An International Journal of Otorhinolaryngology Clinics

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2023 | January-April | Volume 15 | Issue 1

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Yasser M Mandour, Mohammed Shendy, Ahmed H El-Zobeir, Ayman A Mohammady, Shuzan A Mohammed, Naslshah G Kazem

Tumor Necrosis Factor Alpha Gene Level in Patients with Tympanosclerosis

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:1 - 4]

Keywords: Chronic otitis media with effusion, COME, OM, Otitis media, PCR, Polymerase chain reaction, QRT-PCR, Quantitative real time PCR, TNF-α, Tumor necrosis factor alpha

   DOI: 10.5005/jp-journals-10003-1418  |  Open Access |  How to cite  | 


Background: Tympanosclerosis is the calcification of middle ear connective tissue, including tympanic membrane, which sometimes occurs after middle ear inflammation. Tumor necrosis factor (TNF)-α tends to induce and maintain inflammatory responses in various diseases, including chronic otitis media with effusion (COME). Aim: To assay plasma level of TNF-α gene expression in patients with tympanosclerosis due to ventilation tube insertion. Methods: Sixty patients were included in this study. Patients were divided into two groups: Group A: 60 patients, according to inclusion and exclusion criteria, and Group B: 20 volunteers. Patients were subjected to history taking, full clinical examination, and laboratory investigation of TNF-α gene expression [quantitative real-time PCR (qRT-PCR)]. Results: There was a statistical difference between groups according to TNF-α gene expression, as the mean TNF-α in the case group (3.87) was statistically higher than in the control group I, p < 0.001. There was a statistical difference in TNF-α level regarding the number of tube insertion (p = 0.005) and duration of secretory otitis media (OM) (p = 0.042). However, there was no statistical difference in TNF-α level regarding medication use or episodes of acute OM. Conclusion: The degree of gene profile expression for TNF-α in selected middle ear structures with tympanosclerosis was statistically important, higher than the control group.



Abhinav Agarwal, JC Passey, Vikas Malhotra

Predictive Value of Middle Ear Risk Index Score in the Outcome of Tympanomastoidectomy and Tympanoplasty

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:5 - 8]

Keywords: Chronic Otitis Media, Middle ear risk index score, Tympanoplasty

   DOI: 10.5005/jp-journals-10003-1442  |  Open Access |  How to cite  | 


Background and objectives: Chronic otitis media (COM) is an otological challenge especially prevalent in developing countries like India for which tympanoplasty with or without mastoidectomy is the treatment of choice. In this study, we aim to assess the predictive value of the middle ear risk index (MERI) score in the outcome of tympanoplasty. Subjects and methods: Fifty patients who underwent surgery at Lok Nayak Hospital for chronic suppurative otitis media received preoperative MERI score assessments. They were subsequently followed, and their results were evaluated based on the MERI score. Results: There is a statistical significance concerning graft uptake and hearing gain based on the MERI score. As the MERI score increased, the chances of graft uptake decreased, and the mean hearing gain also decreased accordingly. Conclusion: All patients undergoing surgery for COM should be assessed preoperatively for MERI score so that appropriate counselling and prognostication can be done about the chances of success of surgery.



Surender Kumar, Deepak Verma, Uma Garg, M Hareesh

Correlation between Adenoidal–nasopharyngeal Ratio and Otitis Media with Effusion: A Cross-sectional Study

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:5] [Pages No:9 - 13]

Keywords: Adenoid hypertrophy, Adenoidal–nasopharyngeal ratio, Otitis media with effusion, Tympanogram, X-ray nasopharynx

   DOI: 10.5005/jp-journals-10003-1446  |  Open Access |  How to cite  | 


Background: Adenoid hypertrophy is one of the most common health problems affecting the pediatric population. This study aims to correlate the adenoidal–nasopharyngeal ratio (ANR) with otitis media with effusion (OME). If OME is left undiagnosed it can lead to long-term consequences like hearing impairment, learning and speech disabilities, and even chronic otitis media in children. The current study was a cross-sectional study conducted at a tertiary care center in Haryana, India. ANR was determined by dividing adenoidal depth with nasopharyngeal depth on the plain lateral radiographs and OME was diagnosed by tympanometry. Results: The study consists of 70 children in the age group of 3–12 years with symptoms of adenoid hypertrophy. The children were almost similar in number in the three age groups we had selected with male preponderance. Otoscopy and tympanogram results were matching in our study. Types B and C tympanograms indicate middle-ear effusion seen in either one ear or both. In our study, type-A curves (non-diseased) were well correlated with low ANR, and types B and C curves (diseased) were well correlated with high ANR. Conclusion: Adenoidal–nasopharyngeal ratio obtained from the X-ray will give an arithmetic measurement of adenoid mass with respect to available nasopharyngeal space. The simple outpatient tympanometry provides objective evidence of OME. The present study proved the positive correlation between ANR and OME by correlating ANR with tympanogram findings.



Poonam Kumar Saidha, Vikas Kakkar, Pooja Das, Sahil Kapoor

Malignant Otitis Externa: Association of Biochemical Markers with Staging of the Disease and Emergence of Methicillin Resistant Staphylococcus aureus as a Causative Agent

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:5] [Pages No:14 - 18]

Keywords: C-reactive protein, Diabetes mellitus, Glycosylated Hb, Methicillin resistant Staphylococcus aureus, Skull base osteomyelitis

   DOI: 10.5005/jp-journals-10003-1430  |  Open Access |  How to cite  | 


Background and objectives: Malignant otitis externa (MOE) is a potentially fatal illness that affects the soft tissues of the exterior ear and neighboring structures and has a propensity to advance fast to the skull base and the periosteum. The goals of this study were to demonstrate a clinical association between MOE phases and biochemical markers such as glycosylated Hb (HbA1c), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) levels, as well as to detect improvements in clinical symptomatology and the emergence of Methicillin resistant Staphylococcus aureus (MRSA) as a causative agent. Methodology: Patients coming to the ear nose throat out patient department (ENT OPD) with diabetes mellitus (DM), otalgia, and ear discharge were given a detailed history and clinical examination. An otoscope was used to examine and look for external canal edema, granulation tissue, bone erosion, and TM perforation. Under aseptic conditions, pus from the external auditory canal (EAC) was collected for culture and sensitivity testing. Baseline HbA1c, ESR, and CRP levels were measured, and high resolution computed tomography (HRCT) temporal bone in the axial and coronal planes was done. The patients were staged using Chandler's clinical pathological staging based on CT and clinical findings. Intravenous course of antibiotics, paracetamol, and local aural flushes were administered. After the first and second months, the patients were asked for a follow-up visit. The otoscopic evaluation was repeated under a microscope. Further under all aseptic conditions, pus from the EAC was collected for culture and sensitivity and HbA1c, ESR, and CRP levels were sent again. Patients was staged afresh as per the Chandler's classification. Results: A drop in HbA1c levels is an excellent prognostic predictor of the illness. The periodicity of diabetes has little effect on the diseases prognosis. Pseudomonas aeruginosa is the most prevalent etiological factor, although MRSA was also witnessed in the culture sensitivity report from these selected patients. A decline was observed in ESR and CRP values after 2 months of treatment. Conclusion: In conclusion, “MOE is an invasive, potentially life-threatening infection of the external ear” which rapidly advances to the skull base in uncontrolled diabetics and immunocompromised patients. Response to medication can be tracked by ESR, CRP, and glycated HbA1c. The research focuses the need of controlling this infection with medical treatment, emphasizing the fact that surgical care is restricted for stages I, II, and III.



Urvi Saini, Poonam K Saidha, Garima Singal, Sahil Kapoor, Ayushi Gupta

Automastoidectomy: A Rare Autocorrected Chronic Suppurative Otitis Media Sequelae

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:6] [Pages No:19 - 24]

Keywords: Automastoid cavity, Automastoidectomy, Chronic otitis media, Complicated chronic otitis media

   DOI: 10.5005/jp-journals-10003-1431  |  Open Access |  How to cite  | 


Aim: To study the various presentations of automastoidectomy cavity. Materials and methods: A retrospective study was conducted in the Department of Otorhinolaryngology, SGT Hospital and Research Institute, Gurugram, Haryana, India from June 2021 to December 2021. We present a report of six cases who presented to the Department of ENT with a self-healing automastoidectomy cavity. The diagnosis of automastoidectomy was made based on history, clinical examination, and high-resolution computed tomography (HRCT) findings wherein there was no history of any ear surgery in the past and the HRCT findings were like that of postoperative changes following a post-mastoidectomy cavity. Conclusion: Automastoidectomy cavity is an uncommon sequela of chronic cholesteatomatous otitis media. Spontaneous drainage of the cholesteatoma through the bony defect can explain the rare genesis of a self-treated automastoidectomy cavity which can mimic post-mastoidectomy changes on HRCT if proper history is not taken. Clinical significance: The topic of automastoidectomy leads us to interesting challenges to be explored and evaluated. Constraint being lack of available literature; hence, more research is needed.


Original Article

Ravneet Ravinder Verma, Ravinder Verma

Transcanal Microscopic vs Endoscopic Type 1 Tympanoplasty in Dry Central Perforation: A Comparative Retrospective Study

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:25 - 28]

Keywords: Endoscopic approach, Microscope, Myringoplasty, Tympanoplasty

   DOI: 10.5005/jp-journals-10003-1439  |  Open Access |  How to cite  | 


Introduction: Type 1 tympanoplasty or myringoplasty is the repair of the perforated ear drum. Comparisons of microscopic and endoscopic techniques present in literature use different routes of access and cannot be compared head-on. Objective: The objective of this study was to compare an endoscopic and a microscopic myringoplasty results when both are performed via the transcanal route. Materials and methods: We present a retrospective study done at a single center to compare endoscopic and microscopic type 1 tympanoplasties, both done via the transcanal route. A total of 70 patients, 30 operated with endoscope and 40 with microscope, were included in the analysis. Patients of either sex, between 18 and 60 years of age, with a dry perforation, and air–bone gap of ≤30 dB were included. Results: Perforations were completely closed in 93% of the endoscopic group and 92.5% in the microscopic group. The air–bone gap closure was 12.89 dB in the endoscopic and 11.97 dB in the microscopic group. There was no association between the site or size of the perforation and the failure of surgery. The time taken for surgery was also equivalent. The endoscope had the advantage of avoiding a canaloplasty and of looking into the hidden areas of the middle ear. Conclusion: For transcanal, minimally invasive type 1 tympanoplasty, both techniques provide equivalent results. We recommend the use of an endoscope as the primary or an accessory tool for better visualization.


Original Article

Utkarsh Shrivastava

Sensitivity and Resistance Patterns of Antimicrobials in Chronic Otitis Media Squamosal

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:29 - 32]

Keywords: Antimicrobials, Chronic otitis, Resistance, Sensitivity, Squamosal

   DOI: 10.5005/jp-journals-10003-1447  |  Open Access |  How to cite  | 


Background: Chronic otitis media (COM) is a chronic inflammatory disease of the middle ear and mastoid. This study has shown the current patterns of antimicrobial sensitivity and resistance of the commonly prescribed antimicrobials in patients with COM (squamosal), of our catchment area, visiting the ear, nose, and throat outpatient department (ENT OPD). Methods: Observational cross-sectional study—a total of 332 patients with a chronically discharging ear presented to the ENT OPD during the study period, and among these patients, 34 cases diagnosed as squamosal COM were taken for this study. Ear discharge was sent for culture and sensitivity testing, and processed immediately in the laboratory. Role of antimicrobials in squamosal COM—although the primary modality for treatment is surgical/mastoid exploration, knowledge of the antimicrobial sensitivity patterns helps in prescribing postoperative antibiotics (when required) and also helps in countering the emergence of “resistant strains” due to empirical therapy in such cases. Results: In squamosal COM, the most common organisms were in the order Staphylococcus aureus followed by Pseudomonas aeruginosa, Kelbsiella, and Proteus mirabalis. Staphylococcus aureus: The antibiotics showing maximum sensitivity were piperacillin + tazobactam, almost equally with imipenem or meropenem, and followed by azithromycin. Pseudomonas aeruginosa: Most sensitive for piperacillin + tazobactam followed by fourth-generation cephalosporins. Ciprofloxacin was also found to show intermediate sensitivity. Klebsiella: Most sensitive for second-generation cephalosporins followed almost equally by piperacillin + tazobactam and levofloxacin. Conclusion: Analysis of the antibiotic susceptibility revealed that the penicillin group of antibiotics showed tremendous resistance. Resistance has also been shown toward older macrolide antibiotics such as azithromycin. Cephalosporin antibiotics have shown good sensitivity but resistance has emerged against these as well, which could be attributed to their indiscriminate usage in recent times. Newer antibiotics such as imipenem and meropenem and piperacillin + tazobactam have shown excellent sensitivity in this study. We recommend their judicious use to prevent resistance.


Original Article

Amit Kumar, Vivek Kumar, Neha Chaubey, Somya Sinha

Scope and Challenges of Online ENT Teaching: Lessons from COVID-19 Pandemic

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:5] [Pages No:33 - 37]

Keywords: COVID-19, E-learning, ENT teaching, Medical education, Online learning, Survey

   DOI: 10.5005/jp-journals-10003-1399  |  Open Access |  How to cite  | 


Aim: This article aims (1) to study the apparent level of ability, accessibility, and outlook towards e-learning in ENT undergraduate students and (2) to assess the feasibility and adequacy of online classes and to recognize the obstacle and solutions in designing and implementing an ENT e-learning environment for undergraduate teaching. Materials and methods: Online ENT classes were conducted for undergraduate medical student due to social distancing measures imposed in light of COVID-19 pandemic. At semester completion, a self-administered questionnaire was developed after an extensive review of literature on relevant topics to assess the level of technological understanding, experiences and attitude toward e-learning in ENT medical undergraduates. Several factors and indices influencing the effectiveness of online learning were studied by the authors, and statistical analysis was conducted using tables and charts. Results: The questionnaire was shared with 100 medical undergraduates of seventh semester, out of which there were 76 respondents. No single teaching medium was preferable for online classes with maximum students (53.3%) advocating for a combined approach. When it came to learning the complex anatomy in otolaryngology and head and neck surgery, half of the students wanted to see videos of the concerned topic, whereas around 36% students wanted to see PowerPoint with pictorial descriptions. Students preferred logging online with the daily rounds (40.8%) and studying simulated patients (38%) as additional methods of learning ENT clinical skills. Conclusion: ENT faculties who are responsible for designing e-learning protocols in institutions need to develop methods that interact with students and encourage comprehensive approaches to learning. We must prioritize learning from the experience of this health crisis to develop practical solutions to the challenges of the future. Clinical significance: Development of an adaptable e-learning environment using learner- and teacher-centered mediums can positively influence the effectiveness of ENT teaching methodology.


Original Article

Ruchika, Harendra Kumar Gautam, Surendra Kumar Kanaujia, Mahendra Singh, Ashish Kumar Purwar, AK Arya, Shiroman Singh, Amrita Srivastava

Role of Platelet-rich Plasma in Sensory Neural Hearing Loss

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:38 - 41]

Keywords: Intratympanic injection, Platelet-rich plasma, Sensory neural hearing loss

   DOI: 10.5005/jp-journals-10003-1438  |  Open Access |  How to cite  | 


Introduction: Platelet-rich plasma (PRP) is also known as autologous plasma. Platelets release various growth factors, some of which are recognized to improve nerve growth by contents within the alpha and dense granules. Material and methods: A prospective hospital-based interventional study was carried out at a tertiary care center for a period of 22 months from January 2020 to October 2021. Results: A total of 70 patients were selected according to inclusion criteria and exclusion criteria. In our study, 70 patients with sensory neural hearing loss (SNHL) were selected on the basis of pure-tone audiometry (PTA) and intratympanic PRP injections were given in the affected ear. Post-PRP, patients were followed up till 6 months. Among those patients who had hearing loss for less than six months duration, 85.2% recovered completely while in 14.8% partial recovery was observed. Patients with mild SNHL showed complete recovery in 70.8% and partial recovery in 29.2%. Individuals having moderate SNHL showed complete recovery in 25%, partial in 50%, and no recovery in 25% of cases. Patients in the moderately severe deafness category showed complete recovery in 66.7%, partial in 11.1%, and no recovery in 22.2%. However, in patients with severe SNHL complete recovery was seen only in 42.9%, partial in 14.2%, and in as high as 42.9% no recovery was observed. Only partial improvement was observed in 50% while the remaining 50% showed no recovery. In our study, 41.4% of cases complained of transient dizziness after PRP injection while 61.4% reported pain.


Original Article

Charai Henba, Pallika Kumar, Gaurang Singhal

Efficacy of Medical and Surgical Management in Otitis Media with Effusion in Children: A Comparative Study

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:3] [Pages No:42 - 44]

Keywords: Antihistaminics, Antimicrobials, Corticosteroid, Decongestants, Grommet, Myringotomy, Otitis media with effusion, Randomized control study

   DOI: 10.5005/jp-journals-10003-1437  |  Open Access |  How to cite  | 


Background: Otitis media with effusion (OME) is a common disease seen in 90% of children before going to school. The management of the condition includes both medical management and surgical management. Thus, a randomized control study was conducted in the Department of Otorhinolaryngology, Regional Institute of Medical Sciences, Imphal, Manipur, India from 2014 to 2016, in which 126 cases of newly diagnosed case of OME from 4 to 14 years of age were included. Patients were divided into two groups randomly. One group was treated by medical therapy alone and the other group by surgical therapy only. Patients were followed up every 2 weeks for the first 2 months and then every month for the next 3 months and symptoms along with pure-tone audiometry and Impedance audiometry were noted. Symptoms, pure-tone audiogram, and impedance audiometry in the first and third months were compared with the initial readings. Result: In this study, we found pre-intervention mean air-bone (AB) gap was found to be 27 ± 4.6 dB in the medical arm while 28.5 ± 5.9 dB was found in the surgical arm. Following medical and surgical management of patients, the mean AB gap at 1 month period was 18 ± 2.7 dB in the medical arm and 15 ± 4.2 dB in the surgical arm. Similar trends were seen at 3 months postintervention in which the mean AB gap was 16 ± 2.5 dB in the medical arm and 9.04 ± 2.4 dB in the surgical arm. The findings were found to be statistically significant (p < 0.05). Conclusion: Improvement in hearing and reduction in the AB gap is more in the surgical group during the third month. Clinical significance: The study was conducted to compare the outcomes of the surgical and medical management of OME as it poses a great risk to children who are the building blocks of society.



Veerasigamani Narendrakumar, VK Sathiya

Pilomatricoma of Pinna: Case Report

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:3] [Pages No:45 - 47]

Keywords: Benign tumor, Case report, Pilomatricoma, Pinna

   DOI: 10.5005/jp-journals-10003-1440  |  Open Access |  How to cite  | 


Pilomatrixoma, also known as pilomatricoma, is a rare benign appendageal neoplasm of the hair follicle matrix. It usually presents as a superficial, firm mass, commonly found in the head and neck region which may pose a diagnostic challenge as it may resemble other common benign lesions. Pilomatricoma remains to be misdiagnosed and is usually not considered in the differential diagnosis. Two cases of pilomatricoma are reported here due to the rarity of its location.



Mahamad Almyzan Awang, Rosdan Salim, Mohd Fadzil Nor Rashid, Wan Najibah Wan Mohamad, Marniza Omar, Mohd Normani Zakaria

The Clinical Usefulness of the Traditional Auropalpebral Reflex Test When Assessing a Mentally Challenged Hearing-impaired Adult

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:3] [Pages No:48 - 50]

Keywords: Auditory brainstem response, Auropalpebral reflex, Case report, Hearing loss, Pure-tone audiometry

   DOI: 10.5005/jp-journals-10003-1443  |  Open Access |  How to cite  | 


Aim: This report highlights the usefulness of performing the traditional auropalpebral reflex (APR) test for hearing diagnosis in a difficult-to-test adult patient. Background: Getting an accurate hearing diagnosis is the ultimate aim when assessing patients with hearing loss. Even though there are many sophisticated hearing tests available nowadays, the use of an old-fashioned hearing test is still beneficial. Case description: Attempts were made to diagnose the hearing status of a mentally challenged 35-year-old man. Pure-tone audiometry (PTA) testing failed to provide reliable results as the patient was unable to understand even simple instructions. The APR test was carried out, and he was found to have at least bilateral severe hearing loss, consistent with the results of the auditory brainstem response (ABR) test. Conclusion: Performing the traditional APR test is advantageous in clinical settings as it is simple to administer and able to estimate hearing levels in bilateral severe or profound hearing loss cases (particularly in situations where other audiological tests are not available).



Mohamad Najib Salleh, Nik Adilah Nik Othman, Suzana Mansor, Zulkiflee Salehuddin, Dinsuhaimi Sidek, Mohd Normani Zakaria

In the Wrong Place but Perhaps at the Right Time: A Cochlear Implant Electrode Impinging on Tympanic Membrane

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:51 - 54]

Keywords: Cochlear implant, Electrode migration, High resolution computed tomography, Meningitis, Postimplantation

   DOI: 10.5005/jp-journals-10003-1444  |  Open Access |  How to cite  | 


Aim: This case report demonstrates the incidental finding of a cochlear implant (CI) electrode impinging on the tympanic membrane (TM). Background: The cochlear implant is the most successful neural prosthesis that has been developed in the last few decades. It has helped thousands of profoundly deaf recipients to have better hearing and improved quality of life. Nevertheless, extracochlear electrode extrusion or migration would occur and this requires special consideration. Case description: We report a case of a 4-year-old boy who was implanted with bilateral CIs for profound hearing loss postmeningitis at 1 year of age, with an incidental finding of the CI electrode impinging on the medial surface of his left TM. A computed tomography (CT) scan confirmed this finding, and the patient had revision surgery and reimplantation of CI. Conclusion: It is advisable for patients to continue follow-up postimplantation in the otorhinolaryngology (ORL) clinic even after years of CI surgery. The early detection of electrode malfunction, extrusion, migration, or misplacement is mandatory to improve patients’ quality of life and prevent further complications.



Maria Veronika Simatupang, Titiek Hidayati Ahadiah

Management of Subgaleal Abscess as A Rare Complication of Chronic Suppurative Otitis Media Dangerous Type

[Year:2023] [Month:January-April] [Volume:15] [Number:1] [Pages:4] [Pages No:55 - 58]

Keywords: Canal wall down mastoidectomy, Case report chronic suppurative otitis media, Subgaleal abscess

   DOI: 10.5005/jp-journals-10003-1445  |  Open Access |  How to cite  | 


Background: Subgaleal abscess (SGA) is a purulent infection under the galea aponeurotic of the scalp. Also, SGA is a rare extracranial complication of chronic suppurative otitis media (CSOM). Purpose: Reporting management of SGA due to CSOM. Case description: A 6-year-old boy with right ear CSOM was found to have SGA. A swelling was found behind the right ear, right side of the head, and eyes. There was a history of right ear discharge. The management was conservative therapy by intravenous antibiotics after complete aspiration of abscess followed by canal wall down (CWD) mastoidectomy after 1 week. Method: An evidence-based literature search regarding the management of SGA due to CSOM using the keywords “subgaleal abscess” “Pott's puffy tumor,” “chronic otitis media,” “mastoiditis,” and “management” was conducted on SAGE, Science Direct, Google Scholar, and Semantic Scholar. Further selection is based on inclusion and exclusion criteria. Results: Two journals obtained are case reports. Management based on clinical and radiological findings, incision drainage was performed, and administered intravenous antibiotics followed by mastoidectomy showed improvement. Conclusion: Subgaleal abscess as a complication of CSOM was treated by intravenous antibiotics after complete aspiration of abscess and eradication primary source of infection with CWD mastoidectomy showed clinical improvement.


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