tympanoplasty with or without mastoidectomy improves symptoms compared with no surgery or other treatments in adults or children with CSOM.
In children with CSOM, the benefits of ear cleansing are unknown, although this treatment is usually recommended for children with ear discharge. We don't know whether topical antiseptics, topical or systemic antibiotics, or topical corticosteroids, alone or in combination with antibiotics, improve symptoms in children with CSOM compared with placebo or other treatments.It is possible that topical antibiotics improve resolution of ear discharge compared with topical antiseptics, but they may increase the risk of ototoxicity.
PMCID: PMC2943814  PMID: 19454051
5.  To Study the Level of Awareness About Complications of Chronic Suppurative Otitis Media (CSOM) in CSOM Patients 
Introduction: Chronic Suppurative Otitis Media (CSOM) is one of the most common diseases in clinical practice. It affects large number of people. Disease causes disability and mortality because of its ability to cause complications. Patients develop complications because of lack of awareness about the disease, scarce availability of qualified otologists at peripheral areas and economical constraints. This study was conducted to study the awareness about CSOM and its complications.
Materials and Methods: Patients suffering from CSOM attending outpatient department of Ear, Nose and Throat Department were included in this study. After taking proper history and examination to confirm the diagnosis patients were given structured questionnaire to assess their knowledge about CSOM and its complications. Results tabulated and compared with literature.
Results: Majority of our patients (77.6%) were from low socio-economic status group. Maximum number of patients was from 3rd and 4th decade of life. Only 29.5% patients understood perforation in Tympanic Membrane (TM) as a cause for continued discharge. 94% patients did not differentiate between safe and unsafe CSOM. 52.2% had knowledge about entry of water in ear as cause for recurrence of discharge in CSOM. 44.7% said CSOM can be cured by surgery. Only 7.4% said infection can spread to brain, 23.3% knew about collection of pus around ear, 11.9% said it can cause vertigo, but none of them recognized facial nerve palsy as complication of CSOM. 38.8% took self medication and 16.4% consulted qualified ear nose throat (ENT) doctor.
Conclusion: Although CSOM is a major disease affecting large number of people, awareness regarding disease and its complications is still poor. Mass education programs aimed at educating people about CSOM are need of the hour.
doi:10.7860/JCDR/2014/8009.4008
PMCID: PMC3972599  PMID: 24701483
Chronic suppurative otitis media; Socio-economic status; Otorhinolaryngology
6.  A Survey of the Burden of Management of Chronic Suppurative Otitis Media in a Developing Country 
Background:
Although the prevalence of chronic suppurative otitis media (CSOM) is much higher in developing counties, most surgical treatment techniques are not easily accessible in many poor resource countries.
Aim:
The survey aims to examine the extent to which health care facilities in Nigeria are equipped to address the management challenges of CSOM.
Subjects and Methods:
Online questionnaires were sent and received from otolaryngologists practicing in across Nigerian public health institutions to evaluate the institutional practice concerning management of CSOM. Information enquired include: Proportion of CSOM among the ear, nose and throat (ENT) patient load, routinely applied treatments and challenges facing availability of standard treatment options. Data were analyzed with Statistical Package for the Social Sciences version 15 (Chicago Illinois, USA), and presented descriptively.
Results:
Responses were returned from 17 otolaryngologists (68% [17/25]) practicing in institutions across the six geopolitical zones with a mean duration of otolaryngology services of 22.4 (14.8) years. The CSOM patients constitute an average of 25.3% (13.1) of ENT patient load, with an average of 31 (15.3) % having significant hearing loss. Surgery have never been tried in 41% (7/17) of the institutions due to lack of facilities and/or expertise. Among institutions that offer surgery, 40% (4/10) offer only cortical mastoidectomy and only 30% (3/10) offer type 1 tympanoplasty. Achievements of permanent dry ears were reported more in institutions that offer surgery. Unaffordable cost of hearing aid and lack of expertise for tympanoplasty are the major challenging factors for rehabilitation of CSOM induced hearing loss.
Conclusion:
Considering the enormity of CSOM in Nigeria, and the fact that > 40% (7/17) of the public health institutions still lack facilities and/or expertise for surgical treatments for CSOM, public otolaryngological centers should not only be adequately equipped for tympanomastoid surgeries, attention should be focused on further training of experts in the operative techniques from within and outside the country.
doi:10.4103/2141-9248.122126
PMCID: PMC3868131  PMID: 24380016
Chronic suppurative otitis media; Ear discharge; Hearing aids; Hearing loss; Mastoidectomy; Tympanoplasty
7.  The use of nasal packing post rhinoplasty: does it increase periorbital ecchymosis? A prospective study 
Background
Periorbital edema and ecchymosis following rhinoplasty is disturbing for both the patients and their surgeons. The study aim was to determine whether nasal packing after lateral osteotomies in rhinoplasty surgery increases the risk of periorbital ecchymosis post-operatively.
Methods
This was a prospective self-controlled single-blinded study. Seventy four patients who underwent rhinoplasty with bilateral lateral osteotomies by a single surgeon were enrolled in the study. Nasal cavity packing for one side was done while the other side was left unpacked. Periorbital ecchymosis was evaluated by the operating surgeon and a separate surgeon who is unaware of the packing side separately on the first, fourth and seventh day post-operatively. A 4-grade scale was utilized to assess the ecchymosis with grade 4 being the most severe.
Results
Nasal packing was found to significantly increase the severity and duration of periorbital ecchymosis post rhinoplasty. While no difference was observed between the packed and unpacked sides on the first post-operative day, significant difference was noted on the 4th day (mean score 2.36 and 1.15 for the packed and unpacked sides, respectively) and on the 7th day after surgery in favor of the unpacked side (score 1.24 and 0.61 for the packed and unpacked sides, respectively).
Conclusion
We advise against the routine use of nasal packing in rhinoplasty unless necessary as it contributes to worsen the periorbital ecchymosis from lateral osteotomies and thereby increases the patients’ “down time” after surgery.
doi:10.1186/s40463-015-0075-5
PMCID: PMC4470049  PMID: 26077040
Rhinoplasty; Septorhinoplasty; Ecchymosis; Packing; Complications
8.  A study of surgical management of chronic suppurative otitis media with cholesteatoma and its outcome 
Objective
Aim of this study is evaluation of course of improvement of surgically treated cases of chronic suppurative otitis media (CSOM) with cholesteatoma; it includes hearing status, condition of mastoid cavity, study of different, natural and surgical condition and recurrence of disease within the study period.
Design
It is a prospective study.
Settings
This study was conducted in a premiere government hospital in Kolkata between May 2007 to April 2008.
Patients
Total 40 patients between age group of 6–70 years were included in the present study which includes 19 males and 21 females.
Intervention
Surgical interventions were done in all the cases. Different types of mastoidectomy with or without tympanoplasty was done according to extent of disease process.
Outcome
Audiometrically documentable hearing improvement occurred in 35% cases (p = 14), in rest of the ears hearing status remained unaltered. At the end of 6 months follow up 92.5% (p = 14) in rest (p = 37) operated ears become completely dry. Five percent cases (p = 2) presented with facial paralysis; among them one patient improved completely and another patient improved from grade V to grade III facial paralysis. No patient developed any post operative intracranial complications and recurrence of cholesteatema not found in 6 months follow up. Meatal stenosis developed in 5% cases (p = 2) at the end of 6 months.
Conclusion
Surgery is mainstay of treatment in CSOM with cholesteatoma. Eradication of disease, prevention of complication, maintenance and restoration of hearing, and giving the patient a non-discharging ear are main aim of treatment.
doi:10.1007/s12070-010-0043-3
PMCID: PMC3450313  PMID: 23120707
Cholesteatoma; Chronic suppurative otitis media
9.  Inflation-deflation test as a predictor of aditus patency in patients with chronic suppurative otitis media 
Aims
To assess eustachian tubal function (ETF) preoperatively in patients with chronic suppurative otitis media (CSOM) with central perforation by performing the inflation-deflation test. To correlate the results of the inflation-deflation test with the finding of aditus patency or block in patients with CSOM
Study design
Prospective, cohort
Setting
Tertiary care hospital
Subjects
Eighty adult patients with chronic suppurative otitis media and central perforation were recruited into the study. There were 45 males and 35 females.
Methods
All patients underwent preoperative inflation-deflation test followed by cortical mastoidectomy and tympanoplasty. The patency of the aditus was assessed intraoperatively.
Main outcome measure
Equalization of pressure on inflation-deflation test and intraoperative assessment of aditus patency
Results
Of a total of 80 patients, 49 patients were found to have discharging ears and 31 had dry ears at the time of surgery. In dry ears the inflation-deflation test had a sensitivity of 93% in predicting aditus patency although the specificity was lower at 67%. In discharging ears the sensitivity in predicting aditus patency was 72% and the specificity was 67%.
Conclusion
The eustachian tube inflation-deflation test is a sensitive test for predicting aditus patency in patients with dry ears but less so in patients with discharging ears. Hence, it could be used in the former to avoid unnecessary exploration of the mastoid.
doi:10.1007/s12070-009-0060-2
PMCID: PMC3449973  PMID: 23120629
Chronic suppurative otitis media (CSOM); Eustachian tube inflation-deflation test; Aditus patency
10.  Peribulbar anesthesia in 750 patients treated with oral anticoagulants 
AIM
To check the safety of continuation of oral anticoagulants in ophthalmic procedures requiring a peribulbar anesthesia.
METHOD
A prospective case control study included 750 patients with oral anticoagulants in group A and 750 patients who had never been treated with oral anticoagulant in group B. Hemorrhages were graded as follows: 1) spot ecchymosis of eyelid and or subconjunctival hemorrhage; 2) eyelid ecchymosis involving half of the lid surface area; 3) eyelid ecchymosis all around the eye, no increase in intraocular pressure; 4) retrobulbar hemorrhage with increased intraocular pressure.
RESULTS
In group A, grade 1 was observed in 13 patients (1.74%) and grade 2 in 2 patients (0.26%). In group B, grade 1 was observed in 12 patients (1.6%) and grade 2 was absent. No 3 or 4 hemorrhage grade was encountered in both groups. There was not significant difference in grade 1 hemorrhage between both groups (P=0.21).
CONCLUSION
Oral anticoagulants were not associated with a significant increase in potentially sight-threatening local anesthetic complications.
doi:10.3980/j.issn.2222-3959.2014.01.20
PMCID: PMC3949469  PMID: 24634874
oral anticoagulants; eye procedure; hemorrhage; peribulbar block
11.  General and disease-specific quality of life in patients with chronic suppurative otitis media - a prospective study 
Background
Chronic suppurative otitis media (CSOM) is frequently associated with symptoms of inflammation like discharge from the ear or pain. In many cases, patients suffer from hearing loss causing communication problems and social withdrawal. The objective of this work was to collect prospective audiological data and data on general and disease-specific quality of life with validated quality of life measurement instruments to assess the impact of the disease on health-related quality of life (HR-QOL).
Methods
121 patients were included in the study. Patients were clinically examined in the hospital before and 6 months after surgery including audiological testing. They filled in the quality of life questionnaires SF-36 and Chronic Otitis Media Outcome Test 15 (COMOT-15) pre-operatively and 6 and 12 months post-operatively, respectively.
Results
Complete data records from 90 patients were available for statistical analysis. Disease-specific HR-QOL in patients with CSOM improved after tympanoplasty in all the scales of the COMOT-15. There was no difference in HR-QOL assessment between patients with mesotympanic respectively epitympanic CSOM. However, we did find the outcome to be worse in patients who received revision surgery compared with those receiving primary surgery. Audiometric findings correlated very well with the subscale hearing function from the COMOT-15 questionnaire. General HR-QOL measured with the SF-36 was not significantly changed by tympanoplasty.
Conclusions
Tympanoplasty did lead to a significant improvement of disease-specific HR-QOL in patients with CSOM while general HR-QOL did not change. Very well correlations were found between the subscale hearing function from the COMOT-15 questionnaire and audiological findings. Revision surgery seems to be a predictor for a worse outcome.
doi:10.1186/1477-7525-9-48
PMCID: PMC3148957  PMID: 21711571
12.  Periorbital Ecchymosis (Raccoon Eye) and Orbital Hematoma following Endoscopic Retrograde Cholangiopancreatography 
Case Reports in Gastroenterology  2017;11(1):134-141.
Endoscopic retrograde cholangiopancreatography (ERCP) is a conventional technique for diagnosis and treatment of pancratobiliary diseases, which is associated with various complications, including pancreatitis, hemorrhage, cholangitis, perforation, and mortality. In our case, a 69-year-old woman with positive hepatobiliary symptoms underwent ERCP, at the end of which a rare complication (raccoon eye) occurred, which was hypothesized to be due to amyloidosis, but the patient refused to complete the diagnostic procedure and became symptom free after 3 weeks. Racoon eye or periorbital ecchymosis is caused by blood tracking into periorbital tissues, which is frequently observed after head trauma but is also observed in systemic diseases, such as amyloidosis, neuroblastoma, and surgical interventions. To the best of our knowledge, this is the first report of raccoon eye after ERCP; further reports will help to confirm that this complication should also be considered before performing ERCP and that complete diagnostic tests for the predisposing diseases prior to ERCP are necessary.
doi:10.1159/000456657
PMCID: PMC5465703
Eye; Ecchymosis; Cholangiopancreatography; Endoscopic retrograde cholangiopancreatography
13.  Complications of Chronic Suppurative Otitis Media and Their Management: A Single Institution 12 Years Experience 
To determine the incidence of otogenic complications of Chronic suppurative otitis media (CSOM) and its management. The study was conducted at the tertiary referral centre and teaching hospital. An analysis was made about the clinical and operative findings, surgical techniques and approaches, the overall management and recovery of the patient. The data were then compared with the relevant and available literature. Over the study period of 12 years, a total 45 cases of CSOM with complications were reviewed. Out of these 45 cases, 20 cases had extracranial (EC) while 25 cases had intracranial (IC) complications. The prevalence of each complication was 0.17 and 0.13 %, IC and EC respectively. The commonly encountered IC complications were brain abscess, meningitis and lateral sinus thrombophlebitis. Among the EC complications, mastoid abscess followed by labyrinthitis and facial nerve palsy were encountered. The reliable warning signs and symptoms of IC complications were fever, headache, earache vestibular symptoms, meningeal signs and impairment of consciousness. Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus epidermidis were the common organism isolated. Cholesteatoma and granulation in the middle ear were the major findings in both groups of cases. Surgery was main modality of management of these conditions. We observed that two patients fail to regain full facial nerve function despite of surgery. Mortality rate was zero but morbidity was seen in 15 % (3) and 28 % (7) of cases in EC and IC group respectively. The epidemiological presentation, clinical features and results of treatment are discussed. CSOM complications, despite its reduced incidence still pose a great challenge in developing countries, as the disease present in the advanced stage leading to difficulty in management and consequently higher morbidity. In this study we emphasize the importance of the accurate and early diagnosis followed by adequate surgical therapy with multidisciplinary approach.
doi:10.1007/s12070-015-0836-5
PMCID: PMC4678280  PMID: 26693451
Chronic suppurative otitis media (CSOM); Extracranial complications; Intracranial complications; Cerebellar abscess; Meningitis; Lateral sinus thrombophlebitis
14.  Case Report of Youngest Successful Bilateral Cartilage Tympanoplasty in India 
Paediatric Chronic Suppurative Otitis Media (CSOM) remains a challenge for the treating otologists. Usually, concurrent foci of infection lie in the oropharynx or nasopharynx and treating these eventually leads to resolution of ear discharge. However, refractory cases can be threatening in view of complications secondary to CSOM.
A two year and 10-month-old child presented with recurrent profuse mucopurulent ear discharge which had been refractory to multiple medical treatment. Recently she had recurrent otitis external episodes with excoriations of canal skin. Child underwent bilateral tympanoplasty with cartilage palisading technique. At eight months follow-up, the neotympanum is intact and the child had no further episodes of ear discharge.
This case to our knowledge is the youngest child to undergo a bilateral successful cartilage tympanoplasty in Indian subcontinent. This case report is written with the aim to highlight the fact that cartilage tympanoplasty can be considered in treating refractory cases of paediatric CSOM.
doi:10.7860/JCDR/2016/20434.8967
PMCID: PMC5296467
Chronic suppurative otitis media; Neotympanum; Pseudomonas aeruginosa
15.  Demography, types, outcome and relationship of surgically treated intracranial suppuration complicating chronic suppurative otitis media and bacterial rhinosinusitis 
Introduction:
Surgically treated intracranial suppurations (ICS) are uncommon, life-threatening neurosurgical emergencies. They can result from complication of chronic suppurative otitis media (CSOM) and bacterial rhinosinusitis (BRS). The objective of this study was to know the frequency of BRS and CSOM and relate it to its rare complication of surgically treated ICS while also describing the demography, type and outcome of ICS that resulted from BRS and CSOM.
Materials and Methods:
All patients that presented to the Otorhinolaryngological department and Neurosurgical unit of the same institution with clinical and radiological features of CSOM, BRS, and ICS were prospectively studied over a 5-year period. Patients were followed up for a minimum of 3 months.
Results:
Two thousand, two hundred and seventy-nine patients presented during the 5-year study period. Of all these patients, 1511 had CSOM (66.3%) and 768 (33.7%) presented with features of BRS. Eleven (0.73%) had ICS complicating their CSOM while 8 (1.04%) cases of surgically treated ICS followed BRS. Bacterial rhinosinusitis was not more likely to lead to ICS (P = 0.4348). The Odds ratio (OR) of a child ≤ 18 years of age with CSOM developing ICS was 5.24 (95% Confidence interval 1.13-24.34; P = 0.0345), while it was 7.60 (95% Confidence interval 1.52-37.97; P = 0.0134) for children with BRS.
Conclusions:
The most common type of ICS complicating CSOM and BRS was brain abscess and subdural empyema, respectively. Children are more prone to develop surgical ICS following CSOM and BRS. The proportion of males that had ICS was higher in both CSOM and BRS patients. Optimal outcome is achieved in patients that presented with GCS of 13 and above.
doi:10.4103/0976-3147.145202
PMCID: PMC4271382  PMID: 25540539
Bacterial rhinosinusitis; brain abscess; chronic suppurative otitis media; epidural abscess; subdural empyemas
16.  Aerocyst urethral catheter insertion compared to expansion sponges application in external dacryocystorhinostomy 
AIM
To evaluate the clinical effect and complications of two different filling materials (aerocyst urethral catheter and expansion sponges) applying in external dacryocystorhinostomy (EXT-DCR) and compare their advantages and disadvantages.
METHODS
A retrospective study was made in the period from April, 1 2000 to April, 1 2005. Totally 180 patients (240 eyes) underwent the EX-DCR using different filling materials and divided into three groups randomly: negative control groups (group 1), expansion sponges group (group 2) and aerocyst urethral catheter group (group 3). The gender, etiology, clinical findings, surgical technique, filling materials, the condition of ocular surface and complications were analyzed. Filling materials were removed during day 7. Postoperative success was determined by lacrimal patency to irrigation, a positive dye test, hemorrhage and errhysis conditions after extubation and subjective resolution of epiphora and liquor puris.
RESULTS
During a mean follow-up of 5.14±1.69 years, the success rate were 73.7% (group 1), 86.5% (group 2), 98.7% (group 3) in three groups. There was significant statistical difference among three groups in the surgical success rate and the operative complications (including hemorrhage, errhysis, periorbital ecchymosis after extubation)(P<0.05).
CONCLUSION
EXT-DCR with aerocyst urethral cathete intraoperatively have higher success rate, fewer operative complications and a high patient satisfaction ,and can be used to simplify and speed up traditional EXT-DCR.
doi:10.3980/j.issn.2222-3959.2011.05.08
PMCID: PMC3340728  PMID: 22553710
aerocyst urethral catheter; filling material; dacryocystorhinostomy
17.  A Study of the Bacteriological Profile of Chronic Suppurative Otitis Media in Agartala 
Chronic suppurative otitis media (CSOM) is one of the most commonly encountered diseases in otolaryngology practice. Even in this era of powerful antibiotics, CSOM still consumes considerable medical expenditure, especially in the poorer sections of the society. The present prospective study was conducted at the IGM Hospital, Agartala, in North East India towards clinico-microbiologic evaluation of chronic suppurative otitis media. The focus was mainly on aerobic bacteria, involved in active CSOM in adults as well as children. An attempt was made, despite resource and man power constraints, to have a glimpse of the current antibiotic sensitivity pattern, with special reference to ciprofloxacin. However, the main aim of this study is to see the types of aerobic bacteria involved in CSOM, in our region. Aural swabs were collected from 100 ears, from 97 patients complaining of ear discharge, continuous or intermittent, with a non- intact tympanic membrane for at least 12 weeks. Swabs were sent to the hospitals microbiology laboratory for culture and sensitivity tests. Bacteria could be isolated in 53 cases and 47 swabs were culture negative. The commonest bacteria isolated was pseudomonas (20) followed by Staphylococcus aureus (11), E. coli (11), proteus (9) and klebseilla (2). Three patients had bilateral ear discharge of which one had proteus in both ear swabs, one grew proteus in one ear and no growth in the other, and one patient showed no aerobic bacteria in any of his ear swabs. Among the culture positive cases (n = 53) gram negative bacteria were isolated in 79.24% (n = 42) and S. aureus in 11(20.75%) cases. Among 97 patients number of male and female patients was 50 and 47, respectively. Pseudomonas, E. coli, Bacilli proteus and S. aureus were the predominant bacteria involved in CSOM. Out of the 53 positive isolates ciprofloxacin could be tested against 35 i.e., 66%. Ciprofloxacin was sensitive in 26 isolates, intermediately sensitive in 4 and resistant in only five isolates. It is concluded that, gram negative bacteria especially pseudomonas is the commonest bacteria involved in CSOM in this part of north east India. Ciprofloxacin is an important tool in the management of active CSOM as it is cheap, less ototoxic and widely available as topical preparations.
doi:10.1007/s12070-011-0323-6
PMCID: PMC3477440  PMID: 24294571
Aerobic bacteria; CSOM; Culture and sensitivity; Ciprofloxacin
18.  Effect of Type 1 Tympanoplasty on the Quality of Life of CSOM Patients 
Chronic suppurative otitis media (CSOM) continues to be an important public health problem despite significant advances in medical science. Ear discharge, pain, discomfort, difficulty in hearing, limitation of routine activities and emotional problems due to CSOM cause a significant impact on the health and general well being of the patient. We have done Type 1 tympanoplasty in tubotympanic type of COM to reconstruct the tympanic membrane and alleviate the symptoms of the patients. This study presents an analysis of the impact of the surgery on the patient subjectively and its correlation with objective outcomes. 45 patients were selected to fill the chronic otitis media-5 (COM-5) questionnaire and underwent pure tone audiometry preoperatively. All the patients underwent Type 1 tympanoplasty by using temporalis fascia graft. The status of the ossicles was checked and documented intraoperatively. Patients requiring ossicular reconstruction or with attico antral disease were excluded. Patients were followed up for a period of 6 months and those with an intact graft after 6 months were included in the study. These patients were again made to fill the questionnaire and undergo pure tone audiometry postoperatively. 37 out of 45 patients (82 %) had an intact graft 6 months after surgery. Marked improvement was observed in subjective scores as documented by the questionnaire, pre- and postoperatively with the mean improvement in total scores being 7.89 ± 4.81 on a Visual Analogue Scale. Also significant improvement was achieved in closure of air-bone gap with the mean improvement being 14.73 ± 8.58 dB. Significant correlation was found between subjective and objective scores in most patients. This study showed that Type 1 tympanoplasty brings about a significant improvement in the quality of life of chronic suppurative otitis media patients. Most patients showed a marked improvement in subjective scores which correlated well with the objective findings of the status of the graft and improvement in air-bone gap. Asymptomatic patients with less preoperative scores showed less improvement in subjective scores which did not correlate with the objective outcomes.
Electronic supplementary material
The online version of this article (doi:10.1007/s12070-016-0989-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s12070-016-0989-x
PMCID: PMC5083660  PMID: 27833874
Quality of life; Type 1 tympanoplasty; CSOM
19.  Aetiological agents in chronic suppurative otitis media in Sri Lanka 
The Australasian Medical Journal  2011;4(2):101-104.
Background
Chronic suppurative otitis media (CSOM) is assumed to be a complication of acute otitis media (AOM), but the risk factors for CSOM are not clear. Objectives: 1. To study the aetiological organisms for CSOM. 2. To identify the effect of demographic factors on disease manifestation.
Method
This retrospective study included a case series of 234 patients who had been admitted to National Hospital of Sri Lanka (NHSL), with the complaint of ear discharge and from whom the specimens were sent for microscopy and culture at Department Of Microbiology, NHSL. The period of analysis was 1 year extending from 1 January 2009 to 31 December 2009.Consecutive patients who fulfilled the inclusion criteria were recruited to the retrospective analysis.
Results
Among 234 patients studied, 129 (55.1%) were male and 150 (64.1%) were under 40 yrs old. The mean age was 39.5 yrs (range 12 to 60 yrs, SD = 22.6). The mean duration of ear discharge was 1.2 yrs. (range 6 weeks to 20 yrs.) Pseudomonas species (29.5%) was the commonest microbial organism to cause ear discharge, followed by staphylococcus (20.5%) and coliform (16.7%) species. Among the fungal agents identified, candida was the most common. 23.1% of the cultures did not reveal any microbiological agent. Eighteen patients (8%) had a prior history of trauma to the affected ear and 51 patients (21.8%) were diagnosed with diabetes mellitus.
Conclusion
The commonest microbial agents implicated in CSOM was pseudomonas species followed by staphylococci and coliforms. Demographic variables such as gender or age did not seem to affect the disease manifestation significantly, though CSOM was less common among elderly and women.
doi:10.4066/AMJ.2011.549
PMCID: PMC3562924  PMID: 23386888
Chronic suppurative otitis media; aetiology
20.  Use of Kaolin-impregnated Gauze for Improvement of Intraoperative Hemostasis and Postoperative Wound Healing in Blepharoplasty 
Purpose: Kaolin is a mineral shown to be effective in controlling hemorrhage when combined with standard gauze and applied to wounds. This study investigates the application of kaolin to control intraoperative bleeding and promote wound healing in eyelid surgery. Methods: This prospective, randomized, double-blind study recruited patients who underwent eyelid surgery. Following skin incision, kaolin-impregnated gauzewas placed in one eyelid wound bed and cotton gauze in the other, then removed. Distinct, individual areas of bleeding were recorded. Standardized photographs were obtained postoperatively on Day 1, 4, and 7. Photographs were graded for edema and ecchymosis by four blinded observers. Patients also completed a survey inquiring which side had more bruising, swelling, and pain at each return visit. Results: A total of 46 patients completed the study. The number of intraoperative bleeding sites for kaolin versus plain gauze was not significantly different (p=0.96). Photographic grading by blinded observers did not identify any statistically significant differences in postoperative edema at any time point between lids. There was a statistically significant difference for ecchymosis at postoperative Day 4 (p=0.009) and Day 7 (p=0.016). Patient surveys did not show any difference in perceived edema, ecchymosis, or pain between lids. Conclusion: Intraoperative hemostasis was not affected by the use of kaolin-impregnated gauze. The effectiveness of kaolin in wound healing showed improved ecchymosis at Days 4 and 7 when assessed by blinded observers. Patients did not notice any improvement in postoperative edema, ecchymosis, or pain.
PMCID: PMC4928457  PMID: 27386052
21.  Recurrent bilateral periorbital and circumoral bruising due to vomiting 
BMJ Case Reports  2014;2014:bcr2013202495.
Periorbital ecchymosis is due to extravasations of blood into the periorbital skin and the subcutaneous tissues around the eyes. ‘raccoon eyes’ or ‘panda sign’ is a distinctive type of periorbital ecchymosis where the bruising is characterised by tarsal sparing. This sparing is due to an anatomical structure called the orbital septum, which limits the spread of the discolouration beyond the tarsal plate. Hence ‘raccoon eyes’ description should be limited to orbital ecchymosis due to basal skull fractures only. While the bilateral bruising due to direct trauma to the eyes, or non-traumatic medical conditions, can spread beyond the tarsal plate as in our case. The differential diagnosis varies from trivial benign conditions to serious life-threatening illnesses. We describe a case of recurrent bilateral periorbital ecchymosis and facial bruising due to vomiting.
doi:10.1136/bcr-2013-202495
PMCID: PMC3987509  PMID: 24695659
22.  Nasopharynx as a Microbiologic Reservoir in Chronic Suppurative Otitis Media: Preliminary Study 
Objectives
The present study was designed to identify the correlations of bacterial strains of the middle ear and the nasopharynx in chronic suppurative otitis media (CSOM) patients who were scheduled for operations.
Methods
Sixty-three patients with CSOM were enrolled in the study. Culture specimens were collected from the middle ear and nasopharynx of patients who were admitted for operation. Samples collections were performed 3 times; from the middle ear and nasophaynx at the admission day, from the middle ear during the operation, and from the external auditory canal post-operatively. Bacteria were identified by gram staining and biochemical tests. The correspondence rate of organisms which simultaneously exist in the middle ear and the nasopharynx was measured.
Results
Sixty-eight organisms were isolated from the middle ear and 57 organisms from the nasopharynx among 63 patients. Of 68 bacteria identified in middle ear, 26.52% (18 bacteria) corresponded with those of nasopharynx. MRSA had the high correspondence rate, and of 18 methicillin-resistant Staphylococcus aureus (MRSA) isolated from middle ear, 33.3% (6 bacteria) corresponded with nasophaynx. Meanwhile, 3 organisms of MRSA were detected from the external auditory canal post-operatively, although they were only found in nasopharynx pre-operatively.
Conclusion
The current trend of middle ear swab alone for bacterial detection would be insufficient to identify the potent MRSA and impede early antibiotic intervention for the effective middle ear surgery. Therefore, it is necessary to perform nasopharynx cultures together with conventional middle ear culture to control potent risk for infection pre-operatively.
doi:10.3342/ceo.2011.4.3.122
PMCID: PMC3173702  PMID: 21949577
Bacteriology; Chronic suppurative otitis media; Nasopharynx
23.  Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations 
Supplemental Digital Content is available in the text.
Background:
Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.
Methods:
Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.
Results:
A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).
Conclusions:
Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.
doi:10.1097/GOX.0000000000000545
PMCID: PMC4778899  PMID: 27014557
24.  Allergic Rhinitis in Adults with Chronic Suppurative Otitis Media 
Introduction:
Chronic suppurative otitis media (CSOM) is considered one of the most common causes of acquired hearing impairment in developing countries. CSOM is a multifactorial persistent inflammatory disease of the middle ear. A distinct pathophysiologic mechanism linking allergic rhinitis (AR) and CSOM remains to evolve. The purpose of this study was to investigate the association between AR and CSOM in adults.This was a case-control study.
Materials and Methods:
The subjects were 62 adults (23 male, 39 female) with established CSOM and 61 healthy controls. CSOM was diagnosed when there was a history of chronic (persisting for at least 3 months) otorrhea, accumulation of mucopurulent exudates in the external auditory canal or middle ear and/or perforated tympanic membrane on otoscopy. All participants were evaluated for the presence of AR by clinical evaluation of allergic symptoms, and underwent a skin-prick test for 23 common regional allergens. Statistical analysis was performed using SPSS version 16.
Results:
The prevalence of clinical rhinitis (allergic and non-allergic) was significantly higher among the cases compared with controls (62.5% vs. 37.5%, P=0.02). The prevalence of AR (proven by positive skin-prick test) was also significantly higher among affected adults than controls (24.6% and 13.8%, respectively). Adjusting for age, a logistic regression model showed that there was a significant difference between the two groups. Patients with AR and non-AR were at 3.27- (95% CI=1.15–9.29; P=0.036) and 2.57-(95% CI=1.01–6.57; P=0.048) fold increased risk of developing CSOM, respectively, compared with healthy individuals.
Conclusion:
The study showed a higher prevalence of AR in CSOM patients than in controls. It may be valuable to evaluate and control this factor in these patients.
PMCID: PMC4710877  PMID: 26788473
Allergic; Hypersensitivity; Otorhinolaryngologic diseases; Otitis Media; Rhinitis; Suppurative; Skin test
25.  Observations on the Current Bacteriological Profile of Chronic Suppurative Otitis Media in South Eastern Nigeria 
Background:
Chronic suppurative otitis media (CSOM) is a disease well-known for its recurrence and persistence despite treatment. The situation is compounded by the increasing resistance to antimicrobial agents by bacteria these days.
Aim:
This study was carried out to examine the current local bacteriological profile of CSOM and to compare the profile of either ear in bilaterally discharging ears.
Materials and Methods:
We carried out a retrospective analysis of ear swab cultures from 133 unilateral and 73 bilateral consecutive tubotympanic CSOM cases seen at the Ear-Nose-Throat clinics of a referral health institution during a 4 year period ending 2013. Sensitivities to eight locally available antibiotics were analyzed. Aerobic bacterial isolates were analyzed separately for the unilateral and bilateral cases. Comparison was made between the ears in the bilateral cases.
Results:
We analyzed 279 ear swab culture results from 206 patients with age ranging from 5 months to 86 years and a mean of 21.3 (19.5) years. Pseudomonas aeruginosa was the most common isolated bacteria (44% [109/250]) followed by Staphylococcus aureus (17% [42/250]), and Proteus Mirabilis (15% [38/250]). The most and least sensitive bacteria were Klebsiella Spp and Escherichia Coli, respectively. The most effective antibiotics were gentamicin and ciprofloxacin. The two ears differ significantly in the rates of isolation of S. aureus and E. coli (P = 0.01 and P = 0.04, respectively).
Conclusion:
Pseudomonas is the most common bacteria involved in CSOM in this part of the country. Ciprofloxacin as ear drops is recommended as first-line drug in the management of active CSOM as it is cheap, less ototoxic, and locally available. Separate ear swab culture should be obtained in bilateral CSOM.
doi:10.4103/2141-9248.153622
PMCID: PMC4389327  PMID: 25861532
Bilateral; Chronic; Culture and sensitivity; Otitis Media; Pseudomonas

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