Abstract:

Background: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a challenging condition that substantially impacts the quality of life of patients. The biologic drug, dupilumab, received Food and Drug Administration (FDA) approval in 2019 for treating CRSwNP when conventional therapy or surgery is ineffective. Real-world studies have demonstrated the promising results of dupilumab; however, additional data regarding its effectiveness and safety profile are required. We retrospectively gathered data on the effectiveness and safety of dupilumab in patients with CRSwNP a Saudi Arabian tertiary care setting, specifically focusing on patients that met the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020) criteria for biologic treatment. Methods: Focusing on the efficacy and safety of the medication, 22 adult patients diagnosed with CRSwNP and treated with dupilumab at Dr. Sulaiman Al Habib Hospitals between January 2020 and December 2023 were retrospectively analyzed based on post treatment improvement in: olfaction visual analogue scale (VAS) score, sinonasal outcome test 22 (SNOT22), eosinophil (ESO) count, total immunoglobin E (IgE) levels and total nasal polyp score (NPS). Results: Positive outcomes in terms of median improvement changes in various parameters such as olfaction (VAS) score from 10 to 0 , (SNOT22) from 45 to 15.5, (ESO) count from, total (IgE) levels from 134.7 to 19, and total (NPS) from 4 to 0 were identified. No participant required rescue interventions, the most common side effects were arthralgia and injection site erythema in a mean duration of follow up of 1. 8 years. Conclusion: Dupilumab is a safe and effective treatment for CRSwNP patients in Saudi Arabia, aligning with EPOS2020 criteria for biologic treatment. However, further research and follow-ups are necessary to confirm these initial findings.

Abstract:

Background: Cleft lip and palate, a common congenital anomaly in plastic surgery, occur in approximately one in every 1000 newborns. Effective postoperative pain management in pediatric patients undergoing repair for cleft lip and palate remains a challenge. Therefore, this systematic review and meta-analysis aim to assess the effectiveness of nerve block in controlling postoperative pain compared to other methods in pediatric patients undergoing cleft lip and palate repair. Methods: This systematic literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines . A comprehensive search was conducted across multiple databases, including Embase, MEDLINE, Cochrane, and SCOPUS, without timeframe limitation. Results: The findings of the study indicate that dexmedetomidine achieved the longest duration of nerve block at 89.98%. This was followed by fentanyl (64.12%) and pethidine (51.62%), which also demonstrated significant durations of nerve block. Clonidine exhibited a moderate rate of nerve block at 29.62%. In contrast, the control group exhibited the lowest rate of block at 14.65%. Conclusion: Our systematic review and meta-analysis support the efficacy and safety of nerve blocks, particularly with dexmedetomidine, for postoperative pain management in pediatric cleft lip and palate repair. Adjuvant-enhanced nerve blocks offer extended pain relief and reduce reliance on opioids. Further research and standardized protocols are needed for broader implementation.

Abstract:

Background: Bariatric surgery, widely considered the most effective surgical treatment for obesity and its complications, carries risks and benefits, including a common issue with eustachian tube defects. This study aims to evaluate the association between weight loss following bariatric surgery and Eustachian tube dysfunction (ETD). Methods: This descriptive cross-sectional study included 256 patients who underwent bariatric surgery at a tertiary center in Riyadh, Saudi Arabia between January 2020 and December 2021. Data was obtained through the use of an online questionnaire administered via telephone interviews, which included demographic details, clinical presentation, and an Arabic-validated version of the (ETD-7) questionnaire. Participants with a past history of ear disease, symptoms, or previous ear surgery were excluded from the study. Results: In a study involving 314 initial subjects, 256 patients were included, while 58 were excluded due to various criteria, such as previous ear surgery, a history of Eustachian tube dysfunction, or missing data. The demographic analysis revealed a diverse age distribution, with the majority falling between 31 to 50 years, and a higher representation of females (63.4%) compared to males (36.6%). Most patients were non-smokers (83.7%). The BMI analysis pre- and post-bariatric surgery showed a significant reduction, with a mean pre-op BMI of 45.87 and post-op BMI of 29.41. Only 8.9% of patients experienced Eustachian tube dysfunction post-surgery, while 91.1% did not report such issues. Conclusion: Our findings suggest that sudden and severe weight loss may not be a significant cause of the development of ETD; more research with more extended follow-up periods using tubal dysfunction testing is needed to uncover the potential underlying causes of these symptoms.

Abstract:

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the involvement of multiple organ systems. Among the various manifestations, there is growing recognition of the impact on auditory-vestibular symptoms such as hearing loss. Objectives: To determine the prevalence of hearing loss among SLE patients in our region and to identify predictive factors associated with its development. Methods: A cross-sectional study was conducted at the rheumatology clinic in King Fahad Hospital of the University in Al-Khobar, Saudi Arabia, enrolling patients diagnosed with SLE. Data including demographics, clinical presentation, laboratory, and medication were collected. Pure tone audiometry, speech audiometry, and tympanometry assessments were performed to evaluate the hearing status. Data were analyzed using descriptive frequency, percentage distribution, and logistic regression analysis. Results: A total of 53 SLE patients were included in the study. The prevalence of hearing loss was 15%, of which 87.5% were sensorineural hearing loss (SNHL). Logistic regression analysis revealed that age >36 (p= 0.020), the presence of diabetes mellitus (p= 0.039), cranial nerve disorder (p= 0.009), pyuria (p= 0.012), and the use of hydroxychloroquine (HCQ) (p= 0.00717) were significantly associated with an increased risk of hearing loss in SLE patients. Conclusion: Hearing loss, especially SNHL, has been observed in SLE patients. Factors associated with increased risk are older age, diabetes mellitus, cranial nerve disorders, pyuria, and the use of HCQ. These findings emphasize the significance of regular audiological assessments to mitigate the risk of SLE-related hearing loss.

Abstract:

Background: Suture lateralization was first described by Kirchner in 1979 via endoscopic technique.  In 1984, Lichtenberger introduced a special endo-extralaryngeal needle carrier for endo-extralaryngeal technique. Percutaneous suture lateralization was illustrated initially via the Lasso Technique. In addition, Howell et al found the same technique can be adopted for stent placement. The objectives of the study are reviewing and comparing the published suture lateralization by the addressing indication, the technique, the type of used suture, the anesthetic technique, and their impacts on the outcomes (voice, swallowing, need of revision, vocal cord mobilities). Methods: A systemic review & Meta analysis study. All published studies examining/addressing our objectives “outcomes of suture lateralization” reviewed including all experimental and observational studies. Information sources: Database: PubMed, Web of Science, Cochrane Library, and Embase databases, In addition to studies’ references were reviewed, all studies included till Feb 2024. 

Abstract:

Background: Inferior turbinate hypertrophy (ITH) is a common condition causing chronic nasal obstruction, significantly affecting the quality of patients' life. ITH reduction surgery is indicated when medical treatment fails. This study aims to compare and measure post-operative outcomes among various surgical techniques for reducing inferior turbinate hypertrophy (ITH), and to identify the factors associated with the clinical outcomes of turbinoplasty in patients with this condition. Methods: A cross-sectional study was carried out from January 2021 to December 2022 at the Otorhinolaryngology Department of King Abdulaziz Medical City in Riyadh, Saudi Arabia. A total of 301 adult patients with ITH were included and were divided into different groups. Postoperative follow-up assessments were completed after one week, one month, and 6 months to evaluate outcomes and complications associated with each surgical technique; descriptive analysis, cross-tabulation, and exact logistic regression were utilized as data analysis methods. Results: Most patients in both groups experienced partial or complete improvement after surgery, with 92% showing positive outcomes. Common clinical signs included deviated nasal septum deviation and external nasal deformity, while nasal obstruction was most frequently reported as the primary symptom. Post-surgery bleeding occurred in 3.7% of cases; no adhesions were noted. Microdebrider, medial flap, out-fracture, and submucosal diathermy techniques all demonstrated significantly higher improvement rates than others. Conclusion: The identified techniques with higher improvement rates offer evidence-based guidance for selecting optimal surgical approaches, while the study’s limitations warrant further prospective research to validate these findings. Ultimately, it contributes valuable knowledge to the field of otorhinolaryngology, aiming to enhance patient outcomes and improve the management of ITH worldwide.

Abstract:

Background: Biological therapy is a newer line of treatment that has been utilized in the practice for patients with chronic rhinosinusitis with nasal polyps with excellent results. Similarly, recent advancements in the understanding of the pathophysiology of allergic fungal rhinosinusitis (AFRS) have prompted the investigation of biologics as a possible treatment option. Hence, our aim is to highlight the significance of biologics in the management of AFRS. Methods: Using the Web of Science, Cochrane, MEDLINE, and Embase databases, we analyzed studies that used biologics in AFRS patients which were published until February 2024. The studies were extracted, and data were pooled for meta-analysis. Results: Of 1103 studies identified, eight studies were included in the systematic review, in which five of them were involved in the meta-analysis. Results showed significant effects of biologics in terms of SNOT-22 score, demonstrating a mean improvement of 62%, with the Dupilumab group exhibiting the highest improvement rate. Our pooled analysis showed that biologics have significantly decreased the SNOT-22 and Philpott-Javer staging score (35.5; p<0.0001) and (33.53; p=0.005), respectively. Also, our findings showed that biologics have significantly decreased the level of total IgE and serum eosinophil. Lastly, the overall recurrence rate and adverse events rate were found to be 3.3% and 1.7%, respectively. Conclusion: This review recognized favourable effects and safety of biological therapy in the management of AFRS. Biologics demonstrated a marked improvement in clinical findings, laboratory markers, and perhaps eliminating the burden of surgical revisions and recurrence rates, with the safety profile appearing favourable.

Abstract:

Background: Caudal septal deviation involves displacing the anterior part of the nasal septum, leading to breathing difficulties, nasal obstruction, snoring, and aesthetic concerns. This condition can be congenital, caused by trauma, or result from previous medical procedures. It affects the nasal valve area and tip, complicating surgical management. Challenges include cartilage memory and risks such as loss of nasal tip support. While various surgical techniques are available, they are only sometimes ideal. Methods: We conducted a systematic review and meta-analysis by searching Medline, SCOPUS, PubMed, and Cochrane Library databases and manually checking references until February 2024. We used a random-effects model for meta-analyses to assess functional and aesthetic outcomes and complication rates. Heterogeneity was measured using the I² statistic, and publication bias was evaluated with funnel plots and Egger&#039;s test. Results: We included forty-one articles published from 1994 to 2022, covering 3,055 cases with an average age range of 17 to 49 years. The study designs were retrospective (23), prospective (16), case report (1), and case-control (1). Surgical techniques demonstrated improvements in both functional and aesthetic outcomes. Common complications included hemorrhage/hematoma and dorsal irregularities. The most common causes were developmental, followed by traumatic causes. Severe caudal dislocations often required grafting or extracorporeal techniques, while milder cases utilized less invasive methods like laser-assisted septoplasty and suturing. The study also discussed two classification systems to understand and treat caudal septal deviations better. ComparingSurgical Outcomes: We used Patient-reported Outcome Measures (PROMs) like Nasal Obstruction Symptom Evaluation (NOSE), Visual Analogue Scale (VAS), and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) to evaluate surgical effectiveness. Significant improvements were noted across different techniques, although variability highlighted the need for standardized protocols. VAS scores showed significant pain reduction with the suture technique, and NOSE scores indicated improvements in nasal obstruction symptoms post-surgery. Conclusions: This study provided a comprehensive analysis of surgical techniques for caudal septal dislocation, emphasizing the importance of selecting techniques based on case specifics and patient awareness. It introduced new techniques and classification systems and advocated for further research to enhance patient outcomes and understanding of caudal septal deviations.

Abstract:

Background: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a disease that significantly affects the patient quality of life, it shares it pathogenic mechanism through type-2 inflammation with other diseases like, bronchial asthma and eczema. This disease is known to be more severe with higher recurrence rates comparing to other types of chronic rhinosinusitis.1 Patients with CRSwNP may require multiple surgeries along with medical management, and over the last couple of years this proportion of patients was offered the new biologic therapy “Dupilumab” which is very effective in controlling their disease.2 Dupilumab was approved by the Food and Drug Administration for treating CRSwNP. It is a monoclonal antibody that exerts its effect by blocking the activity of IL-4 and IL-13 which plays an important role in type-2 inflammation.3 Dupilumab was approved by the Food and Drug Administration for treating CRSwNP in 2019 and since then many studies has confirmed its effectiveness.2-6 It is delivered subcutaneously every two weeks for the first year, however following that there has been no agreement on the proper dose adjustment. This medication has been used in JHAH since the late 2020, and the protocol applied here was to shift the patient to once monthly injection after the first year. Objectives: To assess if the change in dosing after the first year has affected the effectiveness of Dupilumab Materials and Methods: The patients who have been receiving Dupilumab for more than a year and has been shifted to the once monthly regimen for at least four months will be included in the study. The following parameters will be used to assess CRSwNP control: Sino-Nasal Outcome Test (SNOT) score, serum IgE levels, absolute eosinophilic count, nasal polyp size and the Lund-Mackay score. These parameters will be compared at three points of time as follows: before starting the treatment, at least four months after starting Dupilumab and at least four months after adjusting the dose.

Abstract:

Background: Septoplasty is a common procedure addressing deviated nasal septums for enhanced nasal airflow. Post-surgery, stabilization, and bleeding control are achieved through either nasal packing or septal stitches. The debate persists on their relative effectiveness and safety. This study aims to compare outcomes and risks, including bleeding, pain, septal issues, nasal obstruction, and patient satisfaction, associated with stitches versus nasal packing after septoplasty. Methods: A comprehensive literature search was conducted across multiple databases, including PubMed, SCOPUS, Cochrane, and Web of Science, spanning from 2000 to March 2024. The inclusion criteria encompassed randomized controlled trials (RCTs) comparing the use of stitches through the septum and nasal packing in patients undergoing septoplasty. Study quality was evaluated using the Cochrane risk of bias tool. Data synthesis employed a random-effects model, computing Risk Ratios (RRs) or Mean Differences (MDs) with corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran’s Q test and the I2 statistic. Results: 25 RCTs were included, with 22 in the meta-analysis. Stitches through the septum had significantly lower rates of adhesions (RR 2.04, 95% CI 1.19-3.48), hematomas (RR 2.32, 95% CI 1.6-3.42), and nasal crusting (RR 2.86, 95% CI 1.17-6.97) compared to packing. Patients with stitches had significantly less post-op pain (MD 5.43, 95% CI 4.26-6.61). No significant dif-ferences in bleeding, infection, septal perforation, or residual septal deviation. Conclusions: Trans-Septal Suturing showed advantages over packing by reducing post-op morbidities like adhesions, hematomas, crusting, and pain while being as effective for controlling bleeding and septal positioning. However, more high-quality research is needed to guide clinical practice.

Abstract:

Background: Tonsillectomy is one of the most common surgical procedures around the world, with over 500,000 cases done annually. There are various reported complications, the most serious complication is post-tonsillectomy bleeding accounting for 1.6- 5.6%. Post tonsillectomy bleeding can be either primary occurring in the first 24 hours or secondary bleeding occurring beyond first 24 hours. The aim of study is to evaluate and analyze risk factors of secondary post tonsillectomy bleeding in Saudi Arabia. Methodology: This is a retrospective study, included all patient whom underwent tonsillectomy from Jan 2020 to May 2024. All patients charts were reviewed, and 26 variables were extracted from patients who developed secondary post tonsillectomy bleeding. Results: A total of 977 patients underwent tonsillectomy, 3.89% of patients developed secondary post tonsillectomy bleeding and 2.14% underwent secondary surgery to arrest the bleeding with male predominance accounting for 60.5%. Furthermore, age and gender has been significantly associated with increased risk of post tonsillectomy bleeding Conclusion: Incidence of secondary post tonsillectomy bleeding account for 3.89%. Not all cases required secondary surgical intervention for arrest of bleeding.

Abstract:

Background: Attention Deficit Hyperactivity Disorder (ADHD) and Sleep Disordered Breathing (SDB) are conditions that are commonly found and diagnosed in pediatric patients with potential interplay. Understanding their association is crucial for early intervention, and management. Objective: This study aims to determine the prevalence and association of ADHD among pediatric patients with Sleep Disordered Breathing (SDB) between the age 3-6 years old in the eastern province. Method: A cross-sectional study design was employed. An online survey including the ADHD rating scale IV – preschool version and the Pediatric Sleep Questionnaire (PSQ) was distributed to parents of children aged 3-6. The case group comprised SDB-positive patients awaiting adenotonsillectomy, while the control group consisted of age-matched children with negative PSQ screenings. Exclusion criteria included prior adenotonsillectomy, psychiatric follow-ups, and other mental disorders. Sampling involved contacting parents of children scheduled for adenotonsillectomy between March 2023 and January 2024. Data analysis was conducted by a biostatistician. Results: 3.3% was the overall prevalence of positive ADHD screenings in both groups (n = 2), with 5% in the case group (n = 1) and 2.5% in the controls (n = 1). 20% of the case group showed hyperactivity/impulsivity alone, 0% percent showed inattentiveness alone, and 5% showed both. Within the control group, 2.5 percent showed impulsivity or hyperactivity on its own, 2.5% showed inattention on its own, and 5% showed both. Even though the case group’s ADHD scores were higher, there was no statistically considerable difference that would prove the relationship between ADHD and SDB. However, a statistically significant positive correlation was found between PSQ scores and ADHD subscales. Conclusion: While a higher prevalence of ADHD symptoms was observed in pediatric SDB patients, the study did not find a statistically significant association, except in the relationship with raw scores of PSQ and ADHD symptoms. Further research with larger sample sizes is warranted to elucidate the relationship between ADHD and SDB in children.

Abstract:

Background: Head and neck cancers, including nasopharyngeal carcinoma (NPC), are relatively common in Saudi Arabia. Radiotherapy is a standard treatment for NPC, but it can lead to side effects, including post-radiation otitis media with effusion (OME). Managing post-radiotherapy OME remains a topic of debate, with various interventions proposed. This study aims to review the efficacy of different methods to manage post- radiotherapy OME in NPC. This includes tympanostomy tube insertion, frequent myringotomies, and observation. Methods: A systematic review was carried out for articles published between 1975 and 2023 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Excluded from the analysis were articles that involved patients undergoing surgical treatment for nasopharyngeal cancer, studies that focused on patients with other head and neck cancers who developed OME after radiotherapy, research investigating the effectiveness of surgical procedures unrelated to tympanostomy tube insertion, studies written in non-English language, and case reports, reviews, or conference letters. Results: A total of 450 studies were screened, of which six studies were included in the review, yielding 328 patients. The mean age ranged between 46 and 52 years. Follow-up varied from six months to 11 years. The intervention in all studies was tympanostomy tube insertion, and the controls were myringotomy, observation, or tympanic membrane fenestration with cauterization. The use of recurrent myringotomies for the treatment of OME in patients with NP post-radiotherapy is associated with improved chances for the resolution of effusion and decreased risk of complications when compared to tympanostomy tube insertion. Hence, we recommend following a step-wise approach when dealing with this group of patients, offering grommets for patients with persistent effusion or those who cannot tolerate frequent procedures.

Abstract:

Background: Tonsillectomy is defined as the surgical excision of tonsils by completely removing it including its capsule from the muscular wall1. It’s considered one of the most common surgical procedures with over 500,000 cases annually. Bleeding post tonsillectomy is one of the most serious complication. injectable local epinephrine consider on of the most effective method to control intra-operative bleeding in oral surgery, for which the current study highlight the effect of it on tonsillectomy procedures. Methods: This systematic review and subsequent meta-analysis were carried out following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The following online databases were searched from inception to January 2024. This analysis aimed to identify related randomized clinical trials (RCTs) from MEDLINE, PubMed, Scopus, Cochrane, Web of Science. An initial search of the five electronic databases yielded 322 potential studies. The data was screened in two stages; title-based and full-text reviews. Based on the PRISMA checklist and guidelines, full-text articles were retrieved and screened. 14 randomized clinical trials remained after exclusions. Results: The fourteen eligible, randomized control trial studies included a total of 876 patients who underwent tonsillectomy with injectable local epinephrine, with or without analgesic agents. Out of these, 545 patients received epinephrine with an analgesic agent (study group) and 495 patients received the placebo (control group). Out of the 14 included studies, 10 studies reported the amount of intra and post-operative bleeding (Epinephrine, 392 patients; Placebo, 393 patients). The use of epinephrine with different analgesic agents significantly reduced the amount of intra and post-operative bleeding. 11 studies have reported the pain scores of the patients, post-tonsillectomy (Epinephrine, 339 patients; Placebo, 349 patients). The use of epinephrine with different analgesics has significantly proved to reduce the pain of the patients after the operation and during the recovery period. Conclusion: In the current study, it shows that injectable local epinephrine during tonsillectomy have a significant effect on decreasing intra-operative bleeding, pain score, operation time, and post-operative recovery. For which the current study recommends the use injectable local epinephrine during tonsillectomy safely, to reduce tonsillectomy related complication.