Ecpg Orlap

Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG
Egyptian clinical practice

guidelines Otorhinolaryngology,
Audiovestibular & Phoniaatrics
2021 (Volume 1) Pages: I I

Disclaimer
The present Egyptian CPG (ECPG) represents an adapted CPG with clear outlined methodology and the
related references to each guideline were cited. Recommendations contained in these adapted ECPGs do not
indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical
judgment to each individual presentation, nor variations based on locality and facility type. The contributors of
these adapted ECPGs have made considerable efforts to ensure the information upon which they are based is
accurate and up to date. The publishers will be pleased to make good any omissions or rectify any mistakes brought
to their attention at the earliest opportunity.
Copyright © 2021 by Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals
All rights reserved. No part of this book may be reproduced or used in any manner without written
permission of the copyright owner except for the use of quotations in a book review.
For more information, address: info@redakamel.com
First edition October 2021

www.rhinoegypt.com
www.rhinoegypt.org
II 2021 (Volume 1) Pages: II

Forward
It is my pleasure to express my sincere appreciation to all the hard work and diligent effort that have been
put into the completion of the “Egyptian Clinical Practice Guidelines of Otorhinolaryngology, Audio-vestibular &
Phoniatrics (ECPG-ORLAP)”.
We value the persistent hard work and effort in the field of Otorhinolaryngology, Audio-vestibular &
Phoniatrics that have given us a fruitful result that eventually came to light by the hands of a group of brilliant
Professors and field experts under the supervision of the Editorial Board.
These guidelines represent the first Egyptian medical guidelines which will not only be the cornerstone
for the standardization of health care but also will allow to provide a safe, evidence based, and effective health
services.
Eventually we would like to extend our appreciation to everyone who shared in the construction of such
work which will pave the way for other Egyptian medical guidelines to follow.
Professor Dr. Khaled Abdel Ghaffar

Minister of Higher Education and Scientific Research
2021 (Volume 1) Pages: III III

Forward
It gives me immense pleasure to witness the creation of the Egyptian Clinical Practice Guidelines of
Otorhinolaryngology, Audio-vestibular & Phoniatrics (ECPG-ORLAP) which is of a great importance and would be
the reference for the Egyptian Otorhinolaryngology, Audio-vestibular & Phoniatrics physicians.
I would like to express my sincere gratitude to the “Egyptian Clinical Practice Guidelines of
Otorhinolaryngology, Audio-vestibular & Phoniatrics Board members for their dedication, hard work and their
willingness to contribute time and commitment to excellence the creation of these valuable guidelines which will be
related to the university hospital facilities.

This will be an authorized landmark for the future practice of Otorhinolaryngology, Audio-vestibular &
Phoniatrics in Egypt.
I extend my best wishes for all our Egyptian doctors and Professors.
Professor Dr. Hossam Abdel Ghaffar

Secretary of the Supreme Council of University Hospitals
IV 2021 (Volume 1) Pages: IV

Preface
Egyptian Clinical Practice Guidelines of Otorhinolaryngology, Audio-vestibular & Phoniatrics

(ECPG-ORLAP)
It is with great honor to be nominated for the post of the board director of the Egyptian Clinical Practice
Guidelines of Otorhinolaryngology, Audio-vestibular & Phoniatrics (ECPG-ORLAP). On behalf of the board members,
I would like to extend our sincere gratitude to his excellency the “Minister of Higher Education and Scientific
Research” and the “Secretary of the Supreme Council of the University Hospitals” for entrusting us with the role of
developing the Egyptian Clinical Practice Guidelines of Otorhinolaryngology, Audio-vestibular & Phoniatrics (ECPG-
ORLAP).
The aim of this significant project is to adapt, and tailor the most recent international clinical practice
guidelines towards our Egyptian community with special focus and attention given to doctors’ trainings, medical
facilities and patients’ culture. Hence, this project is of fundamental importance to bridge the gap between evidence
and clinical practice.
We must acknowledge that without the harmonized and diligent teamwork of the 250 professionals
and experts, from the five subspecialties of the ORLAP, including professors and consultants from all Egyptian
Universities and Medical Institutions, these guidelines would not have been made possible or become a reality.
Moreover, the general and assembly boards, along with graders and reviewers adhered to a strict and
clear methodology in order to produce such a unique and practical manual that encompasses 29 various topics.
The methodology: We avoided the adoption policy and resorted to the more difficult and arduous
adaptation methodology in order to overcome the culprit of impractical international guidelines for our Egyptian
practice, and hence achieve a suitable, common, simple, clear and local language for patient care amongst Egyptian
ORLAP physicians.
The achievement: We can now proudly announce the development of the first volume of our unique,
practical, and up-to-date ECPG of ORLAP, which aims to provide the best care for our Egyptian patients. Even more,
our ECPG-ORLAP Guidelines are feasible for adoption by the Middle East and Africa region.
Next steps: The future entails many responsibilities for the ECPG-ORLAP task force. This valuable work
will not stop at volume I (2012), but will be continuously updated with the addition of more topics and volumes in
the near future.
On behalf of the board

Reda kamel
Professor of Rhinology – Cairo University
Director of the Board for the ECPG-ORLAP
2021 (Volume 1) Pages: V V

Preface
Know more than other. Work more than other. Expect less than other
William Shakespeare
As Wiliam Shakespeare said we strained to offer the keys of success to our practicing otorhinolaryngology
ORL head and neck surgery, audio vestibular medicine and Phoniatric (ORL, HNS, AVM, Ph) physicians. So, with
the present adapted Egyptian Clinical Practice Guidelines (AECPG), our practitioners will know more about sound
clinical practice. Subsequently, they will have the potential to work more properly, reduce inappropriate practice
variation and enhance translation of research into practice. Against the last Shakespeare keys, the expectations will
be more in improving healthcare quality and safety which will allow our country to fly beyond the horizon.
When the CPG committee was formed, we regarded the task will be easy. As we delved into our work,
however, we recognized that more time and efforts are needed and a faultless scientific process is required to
choose the best CPG. So, we select an adaptation process to choose the best existing high-quality guidelines for
local use with the potential to reduce duplication of effort and enhance applicability. The process was upgraded
to fit and consisted of three main phases, including planning and set-up, adaptation, and development of a final
product.
More than 250 academicians, professors, consultants from a variety of otorhinolaryngology, head and neck
surgery (ORL, HNS, AVM, Ph) disciplines, experts from various types of stakeholder entities, and a diverse array of
individuals involved in guideline development and implementation participated in our deliberations and contributed
to this AECPG. More than 2000 publications were reviewed by staff and committee members to allow the present
selections.
I would like to express my great thanks to his excellency the “Minister of Higher Education and Scientific
Research” and the “Secretary of the Supreme Council of the University Hospitals” and our chair Prof Reda Kamel
for the endless efforts. Also, I express our great appreciation to the committee, groups and subgroups members
and staff for their commitment, effort, dedication, and wisdom. Although we worked in difficult times of COVID-
19,the spirited discussions during meetings and the frequent communications all through allow the present product
to sunshine. We hope the committee’s proposed standards and recommendations will foster AECPG that increase
quality of care and improve Egyptian patient outcomes.
Despite all efforts, it is possible that certain errors may have been overlooked in this guide. Please inform
the authors of any errors detected. It is important to remember, that if in doubt, it is the responsibility of the
prescribing medical professional to ensure that the treatment and doses indicated in this manual conform to the
its specifications.
To ensure that this guide continues to evolve while remaining adapted to field realities, please send any
comments and suggestions. As treatment protocols are regularly revised, please check the updates.
Ahmed Ragab MD, PhD Brussels

Prof. ORL HN Surgery, Faculty of Medicine, Menoufia University
Secretary of ORL/HNS/AVM/Ph ECPG
VI 2021 (Volume 1) Pages: VI

Methodology
Egyptian Clinical Practice Guidelines of Otorhinolaryngology, Audio-vestibular & Phoniatrics
(ECPG-ORLAP)
We used modified adapt process that consisted of three main phases, including planning and set-up, adaptation, and development of a final
product:
PHASE I - Set-up (by Assembly Board)
Module 1: Preparation
1. Establish an organizing committee, working panel and resource team.
2. Determine criteria for selection and select a topic according to priority.
3. Check if adaptation is feasible.
4. Identify necessary resources and skills.
5. Write the plan for adaptation.
Module 2: Adaptation plan approval
PHASE II - Adaptation
Module 1: Scope and purpose
1. Arrange meetings for awareness of adaptation process ( 5 large groups specialty meetings).
2. Determine and clarify the health-related question.
Module 2: Search and screen

1. Search for clinical practice guidelines (CPG) and other relevant documentation.
2. Screen the retrieved guidelines and record their characteristics and content.
3. Eliminate a large number of the retrieved guidelines using the AGREE instrument.
Module 3: Assess guidelines with scoring of each retrieved CPG

1. Assess the quality of the CPG.
2. Assess the currency of the CPG.
3. Assess the content (consistency, acceptability and applicability of the recommendations) for the CPG.
Module 4: Decision and selection

1. Review assessments and scoring.
2. Select the guideline of the highest score (quality, contents and currency)
3. Extract the statements and flowcharts of the selected CPG.
Module 5: Customization and adaptation

1. Prepare a draft of the adapted guideline statements and flowchart according to evidence, benefit/harm, cost and applicability to the
community.
2. Approve, modify, omit and/or add statements.
PHASE III — Finalization

Module 1: Review and grade statements and flowcharts (By Grading Team)
1. Revise and grade each statement by the reviewer team Egyptian experts in their related field specialty.
2. Prepare the second draft.
Module 2: External review and acknowledgement

1. Seek feedback and grading of the adapted draft guideline from expert reviewers in the field ( those who would be using it).
2. Consult with endorsement bodies.
Module 3: After-care planning

1. Plan for aftercare of the adapted guideline.
Module 4: Final production

1. Produce a final document of the guideline with printing and revision.
Module 5: Dissemination and implementation

1. Disseminate and implement the adapted ECPG-ORLAP.
References
1. Harrison MB, Légaré F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ.
2010;182(2):E78-E84. doi:10.1503/cmaj.081232.
2. Graham ID, Harrison MB, Brouwers M, et al. Facilitating the use of evidence in practice: evaluating and adapting clinical practice guidelines
for local use by health care organizations. J Obstet Gynecol Neonatal Nurs. 2002;31:599–611.
3. Graham ID, Harrison MB, Brouwers M. Evaluating and adapting practice guidelines for local use: a conceptual framework. In: Pickering S,
Thompson J, editors. Clinical governance in practice. London (UK): Harcourt. 2003:213–29.
4. Fervers B, Burgers JS, Haugh M, et al. Adaptation of clinical guidelines: literature review and proposition for a framework and procedure.
Int J Qual Health Care. 2006;18:167–76.
5. Dizon, J.M., Machingaidze, S. & Grimmer, K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline devel-
opment. BMC Res Notes. 2016;9:442.
6. McCaul, M., de Waal, B., Hodkinson, P. et al. Developing prehospital clinical practice guidelines for resource limited settings: why re-invent
the wheel?. BMC Res Notes. 2018;11:97.
7. McCaul M, Ernstzen D, Temmingh H, et al. Clinical practice guideline adaptation methods in resource-constrained settings: four case studies
from South Africa BMJ Evidence-Based Medicine 2020;25:193-198.
2021 (Volume 1) Pages: VII VII

Flowchart ECPG - ORLAP
VIII 2021 (Volume 1) Pages: VIII

Contents
Chapter 1: Otology
1 Acute Otitis Media in Children Adapted Egyptian Clinical Practice Guidelines 1-6
Sherif Safwat Guindi, Yasser Shewel, Mahmoud Mandour, Usama Kamal, Ahmed Hesham Galal
2 Otitis media with effusion in children: Adapted Egyptian Clinical Practice Guidelines 7-11
Yasser Shewel, Hisham Hamad, Ali Mahrous, Mahmoud Mandour
3 Bell’s palsy in adults: Adapted Egyptian Clinical Practice Guidelines 12-18
Usama Kamal, Mohamed R. Ghonim, Ali Mahrous, Hani El-Garem, Yasser Shewel, Mohamed
Abdelbadie Salem, Ahmed Galal
4 Sudden SNHL: Adapted Egyptian Clinical Practice Guidlines 19-24
Ali Mahrous, Adel Khalifa, Gamal Abdelfattah, Ashraf Lotfy, Mohamed Zaidan, Tawfik Elkholy,
Mohamed Abdelbadie Salem, Doaa Abd Elhalem, Rabie Sayed
5 Tinnitus: Adapted Egyptian clinical practice Guidlines 25-30
Saad Elzayat, Mohamed Modather, Ayman Fouad, Nabila Elneklawy, Doaa Abd Elhalem, Haitham
Elfarargy, Islam Soltan
6 Ménière’s disease: Adapted Egyptian Clinical Practice Guidelines 31-37
Mahmoud Mandour, Yasser Shewel, Aziz Belal, Maged B. Naguib
7 Necrotizing Otitis Externa Adapted Egyptian Clinical Practice Guidelines 38-42
Ayman Fouad, Adel Khalifa, Hisham Hamad, Mahmoud Mandour, Fathy Abdelbaki, Mohamed
Basiony, Lobna El Fiky, Mohamed Mobasher, Yousef Shabana
Chapter 2: Rhinology
8 Acute Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines 43-49
Ahmed Ragab, Reda Kamel, Ashraf Khaled, Baliegh Hamdy, Ahmed Elfarouk, Mohamed
Elsharnouby, Hossam Elsherif
9 Chronic Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines 50-66
Ahmed Elfarouk, Magdy Eisa, Mohamed Osama Tomoum
10 Allergic Rhinitis: Adapted Egyptian Clinical Practice Guidelines 67-79
Ahmed Ragab, Reda Kamel, Mohamed Gamea, Ayman Medani, Zeyad Mandour
11 Epistaxis: Adapted Egyptian Clinical Practice Guidelines 80-86
Ibrahim Rezk Mohammed, Diaa Elhennawi, Mohamed Rifaat Ahmed
12 Cerebrospinal Rhinorrhea (CSF): Adapted Egyptian Clinical Practice Guidlines 87-91
Ismail Elnashar, Mostafa A. El Taher, Ashraf Elhosini, Tamer Orabi
Chapter 3: Head and Neck

13 Early & Late Laryngeal Cancer: Adapted Egyptian Clinical Practice Guidlines 92-97
Mahmoud Abdelaziz, Islam Farid Abu Shady, Mahmoud El Bestar, Ahmad El Naggar, Mohamed
E Rubaie, Yaser Abdel Wahab Khalil, Abdelwahab Mohamed
14 Tonsillectomy: Adapted Egyptian Clinical Practice Guidlines 98-103
Mohamed Elsalmawy, Mohamed Ekram, Tamer Azzam, Heba Abdel Rahem abo Elnaga, Mostafa
Ammar, Islam Farid Abu Shady
15 Thyroid Nodules: Adapted Egyptian Clinical Practice Guidlines 104-111
Ahmad Eltelety, Ahmed Musaad Abd Elfattah, Ahmed S. Elhamshary, Mostafa Ammar
16 Dysphonia: Adapted Egyptian Clinical Practice Guidlines 112-115
Emad Shehata, Mahmoud Abdelaziz, El Shaahrawy Kamal
2021 (Volume 1) Pages: X X

Contents
Chapter 4: Audiovestibular Medicine

17 Pure-Tone Air-Conduction and Bone-Conduction Threshold Audiometry with and 116-124
without Masking: Adapted Egyptian Clinical Practice Guidelines
Trandil El Mehallawi, Nashwa Nada, Mai ElGohary
18 Tympanometry Adapted Egyptian Clinical Practice Guidelines 125-130
Enaas Kolkaila, Mostafa Elrefaie
19 Auditory Brainstem Response (ABR) Testing in Babies: Adapted Egyptian Clinical 131-137
Practice Guidelines
Mona Mourad, Yasmine Hamza, Mai EL Ghazaly
20 Newborn Hearing Screening: Adapted Egyptian Clinical Practice Guidelines 138-144
Soha Mekki, Abir Omara, Salwa Mahmoud
21 Benign Paroxysmal Positional Vertigo (BPPV): Adapted Egyptian Clinical Practice 145-150
Guidelines
Nagwa Hazzaa, Mohamed El Badry, Nahla Gad, Lamees El-Amragy
Chapter 5: Phoniatrics
22 Late Language Emergence / Language Delay Language Disorders / Autism Spectrum 151-170
Disor ders: Adapted Egyptian Clinical Practice Guidelines
Dalia Mostafa Osman, Yossra Abdel Naby Sallam, Rehab Abd ElHafeez Zaytoun, Ahmed Ali
AbdelMonem
23 Childhood Apraxia of Speech: Adapted Egyptian Clinical Practice Guidelines 171-178
Hemmat Mostafa Baz
24 Articulation Disorders (Speech sound disorders): Adapted Egyptian Clinical Practice 179-187
Guidelines
Nirvana Hafiz, Rasha Shoeib, Yossra Sallam
25 Cochlear implantation: Adapted Egyptian Clinical Practice Guidelines 188-192
Samia Bassiouny, Tamer Abou-Elsaad, Ayman Shawky, Ahlam El-Adaawy, Youssra Sallam, Effat
Zaky, Ahmed Ali
26 Learning Disability: Adapted Egyptian Clinical Practice Guidelines 193-206
Safaa Refaat El-Sady, Azza Abdel-Aziz Azzam, Omayma Elsayed Afsah, Aisha Fawzy Abdel Hady
27 Aphasia: Adapted Egyptian Clinical Practice Guidelines 207-212
Nirvana Gamal El Din Hafiz, Iman El-Rouby
28 Dysarthria: Adapted Egyptian Clinical Practice Guidelines 213-225
Nirvana Gamal El Din Hafez Helmy, Ayman Shawky
29 Upper airway assessment in adults with snoring and obstructive sleep 226-231
apnea hypopnea syndrome (OSAHS): Adapted Egyptian Clinical Practice Guidlines
Reham Abdelwakil Ibrahim, Amal Saeed, Hemmat El Baz, Aya Sheikhany
List of Contributors 232-237
Acknowledgement 238
XI 2021 (Volume 1) Pages: XI

Chapter 1
Otology
Acute otitis media
Chapter 1: Otology Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG
Acute Otitis Media in Children: Adapted Egyptian Clinical Practice

Guidelines
Chief Editor: Reda Kamel1
General Secretary: Ahmed Ragab2
General Coordinator: Baliegh Hamdy3
Scientific Board: Ashraf Khaled,4 Mohamed Ghonaim,5 Mahmoud Abdelaziz,6 Tarek Ghannoum,7 Mahmoud Youssef8
Otology Chief Manager: Ali Mahrous9
Otology Executive Managers: Yasser Shewel,10 Mohamed Abdelbadie Salem5
Assembly board: Sherif Safwat Guindi,11 Yasser Shewel,10 Mahmoud Mandour,6 Usama Kamal,12 Ahmed Galal10
Grading Board (In alphabetical order)
Mohamed Abdelbadie Salem,5 Gamal Abdel Fattah,13 Doaa Abd Elhalem,9 Ashraf A. Alhamshary,14 Mohamed Badr El-Dine,10 Aziz
Belal,10 Ezz Eldine Elshikh,15 Fathi Erfan,6 Ayman Fouad,6 Amr Galal,16 Mahmood A. Hamed,17 Haytham Hassan,10 Nabila Ibrahim,9 Ashraf
Lotfy,18 Osama Metwaly,1 Amir Gorguy Mina,10 Waleed Monir,5 Ihab Nada,13 Mohamed Qotb,11 Mohamed Refaat,19 Ashraf Salah ElDine,18
Yousef Shabana5
Reviewing Board (In alphabetical order): Hani Garem,10 Hisham Hamad,6 Saad Elzayat20
1
Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Department, Faculty of Medicine/
Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 4Otorhinolaryngology Department, Faculty
of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology
Department, Faculty of Medicine/ Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/
Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Otorhinolaryngology
Department, Faculty of Medicine/ Al Azhar University, 10Otorhinolaryngology Department, Faculty of Medicine/ Alexandria University,
11
Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University, 12Otorhinolaryngology Department, Faculty of Medicine/
South Valley University, 13Otorhinolaryngology Department, Faculty of Medicine/Misr University for Science and Technology,
14
Otorhinolaryngology Department, Faculty of Medicine/ Banha University, 15Otorhinolaryngology Department, Faculty of Medicine/
Zagazig University, 16Otorhinolaryngology Department/ Hearing and Speech Institute, 17Otorhinolaryngology Department, Faculty of
Medicine/ Sohag University, 18Otorhinolaryngology Department, Faculty of Medicine/ Military Medical Academy, 19Otorhinolaryngology
Department, Faculty of Medicine/ Suez Canal University, 20Otorhinolaryngology Department, Faculty of Medicine/ Kafr El Shiekh
University.
Introduction and background • Give advice on measures to reduce the risk of recurrence.
Acute otitis media (AOM) is an acute, suppurative infectious Methods

process marked by the presence of infected middle ear fluid and
inflammation of the mucosa lining the middle ear space. Acute The adaptation cycle passed over: Set up phase, adaptation
otitis media (AOM) occurs much more commonly in children than phase (Search and screen, assessment: Currency, Content and
in adults. Quality and Decisions/selection) and finalization phase that
include revision.
Scope and purpose
Results
To support primary healthcare professionals to
The guidelines were assessed by otologists and guidelines
• Make an accurate diagnosis of acute otitis media (AOM) from the American Academy of Pediatrics (AAP) and American
Academy of Family Physicians had the highest scores as regards
• Prescribe the proper antibiotic and analgesic treatment if to the currency, contents and quality. It was graded GRADE
and when appropriate. by many expert otologist and reviewed by at least 3 expert
reviewers.
• Manage patients with persistent or recurrent AOM
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision frameworks
(GRADE Working Group 2013)3
Grade Definition
High We are very confident that the true effect lies close to that of the estimate of the effect.
++++
Moderate We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but
+++ there is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the
++ effect.
Very Low We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate
+ of effect
Acute otitis media 2021 (Volume 1) Pages: 1-6 1

Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG Chapter 1: Otology
Evidence Quality for Grades of Evidence
Evidence Quality for Diagnosis Evidence Quality for Treatment and Harm
Well-designed randomized controlled trials
Systematic review of cross-sectional studies with consistentlyapplied
A performed on a population similar to the guideline`s
reference standard and blinding
target population
Individual cross-sectional studies with consistently applied reference Randomized controlled trials; overwhelmingly
B
standard and blinding consistent evidence from observational studies
Nonconsecutive studies, case control studies, or studies with poor, Observational studies (case control and cohort
C
nonindependent, or inconsistently applied reference standards design)
D Mechanism-based reasoning or case reports
Exceptional situations where validating studies cannot
be performed and there is a clear preponderance of
benefit over harm
Guideline Definitions for Evidence-Based Statements
Statement Definition
Strong recommendation means that the

benefit of the recommended approach
clearly exceed the harms (or that the harms,
including monetary costs,clearly exceed the
benefits in the case of a strong negative
recommendation) and that the quality Clinicians should follow a strong
of the supporting evidence is excellent recommendation unless a clear and
Strong recommendation
(grade A or B). In some clearly identified compelling rationale for an alternate
circumstances, strong recommendations approach is present.
may be made based on lesser evidence
when high-quality evidence is impossible to
obtain and the anticipated benefits strongly
outweigh the harms.
A recommendation means that the
benefits exceed the harms (or that the
harms exceed the benefits in the case of a
negative recommendation), but the quality Clinicians should also generally follow a
of evidence is not as strong (grade B or C). recommendation but should remain alert
Recommendation
In some clearly identified circumstances, to new information and sensitive to patient
recommendations may be made based on preferences.
lesser evidence when high-quality evidence
is impossible to obtain and the anticipated
benefits outweigh the harms.
An option means either that the quality of Clinicians should be flexible in their
evidence that exists is suspect (grade D) or decision making regarding appropriate
Option that well-done studies (grade A, B, or C) practice, although they may set bounds
show little clear advantage to 1 approach on alternatives; patient preference should
versus another. have a substantial influencing role.
Clinicians should feel little constraint in
No recommendation means that there is
their decision making and be alert to new
both a lack of pertinent evidence (grade D)
No recommendation published evidence that clarifies the balance
and an unclear balance between benefits
of benefit versus harm; patient preference
and harms.
should have a substantial influencing role.
Recommendations statements
Accepted statements
Modified statements
Added statements
2 2021 (Volume 1) Pages: 1-6 Acute otitis media

Strength according Strength after

Level of
Clinical questions Action recommendation to AAP & AAFP adoption or
evidence
guidelines adaptation
Clinicians should diagnose acute otitis media (AOM)

Diagnosis and in children who present with moderate to severe
Recommendation B ++++
Examination bulging of the tympanic membrane (TM) or new
onset of otorrhea not due to acute otitis externa.
Clinicians should diagnose AOM in children who

present with mild bulging of the TM and recent (less
than 48 hours) onset of ear pain (holding, tugging, Recommendation C ++++
rubbing of the ear in a nonverbal child) or intense
erythema of the TM.
Clinicians should not diagnose AOM in children who
do not have middle ear effusion (MEE) (based on Recommendation B ++++
pneumatic otoscopy and/or tympanometry).
The management of AOM should include an
Strong
Management of pain assessment of pain. If pain is present, the clinician B ++++
Recommendation
should recommend treatment to reduce pain.
The clinician should prescribe antibiotic therapy for
AOM (bilateral or unilateral) in children 6 months
Antibiotic administration Strong
and older with severe signs or symptoms (moderate B ++++
in severe cases Recommendation
or severe otalgia or otalgia for at least 48 hours or
temperature 39°C or higher).
The clinician should prescribe antibiotic therapy
Antibiotic administration for bilateral AOM in children 6 months through 23
in non-severe bilateral months of age without severe signs or symptoms Recommendation B ++++
AOM in young children (ie, mild otalgia for less than 48 hours and
temperature less than 39°C).
The clinician should either prescribe antibiotic
therapy or offer observation with close follow-up
based on joint decision making with the parents/
caregiver for unilateral AOM in children 6 months
to 23 months of age without severe signs or
Non-severe unilateral
symptoms (mild otalgia for less than 48 hours and Recommendation B ++++
AOM in young children
temperature less than 39°C). When observation
is used, a mechanism must be in place to ensure
follow-up and begin antibiotic therapy if the child
worsens or fails to improve within 48 to 72 hours of
onset of symptoms.
The clinician should either prescribe antibiotic
therapy or offer observation with close follow-up
based on joint decision-making with the parents/
caregiver for AOM (bilateral or unilateral) in
children 24 months or older without severe signs or
Non-severe AOM in older
symptoms (mild otalgia for less than 48 hours and Recommendation B +++
children
temperature less than 39°C). When observation
is used, a mechanism must be in place to ensure
follow-up and begin antibiotic therapy if the child
worsens or fails to improve within 48 to 72 hours of
onset of symptoms.
Clinicians should prescribe amoxicillin clavulanate
as first line choice for AOM when a decision to
Choice of antibiotic Recommended B ++++
treat with antibiotics has been made due to high
resistance to amoxicillin.
Clinicians should prescribe Clarithromycin in cases
Recommended B +++
of penicillin allergy or intolerance.
Clinicians should reassess the patient if the caregiver
reports that the child’s symptoms have worsened or
Follow-up of patients failed to respond to the initial antibiotic treatment Recommendation B ++++
within 48 to 72 hours and determine whether a
change in therapy is needed.
Clinicians should not prescribe prophylactic
The use of prophylactic
antibiotics to reduce the frequency of episodes of Recommendation B ++++
antibiotics
AOM in children with recurrent AOM.

Strength according Strength after

Level of
Clinical questions Action recommendation to AAP & AAFP adoption or
evidence
guidelines adaptation
Clinicians may offer tympanostomy tubes for

Role of tympanostomy recurrent AOM (3 episodes in 6 months or 4
Recommendation B ++++
tubes episodes in 1 year with 1 episode in the preceding
6 months).
The additive benefit of adenoidectomy to
tympanostomy tubes in recurrent acute otitis media
Role of Adenoidectomy Option B +++
and otitis media with effusion is controversial and
age-dependent.
Clinicians should recommend pneumococcal
Role of pneumococcal conjugate vaccine to all children according to the Strong
B ++++
vaccine schedule and regulations of the Ministry of Health Recommendation
and Population.
Clinicians should recommend annual influenza
Role of Influenza
vaccine to all children according to the regulations Recommended B ++++
vaccine
of the Ministry of Health and Population.
Immunoglobulin administration is recommended
Role of immunoglobulins for patients with low serum IgG2 levels, whose
Recommended C +++
in otitis-prone children recurrent AOM cannot be controlled by other
available treatment modalities.
Clinicians should encourage exclusive breastfeeding
Role of breast-feeding Recommended B ++++
for at least 6 months.
Role of active and Clinicians should encourage avoidance of tobacco
Recommended C ++++
passive tobacco smoking smoke exposure.

Recommended antimicrobial therapy

References otitis media guidelines in selected developed and

developing countries: uniformity and diversity. Arch
1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. Clinical Dis Child. 2017;102(5):450-457.
Practice Guideline: The Diagnosis and Management
of Acute Otitis Media. Pediatrics. 2013;131(3):e964– 8. Deniz Y, van Uum RT, de Hoog MLA, Schilder AGM,
e999. Damoiseaux RAMJ, Venekamp RP. Impact of acute
otitis media clinical practice guidelines on antibiotic
2. Sabella, Goldfarb J, Applying new guidelines on acute and analgesic prescriptions: a systematic review.
otitis media: from principles to practice. Cleveland Arch Dis Child. 2018;103(6):597-602. 10.1136.
Clinic Journal of Medicine, supplement 4 to volume
71, June 2004. 9. National Institute for Health and Care Excellence;
Otitis media (acute): antimicrobial prescribing NICE
3. Marchisio P, Bellussi L, Di Mauro G, Doria M, Felisati guideline [NG91] Published date: 28 March 2018,
G, Longhi R, Novelli A, Speciale A, Mansi N, Principi https://www.nice.org.uk/guidance/ng91.
N. Acute otitis media: From diagnosis to prevention.
Summary of the Italian guideline. Int J Pediatr 10. Royal Children Hospital Melbourne, Australia; Acute
Otorhinolaryngol. 2010;74(11):1209-16. Otitis media Guidelines, 2018, https://www.rch.org.
au/clinicalguide/guideline_index/Acute_otitis_media.
4. Kitamura K, Iino Y, Kamide Y, Kudo F, Nakayama
T, Suzuki K, Taiji H, Takahashi H, Yamanaka N, 11. Bourgeois T, Griffith C, Johnson EC, Leblanc B,
Uno Y. Clinical practice guidelines for the diagnosis Melancon B. Barriers to Current Guidelines in the
and management of acute otitis media (AOM) in Management of Pediatric Acute Otitis Media. J
children in Japan - 2013 update. Auris Nasus Larynx. Pediatrics & Pediatr Med. 2019;3(3):7-24.
2015;42(2):99-106.
12. Hayashi T, Kitamura K, Hashimoto S, Hotomi M,
5. Heidemann CH, Lous J, Berg J, Christensen JJ, Kojima H, Kudo F, Maruyama Y, Sawada S, Taiji H,
Håkonsen SJ, Jakobsen M, Johansen CJ, Nielsen LH, Takahashi G, Takahashi H, Uno Y, Yano H. Clinical
Hansen MP, Poulsen A, Schousboe LP, Skrubbeltrang practice guidelines for the diagnosis and management
C, Vind AB, Homøe P. Danish guidelines on of acute otitis media in children-2018 update. Auris
management of otitis media in preschool children. Nasus Larynx. 2020;47(4):493-526.
Int J Pediatr Otorhinolaryngol. 2016;87:154-63.
13. Suzuki HG, Dewez JE, Nijman RG, Yeung S. Clinical
6. Institut National d’Excellence en Santé et Services practice guidelines for acute otitis media in children:
Sociaux (INESSS), Otite moyenne aigue chez l’enfant a systematic review and appraisal of European
de 3 mois et plus, published date 2016, Québec, national guidelines. BMJ Open. 2020;10(5).
Canada, https://www.inesss.qc.ca/fileadmin/doc/
CDM/UsageOptimal/Guides-serieI/Guide-Otite- 14. Veenhoven, R., Rijkers, G., Schilder, A. et al.
Enfant.pdf. Immunoglobulins in Otitis-Prone Children. Pediatr
Res. 2004;55:159–162.
7. Ovnat Tamir S, Shemesh S, Oron Y, Marom T. Acute

Otitis media with effusion in children: Adapted Egyptian Clinical Practice

Guidelines
Otology Executive Managers: Yasser Shewel,10 Mohamed Abdelbadie Salem,5
Assembly board: Yasser Shewel,10 Hisham Hamad,6 Ali Mahrous,9 Mahmoud Mandour6
Mohamed Abdelbadie Salem,5 Doaa Abd Elhalem,9 Hani El Garem,10 Saad Elzayat,11 Fthi Erfan,6 Ayman Fouad,6 Ahmed Galal,10 Amr
Galal,12 Amir Gorguy Mina,10 Mahmood A. Hamed,13 Medhat Heshmat,6 Mahmoud Khalifa,13 Adel Khalifa,6 Ahmed Khashaba,14 Ashraf
Lotfy,14 Osama Metwaly,1 Ihab Nada,15 Maged B. Naguib,16 Nbila Naklawy,9 Mohamed Qotb,17 Ashraf salah ElDin14
Reviewing Board: Ahmed Gamea,6 Essam Behairy,2 Ahmed El-Degwi5
1
11
Otorhinolaryngology Department, Faculty of Medicine/ Kafr Elshiekh University, 12Otorhinolaryngology Department, Faculty of Medicine/
Hearing and Speech Institute, 13Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 14Otorhinolaryngology
Department, Faculty of Medicine/ Military Medical Academy, 15Otorhinolaryngology Department, Faculty of Medicine/ Misr University
for Science and Technology, 16Otorhinolaryngology Department, Faculty of Medicine/ Suez Canal University, 17Otorhinolaryngology
Department, Faculty of Medicine/ Fayoum University.
Introduction and background controlled trials.
A condition characterized by accumulation of non-infectious non- Ib: At least one randomized controlled trial.
suppurative fluid in the middle ear behind an intact TM. The
condition is seen most frequently in children under the age of 9 IIa: At least one well-designed, controlled study but without
years. It is the most common cause of hearing loss in children. randomization.
Scope and purpose IIb: least one well-designed, quasi-experimental study.
The purpose of this work is to identify best clinical practice III: At least one well-designed, non-experimental descriptive
guideline in managing OME in children and to create explicit study.
and actionable recommendations regarding the accuracy of
diagnosis, efficacy of medical and surgical intervention. IV: Expert committee reports, opinions, and/or experience of
respected authorities.
Methods
Degree of recommendation
The adaptation cycle passed over: Set up phase, adaptation
phase (Search and screen, assessment: Currency, Content and A. Strongly recommended: strong evidence is available,benefits
Quality and Decisions/selection) and finalization phase that substantially outweigh harms.
include revision.
B. Recommended: sufficient evidence is available,
Results benefitsoutweigh harms.
Eight guidelines were assessed by expert otologists and the C. No recommendation made: fair evidence is available,
Clinical practice guidelines for the diagnosis and management butthe balance of benefits and harms is close.
of otitis media with effusion (OME) in children in Japan, 2015
D. Recommended against: harms outweigh benefits.
had the highest scores as regards to the currency, contents and
quality. It was graded and finally reviewed to have final guideline. E. Insufficient evidence to determine the balance of
benefitsand harms.
Level of evidence
Ia: Meta-analysis (with homogeneity) or randomized
(GRADE Working Group 2013)
Grade Definition
++++
Moderate We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there
+++ is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
++
Very Low We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of
+ effect
Otitis media with effusion 2021 (Volume 1) Pages: 7-11 7

Recommendations statements (From 10-20 recommendations in a Table)

Accepted statements
Modified statements
Added statements
Strength of
Strength after
recommendations
Clinical questions Action recommendation Level of evidence adoption or
according to the
adaptation
selected CPG
A diagnosis of OME is made when the tympanic
membrane findings described below are observed.
The nature of the middle ear effusion in this
disease varies and is largely classified into three
What are the
types: serous, viscous, and mucopurulent.
tympanic
Retraction, bulging or opacity of the membrane,
membrane
diminished or absent light reflex, presence of
findings that aid Not Reported Recommendation ++++
middle ear effusion (e.g., presence of bubbles
in the diagnosis of
and gas or a liquid phase), and/or variously
otitis media with
colored middle ear effusion can be observed on
effusion?
examination of the tympanic membrane in cases of
OME. Furthermore, diminished or reduced mobility
of the tympanic membrane can be confirmed with
a pneumatic Otoscopy.
Is pneumatic
Diagnosis of OME in children is made when the
Otoscopy useful
effusion is present in the middle ear cavity in
for observation of ++ (As it is
the absence of acute inflammatory findings.
the pathological Not Reported Recommendation difficult and non
Visual inspection of the tympanic membrane
condition of available)
by pneumatic otoscopy is the first examination
otitis media with
performed to diagnose OME in children.
effusion?
Is hearing For diagnosing the severity and type of hearing
assessment useful loss, and is performed when confirming hearing
for diagnosing loss before and after tympanostomy tube insertion, Not Reported Recommendation ++++
otitis media with determining surgical indications, and testing for
effusion? the presence of sensorineural hearing loss.
Is tympanometry
After OME in children has been diagnosed by
useful for the
otomicroscopy, otoendoscopy, and pneumatic
diagnosis of Not Reported Recommendation ++++
otoscopy, tympanometry may be used to confirm
otitis media with
middle ear effusion.
effusion?
Findings from regional organs (paranasal sinuses
Are findings on and epipharynx) are helpful in understanding
surrounding diseases considered to be related to OME in
organs (paranasal children. In a clinical setting, a doctor asks the
sinuses and subject about his/her nasal symptoms, the extent
epipharynx) of mouth breathing, snoring, and sleep apnea
Not Reported Recommendation ++++
helpful in at nighttime, and seasonal or perennial rhinitis
understanding the symptoms, then examines the patient’s nasal
clinical condition cavity, oral cavity, and pharynx. Further tests
of otitis media should only be conducted after considering the
with effusion? balance between the reasons for conducting the
tests and the invasiveness and costs of the tests.
Is imaging useful
for diagnosing Imaging of the temporal bone is not recommended
Not Reported Not Reported ++++
otitis media with routinely in otitis media with effusion.
effusion?
Watchful waiting for 3 months from the date of
How long is the effusion onset or from the date of diagnosis is
Strong
appropriate period recommended for managing the child with OME I +++
Recommendation
to monitor OME? who is not at risk, including pathological changes
in the eardrum.
8 2021 (Volume 1) Pages: 7-11 Otitis media with effusion

Strength of
Strength after
recommendations
Clinical questions Action recommendation Level of evidence adoption or
according to the
adaptation
selected CPG
The clinician has an option to continue close
monitoring of OME patients beyond 3 months,
specifically in cases without any pathological
change (i.e., adhesion or retraction) in the I Not Reported +++
eardrum.
However if there is concern about difficult follow

up of children, clinician may offer surgery
Are antibacterial
In cases without bacterial infection of the
agents effective
surrounding organs, administration of antibacterial Recommendation
for the treatment I ++++
agents for OME in children is not recommended Against
of otitis media
because the risks outweigh the benefits.
with effusion?
Macrolide treatment (low-dose clarithromycin) is
not recommended as therapeutic option in children Not Reported Not Reported +++
with OME associated with rhinosinusitis
The efficacy of second-generation antihistamines
and inhaled nasal steroids for the treatment of Insufficient Recommendation +++
OME in children has not been proved, but these evidence Against
treatments should be considered as an option for
Are drug therapies
patients with allergic rhinitis.
other than
antibacterial
Corticosteroids have short-term but not long-term
agents effective efficacy for the treatment of OME in children and
for the treatment are not recommended because the risks outweigh
of otitis media I Recommendation +++
the benefits. The efficacy of first-generation
with effusion? antihistamines for the treatment of OME in Against
children has not been demonstrated, and they are
not recommended because the risks outweigh the
benefits.
Carbocysteine is not recommended as a treatment
I Not Reported +++
option.
Clinicians should determine if a child with OME is
Identifying at-risk at increased risk for speech, language, or learning
children problems from middle ear effusion because of III Not Reported ++++
baseline sensory, physical, cognitive, or behavioral
factors.
Tympanostomy Clinicians may perform Tympanostomy tube

tubes in at-risk insertion in at-risk children with unilateral or III Not reported +++
children bilateral OME that is unlikely to resolve quickly.
Clinicians should offer bilateral tympanostomy tube

insertion for children with bilateral OME that has
persisted for 3 months or more AND documented
Strong ++++
hearing difficulties with hearing loss (above 25
Recommendation
dB) of the ear on both sides. Clinicians should
offer tympanostomy tube insertion for children
with unilateral or bilateral OME for 3 months or
What are surgical longer AND observed pathological changes of
indications for the tympanic membrane such as atelectasis and
adhesion. I
tympanostomy
tube insertion?
Clinicians may consider tympanostomy tube
insertion for children with unilateral or bilateral
OME for 3 months or longer AND observed clinical
findings that may be associated with OME, such as
decreased activity in school, vestibular symptoms,
Insufficient evidence +++
delay in academic performance, ear discomfort,
and decrease in QOL. However, symptoms due to
the developmental disorder are excluded.
Adenoidectomy is effective for the treatment of
OME; however, since it is more invasive, it is not
Indications for Recommendation
recommended as the initial procedure for OME in I ++++
adenoidectomy Against
children in the absence of clear indications with
regard to upper airway lesions.

Algorithm Adapted Egyptian Clinical Practice Guidelines (ECPG) for the diagnosis and management of otitis media with
effusion (OME) in children
10 2021 (Volume 1) Pages: 7-11 Otitis media with effusion

References 5. Blanc F, Ayache D, Calmels MN, Deguine O, François

M, Leboulanger N, Lescanne E, Marianowski R,
1. Lee HJ, Park SK, Choi KY, Park SE, Chun YM, Nevoux J, Nicollas R, Tringali S, Tessier N, Franco-
Kim KS, Park SN, Cho YS, Kim YJ, Kim HJ, Vidal V, Bordure P, Mondain M. Management of otitis
Korean Otologic Society. Korean clinical practice media with effusion in children. Société française
guidelines: otitis media in children Korean Med Sci. d’ORL et de chirurgie cervico-faciale clinical practice
2012;27(8):835-48. guidelines. Eur Ann Otorhinolaryngol Head Neck Dis.
2018;135(4):269-273.
2. Heidemann CH, Lous J, Berg J, Christensen JJ,
Håkonsen SJ, Jakobsen M, Johansen CJ, Nielsen LH, 6. Simon F, Haggard M, Rosenfeld RM, Jia H, Peer S,
Hansen MP, Poulsen A, Schousboe LP, Skrubbeltrang Calmels MN, Couloigner V, Teissier N. International
C, Vind AB, Homøe P.Danish guidelines on consensus (ICON) on management of otitis media
management of otitis media in preschool children.Int with effusion in children.Eur Ann Otorhinolaryngol
J Pediatr Otorhinolaryngol. 2016;87:154-63. Head Neck Dis. 2018;135(1S):S33-S39.
3. Rosenfeld RM, Shin JJ, Schwartz SR, Coggins R, 7. National Institute for Health and Care Excellence (the
Gagnon L, Hackell JM, Hoelting D, Hunter LL, Kummer UK .Otitis media with effusion in under 12s: surgery.
AW, Payne SC, Poe DS, Veling M, Vila PM, Walsh SA, https://www.nice.org.uk/guidance/cg60.2018.
Corrigan MD.Clinical Practice Guideline: Otitis Media
with Effusion (Update).Otolaryngol Head Neck Surg. 8. Núñez-Batalla F, Jáudenes-Casaubón C, Sequí-Canet
2016;154(1 Suppl):S1-S41. JM, Vivanco-Allende A, Zubicaray-Ugarteche J.
Diagnosis and treatment of otitis media with effusion:
4. Ito M, et al. Clinical practice guidelines for the CODEPEH recommendations.Acta Otorrinolaringol
diagnosis and management of otitis media with Esp. 2019;70(1):36-46.
effusion (OME) in children in Japan, 2015. Auris
Nasus Larynx. 2017;44(5):501-508.

Bell’s Palsy in Adults: Adapted Egyptian Clinical Practice Guidelines

Assembly board: Usama Kamal,11 Mohamed R. Ghonim,5 Ali Mahrous,9 Hani El-Garem,10 Yasser Shewel,10 Mohamed Abdelbadie
Salem,5 Ahmed Galal10
Mohamed Badr El-Dine,10 Saad Elzayat,12 Fathy Erfan,6 Ayman Fouad,6 Amr Galal,13 Amir Gorguy Mina,10 Sherif Safwat Guindi,14 Hisham
Hamad,6 Mahmood A. Hamed,15 Ashraf Lotfy,16 Ahmed Mehana,10 Osama Metwaly,1 Mohammed Qotb14
Reviewing Board: Abdelaziz Elsherif,17 Maged B. Naguib,18 Fatthi Abdelbaki,10 Sherif Adly1
1
11
Otorhinolaryngology Department, Faculty of Medicine/ South Valley University, 12Otorhinolaryngology Department, Faculty of Medicine/
Kafr Elshiekh University, 13Otorhinolaryngology Department, Hearing and Speech Institute, 14Otorhinolaryngology Department, Faculty
of Medicine/ Fayoum University, 15Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 16Otorhinolaryngology
Department, Faculty of Medicine/ Military Medical Acadamy, 17Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar Assiut
University, 18Otorhinolaryngology Department, Faculty of Medicine/ Suez Canal University.
Introduction and background Methods
Bell’s palsy is an idiopathic weakness or paralysis of the face The adaptation cycle passed over: set up phase, adaptation
of peripheral nerve origin, with acute onset. It affects 20–30 phase (Search and screen, assessment: Currency, Content
persons per 100 000 annually. The major cause of Bell palsy and Quality and Decisions/selection) and finalization phase
is believed to be an infection of the facial nerve by the herpes that include revision.
simplex virus. As a result of this viral infection, the facial
nerve swells and is compressed in its canal as it courses Results
through the temporal bone
The guidelines were assessed by otologist, the guideline
Scope and purpose of the French Society of ENT and Head and Neck Surgery
(SFORL) 2020 had the highest scores as regards to the
The purpose of this work is to identify best clinical practice currency, contents and quality. It was graded GRADE by many
guideline in managing Bell’s palsy in adults and to create expert otologist and reviewed by at least 3 expert reviewers.
explicit and actionable recommendations to implement these
opportunities in clinical practice.
Grade Definition
++++
+++ there is a possibility that it is substantially different.
++ effect.
+ of effect.
Accepted statements
Modified statements
Added statements
12 2021 (Volume 1) Pages: 12-18 Bell’s palsy

Guidelines were graded A, B, C or “Expert opinion” according to decreasing level of evidence, in line with the French
National Agency
Correspondence between literature assessment and
guidelines grading
Level of evidence according to literature Strength of

recommendation
Text Position paper Guideline
Level 1 Grade A
High-power randomized comparative trial High level of

evidence
Meta-analysis of randomized comparative trials
Decision analysis founded on well-conducted studies
Level 2 Grade B
Low-power randomized comparative trial Moderate level of
evidence
Well-conducted non-randomized comparative trial
Cohort study
Level 3
Case-control study
Grade C
Retrospective comparative trial
Low level of
Level 4 evidence
Comparative study with significant bias
Retrospective study
Case series
Descriptive epidemiological study (transversal,

longitudinal)
Any other publication (case report, expert opinion, etc)
No publication Expert opinion
Bell’s palsy 2021 (Volume 1) Pages: 12-18 13

Strength after adoption

Statement topic Action recommendation Level of evidence
or adaptation
Bell’s palsy is a form of peripheral facial palsy with sudden onset

over 24–48 h, involving the superior and inferior areas of the
hemi-face and affecting voluntary, autonomic and emotional
motricity. It may be preceded by auricular or retroauricular
pain, dysgeusia, hyperacusis and/or facial paresis
• Confirmation of the peripheral nature of the facial palsy B ++++

should be done
• In patients presenting for peripheral facial palsy, B ++++

complete clinical neurologic and ENT examination should
be performed, with otoscopy and parotid and cervical
palpation. Involvement of the superior and inferior facial
areas and absence of autonomic-voluntary dissociation
should be screened to confirm peripheral status.
Neurologic examination can rule out involvement of the
Clinical somatosensory and motor central pathways and other
examination cranial nerves
• In case of peripheral facial palsy progressing beyond A ++++

72 h after onset or showing fluctuation or recurrence or
bilateral involvement, diagnosis of Bell’s palsy should be
questioned and tumoral causes screened for.
• In case of peripheral facial palsy even with rapid B ++++

progression but associated with abnormal otoscopy or
parotid or cervical lymph node palpation or ipsilateral
hearing loss, dizziness or other neurological signs,
diagnosis of Bell’s palsy should be questioned.
• In case of Bell’s palsy, initial workup should assess facial Expert opinion +++
involvement severity on a standardized grading system
(House-Brackmann classification) for inclusion in the
medical file.
Role of Topodiagnosis should be considered. Not Reported ++++
Audiometric assessment should be systematic in case of Bell’s

palsy.
CHL suggesting intratemporal facial nerve tumor, sensorineural

component, suggesting extrinsic facial nerve compression in Expert opinion
++++
Audiological the Ponto cerebellar angle.
evaluation +++
Stapedial reflex screening should be systematic in case of Bell’s
Expert opinion
palsy for prognostic purposes. In case of persistent stapedial
reflex in severe peripheral facial palsy, a diagnosis of Bell’s
palsy should always be questioned and extra-temporal cervical
or parotid lesions should be screened for.
Clinicians should not obtain routine laboratory testing in
patients with new-onset Bell’s palsy( Cause of modification:
Laboratory testing laboratory testing may be indicated in selected patients with C ++++
identifiable risk factors or atypical presentation of sudden
onset unilateral facial paresis/paralysis).
Clinicians should not routinely perform diagnostic imaging for
patients with new-onset Bell’s palsy However, there is a distinct
role for imaging in case of trauma to the temporal bone or
Is imaging useful history of tumor and any presentation of facial paresis/paralysis
for diagnosing non consistent with Bell’s palsy should be further evaluated C ++++
Bell’s palsy? by imaging. Features atypical of Bell’s palsy include a second
paralysis on the same side, paralysis of isolated branches of
the facial nerve, paralysis associated with other cranial nerve
involvement, or no sign of recovery after 3 months.


or adaptation
MRI is the examination of choice in exploring the entire neural ++++
course. It should include brain and parotid, with gadolinium
enhancement.
In Bell’s palsy, there is characteristic but non-specific +++

enhancement of the facial nerve ipsilateral to the neurologic
lesion.
Emergency imaging, on the other hand, is not necessary if ++++

symptomatology is typical of Bell’s palsy. Expert opinion
It should be borne in mind that diffusion-weighted MRI to

++++
rule out stroke does not explore the facial nerve and is thus
insufficient for work-up in Bell’s palsy.
In the absence of the usual favorable progression, imaging

should be repeated at 6 months. +++
Brain or temporal CT is not indicated in work-up for Bell’s palsy. ++++

Electroneuromyography (ENoG) should be performed in +++
severe facial palsy (HB grade V or VI) and is fundamental for
assessing the clinical recovery profile and selection for surgery,
Diagnosis of but should not be performed too early (Between days 9 and C
severity 20).
Role of EMG as tool to assess prognosis and selection for +++

surgery.
In Bell’s palsy, therapy with prednisolone or methyl- A ++++
prednisolone should be implemented as early as possible
(Ideally, within 72 h).
Bell’s palsy should be treated by corticosteroids at1 mg/kg/day Expert opinion +++
for 7–10 days.
Medical treatment
In severe forms (HB grade V or VI), 10 days’ high-
Expert opinion +
dose corticotherapy (2 mg/kg/day) seem justified unless
contraindicated.
Isolated trans tympanic administration is not recommended

Expert opinion ++++
for Bell’s palsy.
Isolated antiviral treatment is not recommended in Bell’s palsy A +++

Antiviral therapy In Bell’s palsy treated early (within 72 h), antiviral treatment
should be associated to corticosteroids. B +++
Ophthalmologic treatment comprising local care, nocturnal

occlusion and patient education should be systematic and
Eye-care in Bell’s
as early as possible. In case of painful red eye, treatment
palsy and Ramsay- Expert opinion ++++
should be entrusted to an ophthalmologist. Ophthalmologic
Hunt syndrome
monitoring should continue for several weeks once recovery
has begun.
Gold weight to protect eye Not Reported +++
Expert opinion ++++

Physical therapy is classically applied in Bell’s palsy persisting
beyond the first months, to hasten recovery and limit sequelae.
However, it is clear that facial muscle rehabilitation improves

Role of physical Expert opinion ++
facial function when Bell’s palsy fails to resolve.
therapy in Bell’s
palsy Electrotherapy and forced exercise (chewing gum, biofeed-
Expert +++
back) are formally contraindicated in Bell’s palsy.
Acupuncture is not recommended in Bell’s palsy.

C +++


or adaptation
Role of hyperbaric
oxygen therapy in Hyperbaric oxygen therapy is not recommended in Bell’s palsy. C ++++
Bell’s palsy
Clinical and ophthalmological follow-up should be continued

Role of follow-up
for several months after recovery begins, to ensure against C +++
in Bell’s palsy
complications, and ophthalmic complications in particular.
There is at present no proof that facial nerve decompression Expert opinion ++++
provides benefit in acute Bell’s palsy.
If surgical facial nerve decompression is implemented, it must Expert opinion +++

include the meatal foramen, the labyrinthine segment, the
Surgical beginning of the second part of the nerve, and the geniculate
facial nerve ganglion. A transmastoid or a supratemporal approach may be
decompression in used, but the latter is the gold standard.
acute Bell’s palsy
There is no benefit in isolated decompression of the third part Expert opinion ++++
of the facial nerve in Bell’s palsy.
Any facial nerve decompression should be performed within30

days and ideally within 14 days of electrically proven onset. Expert opinion +++


References 4. Holger Schünemann, Jan Brożek, Gordon Guyatt ,

and Andrew Oxman. GRADE handbook 2013. https://
1. Murthy JM, Saxena AB. Bell’s palsy: Treatment gdt.gradepro.org/app/handbook/handbook.html.
guidelines. Ann Indian Acad Neurol. 2011;14(Suppl
1):S70-S72. doi:10.4103/0972-2327.83092. 5. de Almeida JR, Guyatt GH, Sud S, Dorion J, Hill
MD, Kolber MR, et al. Management of Bell palsy:
2. Gronseth, GS, Paduga, R. Evidence-based guideline clinical practice guideline. CMAJ : Canadian Medical
update: steroids and antivirals for Bell palsy: report Association journal = journal de l’Association medicale
of the Guideline Development Subcommittee of canadienne. 2014;2;186(12):917-22. PubMed PMID:
the American Academy of Neurology. Neurology. 24934895. Pubmed Central PMCID: 4150706.
2012;79:2209-2213.
6. Fieux M, Franco-Vidal V, Devic P, Bricaire F, Charpiot
3. Baugh RF, Basura GJ, Ishii LE, Schwartz SR, A, Darrouzet V, et al. French Society of ENT (SFORL)
Drumheller CM, Burkholder R, et al. Clinical practice guidelines. Management of acute Bell’s palsy.
guideline: Bell’s palsy. Otolaryngology--head and European annals of otorhinolaryngology, head and
neck surgery : official journal of American Academy of neck diseases. 2020 Jul 4. PubMed PMID: 32636146.
Otolaryngology-Head and Neck Surgery. 2013;149(3
Suppl):S1-27.

Sudden SNHL: Adapted Egyptian Clinical Practice Guidlines

Assembly board: Ali Mahrous,9 Adel Khalifa,6 Gamal Abdelfattah,11 Ashraf Lotfy,12 Mohamed Zaidan,9 Tawfik Elkholy,9 Mohamed
Abdelbadie Salem,5 Doaa Abd Elhalem,9 Rabie Sayed4
Haithem Alfaragy,13 Mohamed Badr El-Dine,10 Saad Elzayat,13 Ayman Fouad,6 Amr Galal,14 Sherif Safwat Guindi,15 Ahmed Mehana,10
Osama Metwaly,1 Amir Gorguy Mina,10 Mohammed Qotb16
Reviewing Board (In alphabetical order): Aziz Belal,12 Hisham Hamad,6 Sherif Elaini17
1
of Medicine/Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology
11
Otorhinolaryngology Department, Faculty of Medicine/ Misr University For Science And Technology, 12Otorhinolaryngology Department,
Faculty of Medicine/ Military Medical Acadamy, 13Otorhinolaryngology Department, Faculty of Medicine/ Kafr Elshiekh University,
14
Otorhinolaryngology Department, Hearing and Speech Institute, 15Otorhinolaryngology Department, Faculty of Medicine/Fayoum
University, 16Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 17Otorhinolaryngology Department, Armed Forces
college of Medicine.
Sudden SNHL is considered an ENT emergency, The secret The adaptation cycle passed over: Set up phase, adaptation
lies in early diagnosis and prompt treatment phase (Search and screen, assessment: Currency, Content
and Quality and Decisions/selection) and finalization phase
Unless we, as clinicians, have a high index of suspicion, this that include revision.
condition can be easily overlooked within the golden period
where the treatment would be expected to yield the best Results
possible results
The guidelines were assessed by expert otologists and the
Scope and purpose Clinical practice guidelines for the diagnosis and management
of Sudden SNHL by American Academy of otolaryngology-
To use the best available published scientific and/or clinical Head and Neck surgery Foundation 2019 had the highest
evidence to enhance diagnostic accuracy and appropriate scores as regards to the currency, contents and quality. It was
therapeutic interventions. graded GRADE and finally reviewed to have final guideline.
Grade Definition
High
We are very confident that the true effect lies close to that of the estimate of the effect.
++++
Low
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
++
+ effect
Sudden SNHL 2021 (Volume 1) Pages: 19-24 19

Well-designed randomized controlled trials

A performed on a population similar to the guideline`s
target population
B
Nonconsecutive studies, case control studies, or studies with poor, Observational studies (case control and cohort
C
nonindependent, or inconsistently applied reference standards design)
Exceptional situations where validating studies
X cannot be performed and there is a clear
preponderance of benefit over harm
Statement Definition Implication

Clinicians should follow a strong
recommendation) and that the quality of the
recommendation unless a clear and
Strong recommendation supporting evidence is excellent (grade A or
compelling rationale for an alternate
B). In some clearly identified circumstances,
approach is present.
strong recommendations may be made
based on lesser evidence when high-quality
evidence is impossible to obtain and the
anticipated benefits strongly outweigh the
harms.
A recommendation means that the benefits
exceed the harms (or that the harms exceed
the benefits in the case of a negative
recommendation), but the quality of evidence Clinicians should also generally follow a
is not as strong (grade B or C). In some clearly recommendation but should remain alert
Recommendation
identified circumstances, recommendations to new information and sensitive to patient
may be made based on lesser evidence when preferences.
high-quality evidence is impossible to obtain
and the anticipated benefits outweigh the
harms.
An option means either that the quality of Clinicians should be flexible in their decision
evidence that exists is suspect (grade D) making regarding appropriate practice,
Option or that well-done studies (grade A, B, or C) although they may set bounds on alternatives;
show little clear advantage to 1 approach patient preference should have a substantial
versus another. influencing role.
Clinicians should feel little constraint in their
No recommendation means that there is both decision making and be alert to new published
No recommendation a lack of pertinent evidence (grade D) and an evidence that clarifies the balance of benefit
unclear balance between benefits and harms. versus harm; patient preference should have
a substantial influencing role.
Recommendations statements (from 10-20 recommendations in a Table)

Accepted statements
Modified statements
Added statements
20 2021 (Volume 1) Pages: 19-24 Sudden SNHL

Strength of
Strength after
recommendations Level of
Statement Action recommendation adoption or
according to the selected evidence
adaptatio
CPG
Clinicians should distinguish
sensorineural hearing loss
1.Exclusion of conductive (SNHL) from conductive
Strong Recommendation B ++++
hearing loss hearing loss (CHL) when a
patient first presents with
SHL.
Clinicians should assess
patients with presumptive
SSNHL through history Recommendation
2.Modifying factors and physical examination C +++
for bilateral SHL, recurrent
episodes of SHL, and/or focal
neurologic findings.
Clinicians should not
order routine computed
tomography (CT) of the head Strong Recommendation
3.Computed tomography B ++++
in the initial evaluation of a against
patient with presumptive
SSNHL.
In patients with SHL,
clinicians should obtain, or
refer to a clinician who can
4.Audiometric
obtain, audiometry as soon Recommendation C ++++
confirmation of SSNHL
as possible (within 14 days of
symptom onset) to confirm
the diagnosis of SSNHL.
Clinicians should not obtain
Strong Recommendation
5.Laboratory testing routine laboratory tests in B ++
Against
patients with SSNHL.
Clinicians should evaluate

patients with SSNHL for
retrocochlear pathology
by obtaining magnetic
6.Retrocochlear pathology resonance imaging ( gold Recommendation B ++++
standard) or auditory
brainstem response (ABR)
.even with complete recovery
of hearing.
Clinicians should educate

patients with SSNHL about
the natural history of the
7.Patient education condition, the benefits and Strong Recommendation A ++++
risks of medical interventions,
and the limitations of existing
evidence regarding efficacy.
Clinicians should offer
8.Initial corticosteroids corticosteroids as initial
therapy to patients with Not Reported C ++++
SSNHL within 2 weeks of
symptom onset.
Clinicians may offer, or refer
to a clinician who can offer,
9a.Initial therapy with hyperbaric oxygen therapy
Option c ++
hyperbaric oxygen therapy (HBOT) combined with
steroid therapy within 2
weeks of onset of SSNHL.
Clinicians offer, or refer to
a clinician who can offer,
9b.Salvage therapy with
HBOT combined with steroid Option C ++
hyperbaric oxygen therapy
therapy as salvage within 1
month of onset of SSNHL.

Strength of
Strength after
recommendations Level of
Statement Action recommendation adoption or
according to the selected evidence
adaptatio
CPG
Clinicians should offer, or
refer to a clinician who can
offer, intratympanic steroid
10.Intratympanic steroids
therapy when patients have Recommendation C +++
for salvage therapy
incomplete recovery from
SSNHL 2 to 6 weeks after
onset of symptoms.
11.Other pharmacologic 11. Other pharmacologic Strong Recommendation
B +++
therapy therapy. against
Clinicians should obtain
follow-up audiometric
evaluation for patients with
12.Outcomes assessment SSNHL at the conclusion Recommendation C +++
of treatment and within 6
months of completion of
treatment.
Clinicians should counsel
patients with SSNHL who
have residual hearing
+++
loss and/or tinnitus about
13a.Rehabilitation Strong Recommendation A
the possible benefits of ++++
audiological rehabilitation
and other supportive
measures.
Clinicians should counsel
patients with SSNHL who
have no residual hearing
and/or tinnitus about the
13b.Rehabilitation Not Reported Not Reported ++++
possible benefits of surgical
rehabilitation such as bone
conduction hearing implant
or cochlear implantation.

Algorithm Adapted Egyptian Clinical Practice Guidelines (ECPG) for the diagnosis and management of sudden
SNHL

References 2017.12.011. Epub 2018 Feb 1. PMID: 29396226.
1. Bhattacharyya, Abir & Thaj, Jabin. (2010). 4. Chandrasekhar SS, Tsai Do BS, Schwartz SR,
Investigation Protocol for Sensorineural Hearing Loss. Bontempo LJ, Faucett EA, Finestone SA, Hollingsworth
Otorhinolaryngology Clinics An International Journal. DB, Kelley DM, Kmucha ST, Moonis G, Poling GL,
2. 107-112. 10.5005/jp-journals-10003-1023. Roberts JK, Stachler RJ, Zeitler DM, Corrigan MD,
Nnacheta LC, Satterfield L. Clinical Practice Guideline:
2. Stachler RJ, Chandrasekhar SS, Archer SM, et al. Sudden Hearing Loss (Update). Otolaryngol Head
Clinical Practice Guideline: Sudden Hearing Loss. Neck Surg. 2019;161(1_suppl):S1-S45. doi:
Otolaryngology–Head and Neck Surgery. 2012;146(3_ 10.1177/0194599819859885. PMID: 31369359.
suppl): S1-S35. doi:10.1177/0194599812436449.
5. Singh A, Kumar Irugu DV. Sudden sensorineural
3. Marx M, Younes E, Chandrasekhar SS, Ito J, Plontke hearing loss - A contemporary review of management
S, O’Leary S, Sterkers O. International consensus issues. J Otol. 2020 Jun;15(2):67-73. doi: 10.1016/j.
(ICON) on treatment of sudden sensorineural joto.2019.07.001. Epub 2019 Jul 30. PMID:
hearing loss. Eur Ann Otorhinolaryngol Head Neck 32440269; PMCID: PMC7231990.
Dis. 2018;135(1S):S23-S28. doi: 10.1016/j.anorl.

Tinnitus: Adapted Egyptian Clinical Practice Guidlines

The following statement and flowchart were adopted from the Clinical practice guidelines for tinnitus of the American Academy of
Otolaryngology, Head and Neck Surgery which had the highest scores as regards the currency, contents and quality

Assembly board: Saad Elzayat,11 Mohamed Modather,12 Ayman Fouad,6 Nabila Elneklawy,9 Doaa Abd Elhalem,9 Haitham Elfarargy,11
Islam Soltan10
Gamal Abdelfatah,13 Ahmed Elkhateeb,14 Fathy Erfan,6 Ahmed Galal,10 Amr Galal,15 Sherif Safwat Guindi,16 Hisham Hamad,6 Adel Khalifa,6
Ashraf Lotfy,14 Ali Mahrous,9 Mahmoud Mandour,6 Amir Gorguy Mina,10 Ihab Nada,13 Mohamed Qotb,16 Ashraf Salah,13 Yasser Shewel10
Reviewing Board: Ismail Zohdi,1 Ahmed Aboul Wafa,12 Ahmed S. Alhamshary17
1
11
Otorhinolaryngology Department, Faculty of Medicine/ Kafr Elshiekh University, 12Otorhinolaryngology Department, Faculty of
Medicine/ Assuit University, 13Otorhinolaryngology Department, Faculty of Medicine/ Misr University for Science and Technology,
14
Otorhinolaryngology Department, Faculty of Medicine/ Military Medical Academy, 15Otorhinolaryngology Department/ Hearing and
Speech Institute, 16Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University, 17Otorhinolaryngology Department,
Faculty of Medicine/ Banha University.
A condition described as ringing, buzzing, clicking or The adaptation cycle passed over: Set up phase, adaptation
pulsating noise perceived only by the patient(subjective) phase (Search and screen, assessment: Currency, Content
or the examiner and the patient objective. it may be and Quality and Decisions/selection) and finalization phase
without abberent cause (Primary) or due to specific cause that include revision.
(Secondery).
Results
Scope and purpose
Five guidelines were assessed by expert otologist and the
The purpose of this work is to identify best clinical practice Clinical practice guidelines for tinnitus of the American
guideline in managing tinnitus . Academy of Otolaryngology – Head and Neck Surgery had
the highest scores as regards to the currency, contents and
quality. It was graded and finally reviewed to have final
guideline.
Grade Definition
High
++++
++ effect.
+ of effect

Well-designed randomized controlled trials performed
A on a population similar to the guideline`s target
population
B
Nonconsecutive studies, case control studies, or studies with poor,
C Observational studies (case control and cohort design)
nonindependent, or inconsistently applied reference standards
X Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit over harm
Tinnitus guidelines 2021 (Volume 1) Pages: 25-30 25


recommendation) and that the quality of the Clinicians should follow a strong
Strong recommendation supporting evidence is excellent (grade A or recommendation unless a clear and compelling
B). In some clearly identified circumstances, rationale for an alternate approach is present.
strong recommendations may be made
based on lesser evidence when high-quality
evidence is impossible to obtain and the
anticipated benefits strongly outweigh the
harms.
the benefits in the case of a negative
recommendation), but the quality of evidence Clinicians should also generally follow a
is not as strong (grade B or C). In some clearly recommendation but should remain alert
Recommendation
identified circumstances, recommendations to new information and sensitive to patient
may be made based on lesser evidence when preferences.
harms.
evidence that exists is suspect (grade D) or making regarding appropriate practice,
Option that well-done studies (grade A, B, or C) show although they may set bounds on alternatives;
little clear advantage to 1 approach versus patient preference should have a substantial
another. influencing role.

Accepted statements
Modified statements
Added statements
Action Grading after

Clinical question Action Level
Recommendation adaptation
A condition described as ringing,
buzzing, clicking or pulsating
noise perceived only by the
Definition of patient(subjective) or the examiner
Recommendation Not Reported High
Tinnitus and the patient objective. it
may be without abberent cause
(Primary) or due to specific cause
(Secondery).
Clinicians should perform a
targeted history and physical
examination at the initial evaluation
History and
of a patient with presumed primary Recommendation C High
physical exam
tinnitus to identify conditions that
if promptly identified and managed
may relieve tinnitus.
Clinicians should obtain a prompt,
comprehensive audiologic
Prompt Audiologic examination in patients with
Recommendation C Moderate
Examination tinnitus that is unilateral, persistent
(≥ 6 months), or associated with
hearing difficulties.
26 2021 (Volume 1) Pages: 25-30 Tinnitus guidelines


Clinicians may obtain an initial
comprehensive audiologic
Routine Audiologic examination in patients who
Optional C Moderate
Examination present with tinnitus (regardless
of laterality, duration,or perceived
hearing status).
Clinicians should obtain imaging
studies of the head and neck in
patients with tinnitus especially
if they have 1 or more of the
following: tinnitus that localizes
to 1 ear, pulsatile tinnitus, focal
neurological abnormalities, or
asymmetric hearing loss.( MRI
Imaging studies Recommendation Not Reported Moderate
temporal bone with contrast with
special emphasis on IAC and CPA
to exclude retrocochlear lesion
, CT temporal bone to exclude
dehiscent jugular vein, dehiscent
carotid canal, glomus, or other
causes and MRI with contrast and
MRA to exclude vascular loop).
Clinicians must distinguish patients
Bothersome with bothersome tinnitus from
Recommendation B High
tinnitus patients with no bothersome
tinnitus.
Clinicians should distinguish
patients with bothersome tinnitus
of recent onset from those with
Persistent tinnitus persistent symptoms (≥ 6 months) Recommendation B Moderate
to prioritize intervention and
facilitate discussions about natural
history and follow-up care.
Clinicians should educate patients
Education and with persistent, bothersome
Recommendation B High
Counseling tinnitus about management
strategies.
Clinicians should recommend a
Hearing aid hearing aid evaluation for patients
Recommendation C Moderate
evaluation with hearing loss and persistent,
bothersome tinnitus.
Clinicians may recommend sound
Sound therapy therapy to patients with persistent, Recommendation B Low
Clinicians should recommend
Cognitive
cognitive behavioral therapy
behavioral therapy Recommendation A Low
to patients with persistent,
(CBT)
Clinicians can recommend
antidepressants, anticonvulsants,
or anxiolytics for a primary
indication of treating persistent,
Medical therapy No Sufficient Evidence Not Reported Moderate
bothersome tinnitus (Neramexane,
Vestipitant alone or in combination
with paroxetine, acamprosate and
dietary zinc supplements).
Clinicians can recommend
Ginkgo biloba, melatonin, zinc,
Dietary
or other dietary supplements for No Sufficient Evidence C Low
supplements
treating patients with persistent,
No recommendation can be
made regarding the effect of
Acupuncture Recommendation Against C High
acupuncture in patients with
persistent bothersome tinnitus.


Intratympanic Clinicians should have enough
injection experience with Intratympanic
injection Intratympanic injection
should be done once weekly for
3-5 times Intratympanic steroids
A-Intratympanic should be used in acute tinnitus,
steroids cases with sudden SNHL and in
cases with SNHL not more than
30 db.
No Sufficient Evidence Not Reported Moderate
B- Intratympanic
Intratympanic lidocaine should be
lidocaine
tried only for chronic tinnitus.
C- combined
Combination reduce irritative effect
Intratympanic
of lidocaine.
steroids and
lidocaine
Surgical treatment is offered in
Surgical treatment
specific causes of tinnitus ( e.g. Recommendation Not Reported Moderate
of tinnitus
glomus , vestibular schwannoma)


References 5. Sakata, Eiji, and Yoshio Umeda. “Treatment of tinnitus

by transtympanic infusion.” Auris Nasus Larynx.
1. Tunkel, David E., et al. “Clinical practice guideline: 1976;3.2:133-138.
tinnitus.” Otolaryngology–Head and Neck Surgery.
2014;151.2_suppl:S1-S40. 6. Cima, R. F. F., et al. “A multidisciplinary European
guideline for tinnitus: diagnostics, assessment, and
2. Weissman, Jane L., and Barry E. Hirsch. “Imaging of treatment.” Hno. 2019;67.1:10-42.
tinnitus: A review.” Radiology. 2000;216.2:342-349.
7. Guideline NG155, N. I. C. E. “Tinnitus: assessment
3. Elzayat, Saad, et al. “Tinnitus: Evaluation of and management.” Methods. 2020.
intratympanic injection of combined lidocaine and
corticosteroids.” ORL. 2016;78.3:159-166. 8. Ogawa, Kaoru, et al. “Clinical practice guidelines for
diagnosis and treatment of chronic tinnitus in Japan.”
4. Shim, Hyun Joon. “Intratympanic steroid injection Auris Nasus Larynx. 2020;47.1:1-6.
in tinnitus management.” Hanyang Medical Reviews.
2016;36.2:125-130. 9. Practice guidance Fitting of combination hearing aids
for subjects with tinnitus. 2020.

Ménière’s Disease: Adapted Egyptian Clinical Practice Guidelines

Assembly board: Mahmoud Mandour,6 Yasser Shewel,10 Aziz Belal,9 Maged B. Naguib11
Haytham El Farargy,10 Saad Elzayat,12 Ayman Fouad,6 Amr Galal,13 Ahmed Galal,10 Sherif Safwat Guindi,14 Hisham Hamad,6 Sherief Lotfy,15
Ahmed Mehanna,10 Amir Gorguy Mina,10 Mohamed Qotb,14 Mohamed Abdelbadie Salem5
Reviewing Board: Hani El Garem,10 Fatthi Abdelbaki,10 Mohamed Salem,16 Lobna ELfeky17
1
11
Otorhinolaryngology Department, Faculty of Medicine/ Suez Canal University, 12Otorhinolaryngology Department, Faculty of Medicine/
Kafr Elshiekh University, 13Otorhinolaryngology Department / Hearing and Speech Institute, 14Otorhinolaryngology Department, Faculty
of Medicine/ Fayoum University, 15Otorhinolaryngology Department, Faculty of Medicine/ Military Medical Acadamy, 16Otorhinolaryngology
Department, Faculty of Medicine/ Assiut University, 17Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University.
Introduction and background reducing unindicted diagnostic testing and/or imaging.
Meniere’s disease (MD) is a clinical syndrome affecting Methods

approximately 50 to 200 per 100,000 adults and is most
common between the ages of 40 and 60 years. The diagnosis The adaptation cycle passed over: set up phase, adaptation
of MD is made clinically, as the disease typically presents with phase (Search and screen, assessment: Currency, Content
unilateral ear symptoms that can last for several decades. and Quality and Decisions/selection) and finalization phase
Typically, symptoms include severe dizziness (vertigo), that include revision.
tinnitus, fluctuant sensorineual hearing loss, and a feeling
Results
of fullness in the ear. To maximize treatment, it is important
to clinically distinguish MD from other independent causes of Three guidelines were assessed by expert otologist and
vertigo that may mimic MD. the clinical practice guidelines for the diagnosis and
management of Ménière’s disease by American Academy of
Scope and purpose
otolaryngology-Head and Neck surgery Foundation 2020 had
To use the best available published scientific and/or clinical the highest scores as regards to the currency, contents and
evidence to enhance diagnostic accuracy and appropriate quality. It was graded GRADE and finally reviewed to have
therapeutic interventions (medical and surgical) while final guideline.
(GRADE Working Group 2013
Grade Definition
++++
++
+ effect.
Ménière’s disease 2021 (Volume 1) Pages: 31-37 31

Well-designed randomized controlled trials per-
Systematic review of cross-sectional studies with consistentlyapplied ref-
A formed on a population similar to the guideline`s
erence standard and blinding
target population
Individual cross-sectional studies with consistently applied reference Randomized controlled trials; overwhelmingly con-
B
standard and blinding sistent evidence from observational studies
Nonconsecutive studies, case control studies, or studies with poor, nonin- Observational studies (case control and cohort de-
C
dependent, or inconsistently applied reference standards sign)

Exceptional situations where validating studies can-
X not be performed and there is a clear preponderance
of benefit over harm

Strong recommendation means that the ben-
efit of the recommended approach clearly ex-
ceed the harms (or that the harms, including
monetary costs,clearly exceed the benefits in
the case of a strong negative recommenda-
Clinicians should follow a strong recommen-
tion) and that the quality of the supporting
Strong recommendation dation unless a clear and compelling rationale
evidence is excellent (grade A or B). In some
for an alternate approach is present.
clearly identified circumstances, strong rec-
ommendations may be made based on lesser
evidence when high-quality evidence is im-
possible to obtain and the anticipated benefits
strongly outweigh the harms.
the benefits in the case of a negative recom-
mendation), but the quality of evidence is Clinicians should also generally follow a rec-
not as strong (grade B or C). In some clearly ommendation but should remain alert to new
Recommendation
identified circumstances, recommendations information and sensitive to patient prefer-
may be made based on lesser evidence when ences.
harms.
evidence that exists is suspect (grade D) or making regarding appropriate practice, al-
Option that well-done studies (grade A, B, or C) show though they may set bounds on alternatives;
little clear advantage to 1 approach versus patient preference should have a substantial
another. influencing role.

Accepted statements
Modified statements
Added statements
32 2021 (Volume 1) Pages: 31-37 Ménière’s disease

Strength of
Strength after
recommendations
Statement Topic Action recommendation Level of evidence adoption or
according to the
adaptation
selected CPG
Clinicians should diagnose Meniere’s
disease in patients presenting with:
1. Two or more episodes of vertigo

lasting 20 minutes up to 12 hours,
audiometrically documented
fluctuating low- to mid-frequency
sensorineural hearing loss in the
affected ear on at least 1 occasion
before, during, or after one of the
Diagnosis of episodes of vertigo. Fluctuating
hearing loss, tinnitus, or pressure B Recommendation ++++
Meniere Disease
in the affected ear. Symptoms are
not better accounted for by another
disorder (Definite Meniere).
2. Two or more episodes of vertigo

lasting 20 minutes up to 24 hours,
fluctuating hearing loss, tinnitus,
or pressure in the affected ear.
Symptoms are not better accounted
for by another disorder (Probable
Meniere)
Clinicians should determine if patients
+++
Assessing for meet diagnostic criteria for vestibular
C Recommendation
vestibular Migraine migraine when assessing for Meniere’s
disease.
Clinicians should obtain an audiogram Strong

Audiometric Testing when assessing a patient for the diagnosis A ++++
of Meniere’s disease. Recommendation
Clinicians should offer magnetic

resonance imaging (MRI) of the internal
Utility of Imaging auditory canal (IAC) and posterior fossa D Not Reported ++++
in patients with audiometrically verified
asymmetric sensorineural hearing loss.
Clinicians may order vestibular function

Indication for testing or electrocochleography to
B Not Reported ++++
Vestibular Testing establish the diagnosis and to follow up
intratympanic injection.
Clinicians should educate patients with

Meniere’s disease about the natural
Patient Education A Recommendation ++++
history, measures for symptom control,
treatment options, and outcomes.
Clinicians should offer a limited course of
vestibular suppressants *
Symptomatic
management of C Recommendation ++++
To patients with Meniere’s disease for
Vertigo management of vertigo only during
attacks.
Clinicians should educate patients with

Symptom reduction B
Ménière’s disease on dietary and lifestyle
and prevention of Recommendation ++++
modifications** that may reduce or
Recurrence
prevent symptoms. 
Clinicians may offer diuretics and/or

Oral treatment for betahistine for maintenance therapy***
D Option ++++
maintenance to reduce symptoms or prevent disease
attacks.
Positive pressure Clinicians should not prescribe positive Recommendation

therapy pressure therapy for patients with A ++++
Meniere’s disease. Against

Strength of
Strength after
recommendations
Statement Topic Action recommendation Level of evidence adoption or
according to the
adaptation
selected CPG
Clinicians may offer, or refer to a clinician

Intratympanic who can offer, intratympanic steroids****
A Recommendation ++++
steroid to patients with active Meniere’s disease
not responsive to noninvasive treatment.
Clinicians should offer, or refer to a clinician

Intratympanic who can offer, intratympanic gentamicin
A Recommendation ++++
gentamicin to patients with active Meniere’s disease
not responsive to non ablative therapy.
Clinicians may offer, or refer to a clinician

who may offer, labyrinthectomy in patients
Surgical ablative
with active Meniere’s disease who have B Recommendation ++++
therapy
failed less definitive therapy and have non
usable hearing.
Role of vestibular Clinicians should offer vestibular

therapy for rehabilitation/physical therapy for
A Recommended ++++
management of Meniere’s disease patients with chronic
chronic imbalance imbalance.
Role of vestibular Clinicians should not recommend

therapy for vestibular rehabilitation/physical therapy Recommendation
A ++++
management of for managing acute vertigo attacks in Against
acute vertigo patients with Meniere’s diseasev.
Clinicians should counsel patients, or refer

Role of Hearing to a clinician who can counsel patients,
Aid and assistive with Meniere’s disease and hearing loss B Recommended ++++
technology on the use of amplification and hearing
assistive technology.
Clinicians should document resolution,
improvement, or worsening of vertigo,
Patient outcome tinnitus, and hearing loss and any change A Recommended ++++
in quality of life in patients with Meniere’s
disease after treatment.
* Vestibular suppressants primarily appear to act by suppressing central vestibular neural activity at the level of the brainstem
and concomitantly suppressing nausea. These medications fall into 3 pharmacologic classes: first-generation antihistamines,
benzodiazepines, and anticholinergics. Chronic use of these drugs is undesirable, as these agents can suppress central
adaptation/compensation.
Commonly used antihistamines include dimenhydrinate (25-50 mg every 6 hours), meclizine (12.5-25 mg every 8 hours), or diphenhydramine
(25-50 mg every 6 hours). All can cause hypersomnolence, dry mouth, and urinary retention.
Benzodiazepines are gamma aminobutyric acid receptor agonists, are also effective at suppressing vertigo. Diazepam (2-10 mg every 8 hours)
, lorazepam (1-2 mg every 8 hours) has rapid onset of action and shorter half-life and Clonazepam (0.5-1.0 mg every 8 hours) has also been
used. Most experts recommend against the use of alprazolam due to tachyphylaxis and complications associated with drug withdrawal. All
benzodiazepines carry significant risk for drug dependence.
** Life style Modifications
• Limit salt/sodium in your diet.
• Avoid excessive caffeine, alcohol, and nicotine
• Eat well-balanced meals throughout the day.
• Drink plenty of water throughout the day, avoiding high-sugar beverages.
• Manage stress appropriately.
• Get plenty of exercise.
• Get enough sleep.
• Join a support group
• Practice breathing exercise

• Identify and manage any allergies
• Patients with increased bouts of vertigo should be assessed for sleep apnea.
*** Maintenance Therapy
The most commonly prescribed diuretics are thiazides with or without potassium-sparing diuretics such as hydro- chlorothiazide/triamterene
or spironolactone as well as the carbonic anhydrase inhibitor acetazolamide (Diamox) as a second-line therapy. Thiazides are contraindicated
in patients with gout, and potassium-sparing diuretics are contraindicated in patients with acute or severe renal failure. Since the prolonged
use of thiazides can precipitate gout, other diuretic options should be considered. Clinicians should monitor electrolytes and blood pressure in
patients who are prescribed diuretics.
**** Intratympanic Steroid Therapy Dosing and Frequency.
Dexamethasone sodium phosphate: 4 mg/mL or 10 mg/mL. Methylprednisolone sodium succinate : 30 mg/mL or 40 mg/mL Compounded:
62.5 mg/mL Frequency Inject 0.4-0.8 mL into middle ear space, from once only or up to 3 to 4 sessions every 3 to 7 days depending on
clinical response.
Algorithm Adapted Egyptian Clinical Practice Guidelines (ECPG) for the diagnosis and management of Ménière’s disease


References Meniere’s Disease. J Int Adv Otol. 2018;14(2):317-

321. doi:10.5152/iao.2018.140818
1. Nevoux J, Franco-Vidal V, Bouccara D, Parietti-
Winkler C, Uziel A, Chays A, Dubernard X, Couloigner 4. Basura GJ, Adams ME, Monfared A, Schwartz
V, Darrouzet V, Mom T; Groupe de Travail de SR, Antonelli PJ, Burkard R, Bush ML, Bykowski
la SFORL. Diagnostic and therapeutic strategy J, Colandrea M, Derebery J, Kelly EA, Kerber KA,
in Menière’s disease. Guidelines of the French Koopman CF, Kuch AA, Marcolini E, McKinnon BJ,
Otorhinolaryngology-Head and Neck Surgery Society Ruckenstein MJ, Valenzuela CV, Vosooney A, Walsh
(SFORL). Eur Ann Otorhinolaryngol Head Neck SA, Nnacheta LC, Dhepyasuwan N, Buchanan
Dis. 2017 Dec;134(6):441-444. doi: 10.1016/j. EM. Clinical Practice Guideline: Ménière’s Disease.
anorl.2016.12.003. Epub 2017 Jan 3. PMID: Otolaryngol Head Neck Surg. 2020 Apr;162(2_
28065602. suppl):S1-S55. doi: 10.1177/0194599820909438.
PMID: 32267799.
2. Nevoux, M. Barbara, J. Dornhoffer, W. Gibson, T.
Kitahara, V. Darrouzet, International consensus 5. Iwasaki S, Shojaku H, Murofushi T, Seo T, Kitahara
(ICON) on treatment of Ménière’s disease, European T, Origasa H, Watanabe Y, Suzuki M, Takeda N;
Annals of Otorhinolaryngology, Head and Neck Committee for Clinical Practice Guidelines of Japan
Diseases, Volume 135, Issue 1, Supplement, Society for Equilibrium Research. Diagnostic and
2018,Pages S29-S32 therapeutic strategies for Meniere’s disease of the
Japan Society for Equilibrium Research. Auris Nasus
3. Magnan J, Özgirgin ON, Trabalzini F, et al. European Larynx. 2021 Feb;48(1):15-22. doi: 10.1016/j.
Position Statement on Diagnosis, and Treatment of anl.2020.10.009. Epub 2020 Oct 29. PMID: 33131962.

Necrotizing Otitis Externa: Adapted Egyptian Clinical Practice Guidelines

The following statement were adopted/adapted from “A retrospective review and multi-specialty, evidence-based guideline for the management
of necrotising otitis externa”1 which had the highest scores as regards the contents

Head and Neck Chief Manager: Ali Mahrous9
Assembly Board: Ayman Fouad,6 Adel Khalifa,6 Hisham Hamad,6 Mahmoud Mandour,6 Fatthi Abdelbaki,10 Mohamed Basiony,10 Lobna Elfeky,11
Mohamed Mobasher,12 Yousef Shabana12
Doaa Abd Elhalem,9 Haitham Elfarargy,13 Ahmed ElKhateeb,14 Saad Elzayat,13 Fathi Erfan,6 Amr Galal,15 Amir Gorguy Mina,10 Ihab Nada,16 Yasser
Shewel,10 Ismail Zohdi1
Reviewing Board: Ali Mahrous,9 Medhat Heshmat6
1
Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Department, Faculty of Medicine/ Menoufia
University, 3Otorhinolaryngology Department, Faculty of Medicine/Minia University, 4Otorhinolaryngology Department, Faculty of Medicine/ Beni-
Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology Department, Faculty of
Medicine/ Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar
University, 10Otorhinolaryngology Department, Faculty of Medicine/ Alexandria University, 11Otorhinolaryngology Department, Faculty of Medicine/
Ain Shams University, 12Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 13Otorhinolaryngology Department, Faculty
of Medicine/ Kafr Elshiekh University, 14Otorhinolaryngology Department, Faculty of Medicine/ Military Medical Academy, 15Otorhinolaryngology
Department, Hearing and Speech Institute, 16Otorhinolaryngology Department, Faculty of Medicine/ Misr University for Science and Technology.
Necrotizing otitis externa is a severe infection of the external The adaptation cycle passed over: set up phase, adaptation
ear canal that can lead to serious mortality and morbidity. The phase (Search and screen, assessment: Currency, Content and
term necrotizing otitis externa is preferred than malignant otitis Quality and Decisions/selection) and finalization phase that
externa as it is a form of severe infection rather than being include revision.
tumor. Therefore, necrotizing otitis externa (NOE) is used in the
reminder of the guideline. Results
Scope and purpose Ten guidelines were assessed by 9 experts otologists and
“A retrospective review and multi-specialty, evidence-based
The purpose of this guideline is to identify quality improvement guideline for the management of necrotising otitis externa”1 had
opportunities in managing NOE and to create explicit and the highest scores as regards to the contents. It was graded
actionable recommendations to implement these opportunities in GRADE by 11 expert otologists.
clinical practice. Specifically, the goals are to improve diagnostic
accuracy for NOE and guide management.

Accepted statements
Modified statements
Added statements
NOE guidelines statements diagnosis, treatment, or follow-up. The great heterogeneity

among all data makes combined figures much less significant.
First of all, all the data available were of low level of scientific Indeed, chronological evolution is biased by data coming from
evidence. In this rare disease, there is no precise protocol for different care units, different countries, and different populations.
38 2021 (Volume 1) Pages: 38-42 Necrotizing otitis externa guidelines

Statement topic Action recommendation Strength after adoption or adaptation

1.Definition of
External ear infection that extends beyond the
Necrotizing Otitis ++++
skin to involve the skull base.
Externa
Bacterial most common (90%).
mainly Pseudomonas aeruginosa (75%).

2.Causative
++++
Organism Fungal less common (10%).
mainly Aspergillus fumigatus (8%).

The main risk factor is any immunocompromised
3.Predisposing
state mainly elderly, uncontrolled diabetes ++++
Factors
mellitus, and HIV cases.
The complication emerges due to skull base
4.Complications ++++
osteomyelitis with spread of the infection.
The population at risk should avoid risk factors,
such as water exposure, iatrogenic or self-inflected
EAC trauma. For example, water irrigation for
5.Prevention cerumen disimpaction in elderly patients who ++
have diabetes is a proposed inciting event, so
better avoided or if needed better to use sterile
water or saline in gentile atraumatic washing.
Otalgia (severe and nocturnal).
Otorrhea (scanty and purulent).

6.Clinical
++++
Presentation Granulation tissue in the floor of the EAC.
Otitis externa not showing response to adequate

local treatment after 2 weeks.
7.Work-up
General CBC, ESR, CRP, DM work-up, Renal and liver

functions.
Microbiology and Tissue biopsy to rule out malignancy, culture and

Histopathology sensitivity for bacteria, and fungal stain.
++++
CT to assess bone erosion and extension.
MRI (ADC) to exclude intracranial extension and

as baseline for follow-up.
Radiology
Tc99 to document osteitis.
Ga67 as baseline for follow-up.

8.Management
General Tight glycemic control Strong pain killers. ++++
Antibiotic (Local and systemic) Choice According

to culture and sensitivity Use antipseudomonal
antibiotics at first injectable (Ceftazidime,
Piperacillin/Tazobactam, Imipenem) then Oral
Targeted therapy
(Ciprofloxacin) Combination may be needed.
Antifungal (If proven by histopathology)

(Amphotericin B, Voriconazole).
Only local debridement
Surgery No need for extensive surgery except for

resistant cases (CWD radical mastoidectomy).
Hyperbaric oxygen Adjuvant.
Necrotizing otitis externa guidelines 2021 (Volume 1) Pages: 38-42 39

Statement topic Action recommendation Strength after adoption or adaptation

Objective/subjective improvement
9.Follow-up / Criteria
Ga67/MRI ADC ++++
to stop medications
ESR/CRP.
Long term follow-up for at least one year is
needed.
Avoid predisposing factors.

10.Recurrence +++
Clinical follow-up.
CRP/ESR elevation indicates recurrence.
Ga67/MRI ADC.

Necrotizing otitis externa guidelines 2021 (Volume 1) Pages: 38-42 41

References survey of 221 UK otolaryngologists. Acta Otolaryngol.

2017;137(8):818-822.
1. Hopkins ME, Bennett A, Henderson N, et al. A
retrospective review and multi-specialty, evidence- 6. Pankhania M, Bashyam A, Judd O, et al. Antibiotic
based guideline for the management of necrotising prescribing trends in necrotising otitis externa:
otitis externa. J Laryngol Otol. 2020;134(6):487-492. a survey of 85 trusts in the United Kingdom: Our
doi: 10.1017/S0022215120001061. Epub. 2020. Experience. Clin Otolaryngol. 2016;41(3):293-6.
2. Holger Schünemann, Jan Brożek, Gordon Guyatt, et 7. Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant
al. GRADE handbook. 2013. treatment for malignant otitis externa. Cochrane
Database Syst Rev. 2013;31:;(5):CD004617.
3. Mahdyoun P, Pulcini C, Gahide I, et al. Necrotizing
otitis externa: a systematic review. Otol Neurotol. 8. Pulcini C, Mahdyoun P, Cua E, et al. Antibiotic
2013;34(4):620-9. therapy in necrotising external otitis: case series of
32 patients and review of the literature. Eur J Clin
4. Courson AM, Vikram HR, Barrs DM. What are the Microbiol Infect Dis. 2012;31(12):3287-94.
criteria for terminating treatment for necrotizing
(malignant) otitis externa? Laryngoscope. 9. Verim A, Naiboğlu B, Karaca Ç, et al. Clinical outcome
2014;124(2):361-2. parameters for necrotizing otitis externa. Otol
Neurotol. 2014;35(2):371-6.
5. Chawdhary G, Pankhania M, Douglas S, et al. Current
management of necrotising otitis externa in the UK:

Chapter 2
Rhinology
Acute Rhinosinusitis ECPG
Chapter 2: Rhinology Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG
Acute Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines

Rhinology Chief Manager: Ashraf Khaled4
Rhinology Excutive Manager: Ahmed Elfarouk,1 Mohamed Elsharnouby,9 Hossam Elsherif6
Assembly Board: Ahmed Ragab,2 Reda Kamel,1 Ashraf Khaled,4 Baliegh Hamdy,3 Ahmed Elfarouk,1 Mohamed Elsharnouby,9
Hossam Elsherif6
Grading team (In alphabetical order)
Hesham Al Adl,5 Ibrahim Abd-elshafy,2 Anas Askora,9 Magdy Eisa,6 Diaa Elhinnawi,10 Esmail Elnashar,11 Hossam Elsisi,5 Amr
Gouda,9 Islam H. Herzallah,11 Sayed Kaddah,12 Yaser Nour,13 Mohamed Qotb,14 Amr Rabie,9 Nassim Talaat,1 Mohamed Osama
Tamoum6
Reviewing Board: Mohamed Hassab,13 Abdelaziz Elsherif,15 Alaa Ghita,16 Khaled Belasy17
1
Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Department, Faculty of
Medicine/ Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/Minia University, 4Otorhinolaryngology
Department, Faculty of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura
University, 6Otorhinolaryngology Department, Faculty of Medicine/ Tanta University, 7Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/
Ain Shams University, 9Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 10Otorhinolaryngology
Department, Faculty of Medicine/ Suez Canal University, 11Otorhinolaryngology Department, Faculty of Medicine/ Zagazig
University, 12Otorhinolaryngology Department, Faculty of Medicine/Al Azhar University, 13Otorhinolaryngology Department,
Faculty of Medicine/ Alexandria University, 14Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University,
15
Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar Assuit University, 16Otorhinolaryngology Department, Faculty
of Medicine/ Military Medical Academy, 17Otorhinolaryngology Department, Police Academy, The Medical Sector MOI.
Introduction and background appropriate use of ancillary tests to confirm diagnosis

and guide management, and promote judicious use
Rhinosinusitis affects about 1 in 8 adults. More than 1 of systemic and topical therapy specially for systemic
in 5 antibiotics prescribed in adults are for rhinosinusitis, antibiotic.
making it the fifth most common diagnosis responsible
for antibiotic therapy. Rhinosinusitis is defined as Methods
symptomatic inflammation of the paranasal sinuses and
nasal cavity. The term rhinosinusitis is preferred because The adaptation cycle passed over: Set up phase,
sinusitis is almost always accompanied by inflammation of adaptation phase {search and screen, assessment of
the contiguous nasal mucosa. Therefore, rhinosinusitis is (currency, content and quality) and Decisions/selection}
used in the remainder of the guideline. and finalization phase that include revision.
Scope and purpose Results
The purpose of this guideline is to identify quality Ten guidelines were assessed by 7 experts rhinologists
improvement opportunities in managing adult acute and the International Consensus on Rhinosinusitis 2021
rhinosinusitis and to create explicit and actionable had the highest scores as regards to the currency,
recommendations to implement these opportunities in contents and quality. It was graded GRADE by 15 expert
clinical practice. Specifically, the goals are to improve rhinologists and reviewed by 4 expert reviewers.
diagnostic accuracy for acute rhinosinusitis, promote
Acute Rhinosinusitis ECPG 2021 (Volume 1) Pages: 43-48 43

Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG Chapter 2: Rhinology
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision
frameworks (GRADE Working Group 2013)3
Grade Definition
High ++++ We are very confident that the true effect lies close to that of the estimate of the effect.
We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of
Moderate +++
the effect, but there is a possibility that it is substantially different.
Our confidence in the effect estimate is limited: The true effect may be substantially different from the
Low ++
estimate of the effect.
We have very little confidence in the effect estimate: The true effect is likely to be substantially different
Very Low +
from the estimate of effect.
Defined strategy for evidence quality and recommendation development according to (American Academy of Pediatric
(AAP) on Quality Improvement and Management)
Preponderance of
Preponderance of benefits Balance of benefit and
Evidence quality harm over Benefit
over harm harm
A. Well-designed RCT Strong recommendations

B.RCT with minor limitations, overwhelm-
ingly consistent evidence from observational against
Option
studies recommendations
C. Observational studies (case control and
cohort design)
Recommendation against
D. Expert opinion, Case reports, Reasoning
Option No recommendation
from first principal
Used colors for recommendations statements

Accepted statements
Modified statements
Added statements
44 2021 (Volume 1) Pages: 43-39 Acute Rhinosinusitis ECPG

ARS guidelines statements

Strength
Strength of rec-
Level of ommendations after
Statement topic Action recommendation
evidence according to the
selected CPG adoption or
adaptation
1.Definition: Accord- Acute rhinosinusitis (ARS) is considered when symptoms
D Option ++++
ing to the duration and signs are present less than 4 weeks.
Symptoms must include:
1–Mucopurulent nasal drainage/discharge (anterior/
posterior) and
2–Nasal blockage/obstruction/congestion or facial pain/
pressure or both Symptoms may include smell affection
and headache in adults and cough in children.
2.Diagnosis: Strong
All can be included in C ++++
Symptoms Recommendation
CPODS
C: Congestion
P: Pain
O: Obstruction
D: Drainage/Discharge
S: Smell affection.
3.Diagnosis: Diagnosis is clinical and depends on symptoms and signs
C Recommendation ++++
Parameters rather than radiology.
A thorough physical examination that includes inspection,
4.Diagnosis: palpation of the maxillary and frontal sinus, as well as
C Not Reported ++++
Examination anterior rhinoscopy (evidence of inflammation, mucosal
oedema, and discharge).
Objective evidence of ARS on nasal endoscopy, antral
++++
5.Diagnosis: puncture, or radiographic imaging (X-ray, ultrasonography, Recommendation
B
Investigations or CT) is not required for the diagnosis in uncomplicated Against Against use
cases.
ESR and CRP are inflammatory markers found to be
elevated during ARS, but they are not routinely used for
diagnosis because of their limited specificity.
Not Recommended
6.Diagnosis: They may have some role in COVID-19 related symptoms C (To use ESR and ++
Investigations in Chinese guidelines for COVID-19: CRP test together CRP)
with other clinical parameters for initial evaluation and
follow-up of coronavirus infection. Cut-off for CRP: 40–50
mg/L (4).
Differentiating between Acute bacterial rhinosinusitis
(ABRS) and acute viral rhinosinusitis (AVR) can be
challenging even in the setting of endoscopy and cultures.
Close follow-up of patient symptomology can often help in
making the diagnosis, especially for patients that do not
improve with supportive care.
Strong
Recommendation
7.Differentiating Duration is thought to be a key factor differentiating ABRS B
(For 10 days duration
viral from from AVR, with persistence of symptoms beyond 7-10 days +++
and worsening of
bacterial or worsening of symptoms after 5 days being indicators of
symptoms within 10
development of post-viral ABRS.
days)
Clinical factors associated with symptoms and signs ABRS
include: Timing of the disease, worsening of the disease,
purulent nasal discharge on rhinoscopy, localized unilateral
pain, severe pain over the teeth and maxilla, and fever >
38˚C.

Strength
Strength of rec-
after
Level of ommendations
evidence according to the adoption
selected CPG or adapta-
tion
8. Pathophysiology
of ARS:
++++
-Anatomic variants The evidence for association between ARS and anatomic
and septal Deviation Limited role
variants is conflicting and limited and largely inferred from
a small number of studies.
+++
-Nasal allergy -Population-based studies seem to support an association
between allergic rhinitis (AR) and ARS. Moderate
C Not Reported role
++++
The epidemiologic studies show that a subset of patients
Strong role
-Viruses with viral URI will develop clinical ARS.
++++
The current literature demonstrates an absence of a
-Odontogenic well-designed and published investigation into the role of strong role
rhinosinusitis odontogenic infections in ARS. in specific
cases
Consider initial watchful waiting in uncomplicated cases,
with institution of antibiotic therapy if no improvement
after 4-7 days or worsening at any time, or for mitigating
circumstances with drug resistance e.g., including severe
symptoms, immunocompromised state, concern for Option
9.a. Treatment: impending complications, suspected odontogenic source, for watchful waiting
B ++
Antibiotics prior antibiotics (1 month), prior hospitalization (5 days) with 7 days with no
and comorbidities. improvement
Watchful waiting should be offered only when there is

assurance of follow-up, such that antibiotic therapy is
started if the patient’s condition fails
If a decision is made to treat ABRS with an antibiotic agent,
the clinician should prescribe amoxicillin with clavulanate
9b. Antibiotics as first-line therapy for 5 to 10 d for most adults.
recommendations C Option ++++
for ABRS Options after failing amoxicillin + clavulanate or for
penicillin allergy include trimethoprim-sulfamethoxazole,
doxycycline, or a fluoroquinolone.
10.Adjunctive A Strong ++
treatments: Recommendation
INCS can be used according to the doctor judgment as
-Intranasal monotherapy in mild to moderate ARS or as adjuvant to
corticosteroids antibiotic therapy in severe cases of ARS. D No recommendation ++++
(INCS)
Given the conflicting evidence, there is no recommendation Not recom-
-Systemic for systemic corticosteroids in cases of uncomplicated mended
corticosteroids ABRS.
-Topical saline spray Saline irrigation may be used in adjunct with antibiotics
B Option +++
and irrigation for ABRS.
Decongestants are an option in ABRS with respecting for
use not more than 5 days. Decongestants can reduce
-Decongestant C Option ++
congestion in patients with ABRS however side effects
should be considered.
Antihistamines are an option in ABRS with comorbid AR
Antihistamimine C Option ++
and can be used to decrease symptoms of AR.


Strength
Strength of rec-
Level of ommendations after
selected CPG adoption or
adaptation
++++
no recommendation can be given for mucolytics or herbals No
Others D
in ABRS. Recommendation Not Recom-
mended
-First time non responders can be based on lack of clinical
improvement following treatment within 5 days in adults
and 3 days in children.
-B-lactamase producing penicillin resistance H.Influenzae

in > 30 % and S.pneumoniae.
11.Non responders
NR NR ++++
managements
-Use second line antimicrobial agents.
-Second time non responders who fail to improve with

second line antibiotic therapy should be evaluated for oth-
er diagnosis or considered for sinus aspiration or endo-
scopically guided middle meatus culture and sensitivity.
- In patients with ABRS suspected to have suppurative
complications, axial, coronal and sagittal views with
contrast-enhanced computed tomography (CT) is rec-
ommended to localize the infection and to guide further
treatment.
-Magnetic resonance imaging (MRI) provides soft tissue

visualization and is useful when there is concern for intra-
cranial involvement. Magnetic resonance venography may
D
be useful for evaluation of the cavernous sinus and other Recommendation
12.Complications vasculature. ++++
for CT with contrast
-The hallmarks of management are swift diagnosis, rapid

initiation of broad-spectrum intravenous antibiotics, and in
many cases surgical intervention.
-While endoscopic sinus surgery (ESS) is usually a suf-

ficient approach for addressing orbital complications,
open neurosurgical intervention is often required for even
sub-centimeter intracranial abscess
13.Recurrent Acute - At least 4 attacks of ABRS/year are a required criterion C Recommendation ++++
Rhinosinusitis
(RARS) -Nasal endoscopy and/or CT imaging are an option during
at least one episode of suspected RARS to appropriately
-Diagnosis confirm and diagnose RARS, and distinguish it from other D Option ++++
diagnoses such as allergy exacerbation or primary head-
ache syndromes.
-Treatment -Consider immunologic testing, allergic testing, and bacte- C Option +++
rial culture in patients with concern for RARS
A. NC -Option for use of INCS spray for sinonasal symptoms B Option +++
during acute exacerbations of RARS.
B. Antibiotics -Follow other ABRS management options B Option +++
C. Endoscopic sinus -Endoscopic sinus surgery (ESS) is recommended for pa- Recommendations ++
B
surgery ESS tients with RARS.


Abbreviations 7. Sinusitis (acute). Antimicrobial prescribing NICE

guideline Published: 27 October 2017. www.nice.org.
CPG: Clinical practice guidline. uk/guidance/ng79 accessed 18/9/2019.
ARS: Acute rhinosinusitis.
ABRS: Acute bacterial rhinosinusitis. 8. Desrosiers M, Evans GA, Keith PK, et al. Canadian
CPODS: Congestion-Pain-Obstruction-Discharge-smell. clinical practice guidelines for acute and chronic
RARS: recuurent acute rhinosinusitis. rhinosinusitis. J Otolaryngol Head Neck Surg
VRS: viral rhinosinusitis,MM:middle meatus. 2011;40(Suppl 2):S99-193.
References 9. Scadding GK, Durham SR, Mirakian R, et al. British

Society for Allergy and Clinical Immunology. BSACI
1. Orlandi RR, Kingdom TT, Smith TL, et al. international guidelines for the management of rhinosinusitis and
consensus statement on allergy and rhinology: nasal polyposis. Clin Exp allergy. 2008;38(2):260-
rhinosinusitis 2021. Int Forum Allergy Rhinol. 275.
2021;11(3):213-739. doi: 10.1002/alr.22741. PMID:
33236525. 10. Wald E. American Academy of Pediatrics. Clinical
practice guideline for the diagnosis and management
2. Ragab A, Kamel R. Personal communication. of acute bacterial sinusitis in children aged 1 to 18
years. Pediatrics. 2013;132(1):e262-e280.
3. Schünemann H, Brożek J, Guyatt G et al. GRADE
handbook 2013. https:// gdt.gradepro.org/app/ 11. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012:
handbook/handbook.html. European position paper on rhinosinusitis and nasal
polyps 2012. A summary for otorhinolaryngologists.
4. Zhou,Yu Ting,Du Ronghui et al. Clinical course and
Rhinology. 2012;50(1):1-12. doi: 10.4193/
risk factors for mortality of adult inpatients with
Rhino50E2.
COVID-19 in Wuhan, China: a retrospective cohort
study. Lancet. 2020;395(10229):1054-1062. 12. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS et al.
Clinical practice guideline (update): Adult sinusitis.
5. Acute rhinosinusitis in adults. University of
Otolaryngology- Head and Neck Surgery, 2015,
Michigan Health System (UMHS) December 2018.
152:SI-S39. (Commissioned by the American
Available at http://www.med.umich.edu/1info/
Academy of Otolaryngology – Head and Neck Surgery
FHP/practiceguides/Rhino/rhino.pdf. accessed
Foundation).
13/12/2019.
13. Chow AW, Benninger MS, Brook I, et al. IDSA clinical
6. Chow AW, Benninger MS, Brook I, et al. Infectious
practice guideline for acute bacterial rhinosinusitis
Diseases Society of America. IDSA clinical practice
in children and adults. Clin Infect Dis. 2012
guideline for acute bacterial rhinosinusitis in children
Apr;54(8):e72- e112. doi: 10.1093/cid/cir1043. Epub
and adults. Clin Infect Dis. 2012;54(8): e72–e112.
2012 Mar 20.

Chronic Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines

The following statement and flowchart were adapted from European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS)
2020 which has the highest scores as regards the currency, contents, and quality.
Rhinology Executive Manager: Ahmed Elfarouk,1 Mohamed Elsharnouby,9 Hossam Elsherif6
Assembly Board: Ahmed Elfarouk,1 Magdy Eisa,6 Mohamed Osama Tomoum6
Magda Abdellatif,9 Ibrahim Abd-elshafy,2 Mostafa A. Eltaher,10 Anas Askoura,11 Hesham El-Adl,5 Ahmed Elfarouk,1 Diaa
Elhinnawi,12 Ismail Elnashar,13 Mohamed Elsharnouby,11 Hosam Elsherif,9 Hossam Elsisi,5 Mohamed Mostafa Gaballah,14 Mohamed
Gamea,15 Alaa Ghita,16 Amr Gouda,11 Baleigh Hamdy,3 Islam R. Herzallah,13 Sayed Kaddah,9 Mohamed Qotb,17 Mena Maher,1
Zeyad Mandour,18 Hesham Mansour,1 Ayman Medani,18 Yasser Nour,18 Mohamed Omar,19 Amr Rabie,11 Ahmed Ragab,2 Ramez
Reda,4 Ibrahim Rezk,10 Sayed Siam,20 Nassim Talaat,1 Soad Yehia9
Reviewing Board: Hossam Abd El-Azeem,21 Mohamed Askar,6 Mohamed El Ayadi,1 Montaser A. Hafez,3 Mohamed Hassab,18
Reda Kamel,1 Ashraf Khaled,4 Ossama Mansour,11 Mohamed Fatehy Ramadan22
1
Medicine/ Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 4Otorhinolaryngology
Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/Ain
Shams University, 9Otorhinolaryngology Department, Faculty of Medicine/ Al-Azhar University for Girls, 10Otorhinolaryngology
Department, Faculty of Medicine/ Sohag University, 11Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University,
12
Otorhinolaryngology Department, Faculty of Medicine/ Suez Kanal University, 13Otorhinolaryngology Department, Faculty of
Medicine/ Zagazig University, 14Otorhinolaryngology Department, Faculty of Medicine/Misr for Science & Technology University,
15
Otorhinolaryngology Department, Faculty of Medicine/ Misr University for Science and Technology, 16Otorhinolaryngology
Department, Faculty of Medicine/ Military Medical Academy, 17Otorhinolaryngology Department, Faculty of Medicine/
Fayoum University, 18Otorhinolaryngology Department, Faculty of Medicine/ Alexandria University, 19Otorhinolaryngology
Department, Faculty of Medicine/ Assiut University, 20Otorhinolaryngology Department, Faculty of Medicine/ Al-Azhar University,
21
Otorhinolaryngology Department, Faculty of Medicine/ Banha University, 22Otorhinolaryngology Department, Faculty of
Medicine/Al Azhar Damietta University.
Chronic rhinosinusitis (CRS) is an inflammatory process The adaptation cycle passed over: set-up phase,
of the nose and paranasal sinuses that persist for more adaptation phase (search and screen, assessment:
than 12 weeks, with a significant impact on the quality currency, content, quality & /decision/selection) and
of life of affected patients, and significant socioeconomic finalization phase that include revision.
burden. Improved knowledge of the diagnostic criteria
and evidence-based care will enhance diagnostic accuracy Results
and ensure optimal CRS management.
We assessed five chronic rhinosinusitis guidelines where
Scope and purpose the European Position Paper on Rhinosinusitis and Nasal
Polyps (EPOS) 2020 had the highest scores as a regard to
The primary purpose of this guideline is to address the the currency, contents, and quality. It was graded by 32
quality improvement for all otorhinolaryngologist to expert rhinologists and reviewed by 9 expert reviewers.
optimize patient care, promote effective diagnosis and
treatment, and reduce harmful or unnecessary variations The Grading of Recommendations, Assessment,
in care of CRS patients. Development and Evaluation (GRADE) approach to
Decision frameworks (GRADE Working Group 2013).
Strength after adaptation
Grade Definition
High
++++
++ effect.
Very Low We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the
+ estimate of effect
50 2021 (Volume 1) Pages: 50-66 Egyptian clinical practice guidelines of chronic sinusitis
Category of evidence “EPOS”

Ia Evidence from meta-analysis of randomized controlled trials
Ib Evidence from at least one randomized controlled trial
IIa Evidence from at least one controlled study without randomization
IIb Evidence from at least one other type of quasi-experimental study
Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control
III
studies
IV Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both
EPOS GRADE recommendation

A Directly based on category I evidence
B Directly based on category II evidence or extrapolated recommendation from category I evidence
C Directly based on category III evidence or extrapolated recommendation from categories I or II evidence
D Directly based on category IV evidence or extrapolated recommendation from categories I, II or III evidence
Accepted statements
Modified statements
Added statements
Summary of Clinical Practice Guidelines (CPG)
Strength Remarks and

Level of EPOS GRADE
Statement Topic Action recommendation Evidence Recommendation
After reviewer
adaptation comment
1.Definition ++++
≥12 weeks symptoms without complete resolution
according to C Recommended
of symptoms.
duration
Twelve weeks or longer of two or more of the
following signs and symptoms:
Mucopurulent drainage.
Nasal obstruction, Facial pain- pressure-fullness, or Smell is not

Decreased sense of smell. a common
Strong ++++
2.Diagnosis B symptom in
And inflammation is documented by one or more of recommendation
Egyptian patient
the following findings:
Purulent mucus, edema, or polyps in the middle

meatus or anterior ethmoid region, radiographic
imaging showing inflammation of the paranasal
sinuses.
Nasal endoscopy Strong
B ++++
recommendation
CT scanning
3.Objective Recommended
confirmation of in certain cases
the diagnosis of MRI for confirmation of diagnosis is discouraged +++ like fungal
CRS Not
because of increased cost and hypersensitivity (over- B rhinosinusitis,
Recommendation
diagnosis) in comparison to CT without contrast. Mucocele,
Complicated
sinusitis s..etc
Clinicians should assess the patients for multiple ++++

4.Modifying
chronic conditions e.g. asthma, cystic fibrosis, A Recommended
factors
immunocompromised state, and ciliary dyskinesia.
5.Multi-slice
detector CT
It shortens the duration of the procedure without
(MSCT) utilizing NR Recommended +++
compromising anatomical accuracy.
low dose
protocols
Egyptian clinical practice guidelines of chronic sinusitis 2021 (Volume 1) Pages: 50-66 51

Level of EPOS GRADE
After reviewer
adaptation comment
Longer scan time, motion artefact and the lack

of soft tissue differentiation are the drawbacks
6.Cone beam CT resulting in loss of some pathological detail such as May be better in
NR Option ++
(CBCT) the hyperdensities seen in sinonasal children, low dose
fungal disease
Few patients
complain.
Subjectively” UPSIT, Sniffin tests”
7.Assessment of
NR Option ++ Specific test
smell objectively“ olfactory-event related potentials “ for our region.
Objective test not
available
Specific pathology
Unilateral disease “pre-operatively” Recommended +++ e.g., inverted
papilloma
NR
8.Biopsies
Option
Specific pathology
Bilateral disease “intra-operatively” ++
Eosinophil
9.Nasal It is not essential to do cytology (Either brushings

Not
brushing and or lavage) at initial presentation to ENT/ secondary NR ++ Research only
Recommended
cytology Care.
Markers for type 2 Evaluation of blood

Recent suggestion
disease e.g. eosinophils, eosinophilia, Ig- E NR +++
for genotyping
IgE levels levels
It is not essential to
Not
10.Blood tests Immunoglobulin do an objective test of NR +++
Recommended
immunodeficiency.
Testing for vasculitis It is not essential to

e.g. anti- neutrophil do an objective test Not
cytoplasmic antibodies for vasculitis at initial NR +++
Recommended
presentation to ENT/
(ANCA) secondary care.
11.Cultured Cultured dependent Cultured dependent

Not
dependent Techniques e.g. nasal and Techniques e.g. nasal NR +++
Recommended
Techniques sinus lavage and sinus lavage.
It is not essential to
12.Mucociliary Mucociliary clearance do an objective test of
testing e.g The Not
clearance mucociliary function at NR +++
Recommended
testing saccharine test. initial presentation to
ENT / secondary care.
Nasal NO is a sensitive
and specific test for
13.Primary PCD in cooperative
Primary ciliary dyskinesia Only in suspected
ciliary patients (generally over NR Option +++
tests e.g. Nitric oxide. cases
dyskinesia five years old) with a
high clinical suspicion
for this disease.

Level of EPOS GRADE
After reviewer
adaptation comment
14.Cystic Cystic fibrosis (CF) tests Sweat chloride testing Only in suspected
NR Option +++
fibrosis (CF) e.g. sweat test should be performed cases
Localized CRS (Type 2

15.Localized or non-type 2) are not
CRS (Type 2 or responsive to medical NR Recommended ++++
non-type 2) treatment and need
surgery.
MRI is more sensitive

(86%) than CT (69%)
Investigation NR Recommended ++++
in detecting invasive
fungal disease.
Systemic antifungals
NR Recommended ++++
therapy.
16.Invasive
fungal RS
Endoscopic surgical
debridement of necrotic NR Recommended ++++
Treatment
sinonasal tissue.
The patient’s immune

suppression should be NR Recommended ++++
reduced.

Level of EPOS GRADE
After reviewer
adaptation comment
Five of the major

criteria in the original
Bent-Kuhn diagnostic
criteria should be met
to make the diagnosis
as three of the five
are common in most
cases of CRSwNP.
These major criteria
consist of the following:
Nasal polyposis.
Fungi on staining.
Eosinophilic mucin
without fungal invasion
into sinus tissue.
Type I hypersensitivity
to fungi and.
Diagnostic criteria NR Recommended +++
Characteristic radiolog-
ical findings with soft
tissue differential den-
sities on CT scanning
and unilaterality or ana-
tomically discrete sinus
involvement.
The minor criteria in-

clude bone erosion,
Charcot Leyden Crys-
tals, unilateral disease,
peripheral eosinophilia,
positive fungal culture
and the absence of im-
munodeficiency or dia-
17.AFRS betes.
CT shows densely
packed hyperdensities
in the sinuses with
expansion and erosion
NR Recommended ++++
of the bony walls
whereas on MRI signal
voids occur on both T1
and T2 sequences.
The mainstay of
treatment remains
surgery as medical NR Recommended ++++
treatment alone is
usually ineffective.
Oral steroids both pre-

and postoperatively are NR Recommended ++++
of benefit.
Management
Nebulized topical
corticosteroids reduce NR Recommended ++++
recurrence.
A l l e r g e n
immunotherapy was
NR Option ++++
also helpful in atopic
individuals.
Oral antifungals may

reduce recurrence
NR Option ++++
but do not improve
symptoms.
EPOS Strength
Level of Remarks and
Statement Topic Action recommendation GRADE After
Evidence
Recommendation reviewer comment
adaptation
ANCA tests have become the

mainstay of diagnosis in vasculitis.
A positive c-ANCA test and

proteinase-3 (PR3) will confirm the
clinical diagnosis of GPA in up to ++++
Investigation 95% of patients with active systemic NR Recommended
disease. An ANCA test should be
considered in any patient with
18.Vasculitis suspicious clinical manifestations,
in particular nasal crusting and
bleeding, especially if they feel
disproportionally unwell.
ANCA-
associated ++++
vasculitis Immunosuppressive treatment. NR Recommended
includes GPA,
EGPA and ++++
microscopic Nasal irrigation. NR Recommended
polyangiitis
(MPA) Topical intranasal corticosteroid
Treatment sprays or creams e.g. triamcinolone ++++
and/or a nasal lubricant such as 25% NR Recommended
glucose and glycerine drops, honey
ointment or an aqueous gel.
Long-term oral co-trimoxazole
+++
(trimethoprim-sulfamethoxazole)
NR Recommended
and topical anti-staphylococcal
creams in the nose.
There is no definitive test for ++++
sarcoidosis other than a positive NR Recommended
biopsy.
Blood tests may include raised
Investigation serum and urinary calcium levels,
raised alkaline phosphatase +++
and raised serum angiotensin- NR Recommended
converting enzyme (SACE) but none
are diagnostic (sensitivity 60%;
specificity 70%).
19.
++++
Sarcoidosis Systemic steroids remain the
NR Recommended
mainstay of treatment in sarcoidosis.
Hydroxychloroquine, steroid-
sparing cytotoxic agents such ++++
Treatment as methotrexate and TNF-alpha NR Recommended
antagonists such as infliximab are
being used.
Oral antifungals may reduce +++
recurrence but do not improve NR Recommended
symptoms.
Treatment evidence and recommendations for adults with chronic rhinosinusitis
Remarks
EPOS Strength
Level of and
Action recommendation GRADE After
Evidence reviewer
comment
*One or two courses of systemic

corticosteroids per year can be a
useful addition to nasal corticosteroid
treatment in patients with partially or
uncontrolled disease.
20.Short course
of systemic **A short course of systemic
corticosteroid (7-21 corticosteroid postoperatively does not Ia Strongly recommended ++++
days) seem to influence quality of life.
***Short course of systemic

corticosteroid (7-21 days), with or
without local corticosteroid treatment
results in a significant reduction in total
symptom score and nasal polyp score.
Nasal corticosteroids in patients with

21.Nasal CRS. There is high-quality evidence that
Corticosteroids long term use of nasal corticosteroids is Ia Strongly recommended ++++
effective and safe for treating patients
with CRS.
The placement of corticosteroid-
Not
eluting sinus implants in the ethmoid of
available.
patients with recurrent polyposis after
22.Corticosteroid-
sinus surgery has a significant but small
eluting sinus Ia Option +++ Expensive
(0.3 on a 0-3 scale) impact on nasal
Implants compared
obstruction but significantly reduces to proofed
the need for surgery and reduces nasal benifit
polyp score.
*Isotonic saline.
**Ringer’s lactate potentially with the

23.Nasal saline addition of Xylitol, sodium hyaluronate,
irrigation and xyloglucan. Ia Recommended ++++
***Advises against the use of baby

shampoo and hypertonic saline
solutions due to side effects).
Uncertain whether the use of a short
24.Short Course of course of antibiotics has an impact on
Antibiotics patient outcomes in adults with acute 1b (-) Option +++
exacerbations of CRS compared with
placebo.
Due to the low quality of the evidence,

is uncertain whether the use of long-
term antibiotics has an impact on
25.Long-Term patient outcomes in adults with CRS,
Antibiotics particularly in the light of potentially 1a (-) Option +++
increased risks of cardiovascular
events. There is a need for the larger
high-quality trials that are presently
being undertaken in Europe.
Due to the very low quality of the

evidence, is uncertain whether the use
of topical antibacterial therapy has an
impact on patient outcomes in adults
26.Topical with CRS compared with placebo.
Antibacterial Therapy Topical antibacterial therapy does not
1b (-) Not Recommended +++
seem to be more effective than placebo
in improving symptoms in patients
with CRS. However, it may give a
clinically non-relevant improvement in
symptoms, SNOT-22 and LK endoscopic
score compared to oral antibiotics.
Remarks
EPOS Strength
Level of and
Evidence reviewer
comment
27.Proton Pump Advice against the use of proton pump

1b (-) Not Recommended +++
Inhibitors inhibitors in the treatment of CRS.
We identified two trials with opposing

findings. The quality of the evidence for
the use of phototherapy in patients with
28.Phototherapy CRS is very low. Based on the evidence, 1b (-) Not Recommended +++
the EPOS2020 steering group cannot
make a recommendation on the use of
phototherapy in patients with CRS.
Not using nasal decongestants in

CRS. In situations where the nose is
29.Nasal very blocked, the temporary addition
1b Not Recommended +++
Decongestants of a nasal decongestant to the nasal
corticosteroid treatment can be
considered.
The quality of the data insufficient

30.Muco-Active to advice on the use of muco-active
1b Option +++
Agents agents in the treatment of patients
with CRS.
Based on the very low quality of the

available evidence, It is unsure about
the potential use of Anti-Leukotrienes
31.Anti-Leukotrienes
(Montelukast) in CRS and does not Ib (-) Not Recommended +++
(Montelukast)
recommend its use unless in situations
where patients do not tolerate nasal
corticosteroids.
Advises against the use of anti-
mycotics in CRS. Local and systemic
antifungal treatments do not have a
32.Local and
positive effect of QOL, symptoms and
systemic antifungal Ia (-) Not Recommended +++
signs of disease in patients with CRS.
treatments
The EPOS2020 steering group advises
against the use of these treatments in
patients with CRS.
Advises against the use of probiotics

33.Probiotics Ib (-) Not Recommended +++
for the treatment of patients with CRS.
There is one DBPCT from 1989

comparing the bacterial lysate
Broncho-Vaxom to placebo in a large
group of CRS patients resulting in a
significant decrease in purulent nasal
discharge and headache over the
34.Bacterial Lysates Ib Option +++
full six-month period compared to
placebo and reduced opacification of
the sinus X-ray. Based on this limited
evidence, we cannot advise on the use
of Broncho-Vaxom in the treatment of
CRS.
Remarks
EPOS Strength
Level of and
Evidence reviewer
comment
Of five RCTs evaluating herbal
treatment, a large DBPCT, using tablets,
showed overall no effect, although a
post- hoc sensitivity analysis, showed
a significant benefit in major symptom
score at 12 weeks of treatment over
placebo in patients with a diagnosis
of CRS for >1 year and a baseline
MSS >9 (out of max 15). Of the four
35.Herbal treatment studies evaluating different local herbal Ib Option +++
treatment, three showed a favorable
effect. However, not all studies were
blinded, and the quality of the studies
was variable.
The treatment does not show

significantly more adverse events than
placebo. The quality of the evidence for
the local treatment is low.
There is no evidence that traditional
Chinese medicine or acupuncture is
more effective than placebo in the
treatment of CRS. The safety of Chinese
36.Acupuncture and medicine is unclear because most of
traditional Chinese the papers are not (easily) accessible. 1b (-) Not Recommended +++
medicine Minor and serious adverse events can
occur during the use of acupuncture
and related modalities, contrary to the
common impression that acupuncture
is harmless.
There is one study evaluating Filgastrim
compared to placebo in CRS. There
was no significant difference in effect
37.Filgastrim
on QOL between the two groups. 1b (-) Option ++
(r-met-HuG-CSF)
Based on the evidence, we cannot
make a recommendation on the use of
Filgastrim in patients with CRS.
One very small study did not find
differences between nasal colloidal
silver spray and placebo. Based on
38.Collodial silver
the evidence, the EPOS2020 steering 1b (-) Option ++
nasal spray
group cannot make a recommendation
on the use of collodial silver nasal spray
in patients with CRS.
Capsaicin showed a significant
decrease in nasal obstruction and
nasal polyp score in two small studies,
however data on other symptoms like
rhinorrhea and smell are either non-
39.Capsaicin significant or unreported. The quality 1b Option +++
of the evidence is low and the EPOS
steering group concludes that capsaicin
may be an option in treatment of CRS
in patients with CRSwNP but that larger
studies are needed.
A recent DBPCT study showed
significantly reduced QOL (SNOT-
22) scores and polyp score (VAS),
and significantly more patients with
an NPS of 0 in the furosemide nasal
40.Nasal Furosemide 1b Not recommended +++
spray treated group versus placebo.
There was no indication of a difference
in adverse events between topical
furosemide and placebo. However, the
quality of the evidence is very low.
Remarks
EPOS Strength
Level of and
Evidence reviewer
comment
The quality of the evidence comparing
antihistamines with placebo was very
41.Antihistamines low. Evidence was downgraded because
Ib Option +++
of the small number of studies and
because the most important measures
of efficacy were not reported.
Oral ATAD has been shown to be
42.Aspirin treatment
significantly more effective and clinically
after desensitization
relevant than placebo in improving QOL Ia Recommended +++
(ATAD) with oral
(measured with SNOT) and total nasal
aspirin in N-ERD
symptom score in patients with N-ERD.
43.Aspirin treatment ATAD with lysine aspirin and platelet
after desensitization inhibitors (like Pradugrel) have not been
(ATAD) with nasal shown to be an effective treatment in Ib (-) Not Recommended +++
lysine aspirin in CRSwNP patients with N-ERD and are
N-ERD not advised.
Anti-IgE therapy has been proposed as

44.Anti-IgE Ib Option +
a promising biologic therapy for CRS.
There is only one large sufficiently

powered study with Mepolizumab
that showed a significant reduction
in patients’ need for surgery and an
improvement in symptoms. Unlike in
CRS, there is a significant experience
45.Anti-Il-5 with anti-Il5 in other type 2 driven Ib Recommended +
diseases like asthma that do show
a favourable safety profile so far.
Mepolizumab can be used in patients
with CRSwNP fulfilling the criteria for
treatment. With monoclonal antibodies
(when approved).
46.Anti IL-4/IL-13 (After fulfillment of the criteria for

Ia Recommended +
(IL-4 receptor α) treatment with monoclonal antibodies)
A very small pilot study showed

significant improvement in QOL (SNOT-
22), polyp score (VAS), and CT scan
(LM-score) of oral verapamil over
47.Oral verapamil placebo. (Potential) side effects limited 1b Not Recommended +++
the dosage. The quality of the evidence
for oral verapamil is very low. Based
on the potential side effects we advise
against the use of oral verapamil.
ATAD, Aspirin treatment after desensitisation ; CRS, chronic rhinosinusitis; CRSsNP, chronic rhinosinusitis without nasal polyps; CRSwNP,
chronic rhinosinusitis with nasal polyps; N-ERD, NSAID-exacerbated respiratory disease.
Evidence supporting therapy of CRS in children
Remarks
EPOS Strength
Level of and
Statement Topic Action recommendation GRADE After
Evidence reviewer
comment
48.Antibiotics There is no high-level evidence to

support the efficacy of either short-
1b (-) Option ++++
(short- or long-term or long-term antibiotics for CRS in
antibiotics) children.
There is no evidence regarding the

efficacy of intranasal steroids in the
49.Nasal treatment of CRS in children. V Recommended ++++
corticosteroids
They have anti-inflammatory effects
and excellent safety record in children.
Adding a taper course of systemic

steroids to an antibiotic (not effective
on its own) is more effective than
50.Systemic Steroids placebo in the treatment of pediatric 1b (+) Option +++
CRS. Judicious use of this regimen
is advised considering systemic side
effects.
There are a few clinical trials

demonstrating the efficacy of saline
irrigations in pediatric patients with
51.Saline Irrigation Ib (+) Recommended ++++
CRS. It has excellent safety record
in children, Addition of antibiotics to
saline irrigations is not recommended.
(In younger children with symptoms

52.Adenoidectomy IV Recommended ++++
of CRS).
(The treatment of older children with

53.FESS CRS refractory to medical therapy or IV Recommended ++++
previous adenoidectomy).
CRS, chronic rhinosinusitis; CRSwNP: chronic rhinosinusitis with nasal polyps; ESS, endoscopic sinus surgery; hpf: high power field (x400);
SNOT-22, sino-nasal outcome test-22.
References 4. Fokkens W.J., Lund V.J. , Hopkins C., et al. European Position
Paper on Rhinosinusitis and Nasal Polyps 2020 Rhinology.
1. Slovick A, Long J, Hopkins C. Updates in the management 2020 Suppl. 29: 1-464.
of chronic rhinosinusitis. Clin Pract.2014; 11, 649–63.
5. Kaper NM, van der Heijden G, Cuijpers SH, , et al. A
2. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical comparison of international clinical practice guidelines on
practice guideline (update): Adult Sinusitis Executive adult chronic rhinosinusitis shows considerable variability
Summary. Otolaryngol Head Neck Surg. 2015;152:598-609. of recommendations for diagnosis and treatment. Eur Arch
Otorhinolaryngol. 2020;277:659-68.
3. Royal College of Surgeon [Internet]. Commissioning
Guide:Chronic Rhinosinusitis. 2016. [Cited 2021 July 28].
Allergic Rhinitis: Adapted Egyptian Clinical Practice Guidelines

Scientific Board: Ashraf Khaled,4 Mohamed Ghonaim,5 Mahmoud Abdelaziz,6 Tarek Ghannoum,7 Mahmoud
Youssef8
Rhinology Executive Manage: Ahmed Elfarouk,1 Mohamed Elsharnouby,9 Hosam Elsherif,6
Assembly Board: Ahmed Ragab,2 Reda Kamel,1 Mohamed Gamea,10 Ayman Medani,11 Zeyad Mandour11
Ibrahim Abd-elshafy,2 Omer Elbanhawy,2 Magdy Eisa,6 Mostafa A. El Taher,12 Ahmed Elfarouk,1 Diaa Elhinnawi,13
Ismail Elnashar,14 Hossam Elsherif,6 Ashraf Kaled,4 Mena Maher,9 Mohamed Qotb,15 Amr Rabie,9 Ayman Ragheb,16
Nassim Talaat,1 Mohamed Osama Tamoum6
Reviewers team: Mohamed Hassab,11 Islam R. Herzalla,14 Alaa Ghita,17 Hesham Shaalan,18 Magdy Abdallah
Al-Ahl,14 Aly Elgarem1
1
Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Department,
Faculty of Medicine/ Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University,
4
Otorhinolaryngology Department, Faculty of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department,
Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology Department, Faculty of Medicine/ Tanta University,
7
Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Otorhinolaryngology Department,
Faculty of Medicine/ Ain Shams University, 10Otorhinolaryngology Department, Faculty of Medicine/Misr University
for Science and Technology, 11Otorhinolaryngology Department, Faculty of Medicine/ Alexandria University,
12
Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 13Otorhinolaryngology Department, Faculty
of Medicine/Suez Canal University, 14Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University,
15
Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University, 16Otorhinolaryngology Department,
Faculty of Medicine/ Military Medical Academy, 17Otorhinolaryngology Department, Hearing and Speech Institute,
16Otorhinolaryngology Department, Nasr City Insrance Hospital, 17Otorhinolaryngology Department, Faculty of
Medicine/ Military Medical Academy, 18Otorhinolaryngology Department, Hearing and Speech Institute.
Introduction and background judicious use of systemic and topical therapy.
The prevalence of allergic rhinitis AR world-wide is Methods

increasing. Approximately 10-30% of adults and 10-40%
of children are affected. In Egypt the current prevalence The adaptation cycle passed over: set up phase,
is variable in different studies ranging from 3.6-34% in adaptation phase (Search and screen, assessment:
different studies. AR is estimated to affect nearly 1 in Currency, Content and Quality and Decisions/selection)
every 6 Americans.About 40-80% of patients with rhinitis and finalization phase that include revision.
may have a combination of AR and non-AR.
Results
Scope and purpose
Sixteen guidelines were assessed by 5 experts rhinologists
The purpose of this guideline is to identify quality where (the International consensus statement on allergy
improvement opportunities in managing patients with AR and rhinology: Allergic rhinitis).1,2 had the highest scores
and to create explicit and actionable recommendations as regards to the currency, contents and quality than
to implement these opportunities in clinical practice. other 15 graded guidelines.1-16 It was graded GRADE by
Specifically, the goals are to improve diagnostic accuracy 15 expert rhinologist and reviewed by other 6 expert
for AR, promote appropriate use of ancillary tests to reviewers. The methodology was documented.17
confirm diagnosis and guide management, and promote
Grade Definition
High
++++
Low
++
+ of effect.
Allergic Rhinitis ECPG 2021 (Volume 1) Pages: 67-79 67

Recommendations statements adapted/adopted/added/deleted

Accepted statements
Modified statements
Added statements
Defined strategy for evidence quality and recommendation development according to (American Academy of Pediatric
(AAP) on Quality Improvement and Management)
Preponderance of
Preponderance of benefits Balance of benefit and
Evidence quality harm over Benefit
over harm harm
A. Well-designed RCT Strong recommendations

B.RCT with minor limitations, overwhelm-
ingly consistent evidence from observational against
Option
studies recommendations
C. Observational studies (case control and
cohort design)
Recommendation against
D. Expert opinion, Case reports, Reasoning
Option No recommendation
from first principal
1. Definitions, classification, and differential diagnosis of allergic rhinitis

Item Statements Egyptian comments
AR is defined as an immunoglobulin E (IgE)–mediated inflammatory
nasal condition resulting from allergen exposure in a sensitized indi-
vidual.
Sensitization to an allergen is indicated by a positive reaction on al-

Def. lergy skin test or antigen-specific IgE test, whereas clinical allergy is ++++
evidenced by active symptoms (characterized by nasal congestion,
rhinorrhea (nasal drainage), sneezing, and/or nasal itching) upon al-
lergen exposure in a sensitized individual. Not all sensitized individuals
exhibit clinical allergy.
Classification of AR typically includes seasonal vs perennial and inter-
mittent vs persistent.
-Seasonal allergic rhinitis (SAR): Disease caused by an IgE-mediated

inflammatory response to seasonal aeroallergens. The length of sea-
sonal exposure to these allergens is dependent on geographic location
and climatic conditions.
-Perennial allergic rhinitis (PAR): Disease caused by an IgE-mediated

inflammatory response to year-round environmental aeroallergens.
Classification ++++
These may include dust mites, mold, animal allergens, or certain oc-
cupational allergens.
-Intermittent allergic rhinitis: Disease caused by an IgE-mediated in-

flammatory response and characterized by frequency of exposure or
symptoms (<4 days per week or <4 weeks per year).
-Persistent allergic rhinitis: Disease caused by an IgE-mediated in-

flammatory response and characterized by persistent symptoms (>4
days per week and >4 weeks per year).
Drug-induced rhinitis
Rhinitis medicamentosa
Occupational rhinitis
Chemical rhinitis
Smoke-induced rhinitis
Infectious rhinitis
Differential diagnosis Rhinitis of pregnancy and hormonally induced rhinitis +++
Food- and alcohol-induced rhinitis
Nonallergic Rhinitis with Eosinophilia Syndrome (NARES)
Vasomotor rhinitis (nonallergic rhinopathy)Age-related rhinitis in the
elderly
Autoimmune, granulomatous, and vasculitic rhinitis
Chronic Rhinosinusitis with and without nasal polyposis.
68 2021 (Volume 1) Pages: 67-79 Allergic Rhinitis ECPG

2. A. Proposed risk factors for the development of AR
Aggregate
Risk factor or Number of
grade of Interpretation Egyptian comments
exposure listed studies
evidence
5 Genome-wide Some genes have been asso-

+++
Genetics association C ciated with development of AR
study (GWAS) and other atopic diseases.
In utero or early +++

6 C Data inconclusive.
exposure (mites)
In utero or
+++
early exposure 2 C Data inconclusive.
(pollen)
In utero or early
+++
exposure (animal 39 C Data inconclusive.
dander)
In utero or early
+++
exposure (fungal 13 C Data inconclusive.
allergens)
Maternal diet restriction while

Restricted diet child is in utero is not a contrib-
++++
(in utero and 5 A uting factor to the development
early childhood) of AR. Food allergy during child-
hood is a risk factor for AR.
+++
Pollution 14 C Data inconclusive.
Most studies found no associa-

tion between active or passive
tobacco smoke and AR. Spe-
++++
Tobacco smoke 9 A cific patient populations and
temporal variations (ie, length
of exposure) should be further
evaluated.
Most studies show an associa-
Socioeconomic tion between high SES and AR,
10 C +++
status (SES) but this is not a consistent find-
ing across all studies.
2. B. Proposed protective factors against the development of AR
Number Aggregate
Protective factor Recommendation Egyptian
of listed grade of Interpretation
or exposure level Grading
studies evidence
Option for breastfeeding for the

specific purpose of AR prevention.
++
Breastfeeding 2 C Option In general, breastfeeding has been
strongly recommended due to its
multiple beneficial effects.
No evidence that pet avoidance in
childhood prevents AR later in life.
++
Pet exposure 6 C — Early pet exposure, especially dog
exposure in nonallergic families early
in childhood, may be protective.
Microbial diversity of the skin, air-
Microbial diver-
ways, and gut is important for the
sity (“hygiene 15 B — +++
prevention of sensitization and aller-
hypothesis”)
gic disease in populations.

3. Effect of AR on the individual: QoL and sleep
Aggregate
Burden of Number of Egyptian
grade of Recommendation level Interpretation
AR listed studies grading
evidence
AR has significant ef-

fects on general and
Effect on disease-specific QoL. ++++
33 B Recommendation
QoL Treatment of AR is rec-
ommended to improve
QoL.
AR has significant neg-
ative effects on sleep.
Effect on
46 B Recommendation Treatment of AR is rec- ++++
sleep
ommended to decrease
sleep disturbance.
• AR = allergic rhinitis; QoL = quality of life.
4. Evaluation and diagnosis
Number Aggregate
Method of Recommendation
of listed grade of Interpretation Egyptian grading
evaluation level
studies evidence
Despite the lack of studies to

address clinical examination
Clinical in the diagnosis of AR, histo-
examination ry-taking is essential and physi- ++++
4 D Recommendation
(history and cal examination is recommend-
physical) ed. Multiple prior guideline
documents support this recom-
mendation.
Findings of AR consistent with

an allergic cause include, but
Clinical
are not limited to, clear rhinor- ++++
diagnostic D Not reported
rhea, nasal congestion, pale
findings
discoloration of the nasal mu-
cosa, and red and watery eyes.
Evidence does not support the

routine use of nasal endoscopy
for diagnosing AR. However,
Nasal it is helpful in ruling out other +++
5 D Option
endoscopy causes of symptoms. Also, it
can show swollen, edematous
mucosa and papillary post end
of inferior turbinate.
Radiologic imaging is not rec- +++

Radiologic Recommend
0 N/A ommended for the diagnosis
imaging Against Against
of AR.
Validated survey instruments

Use of
can be used to screen for AR,
validated Strong +++
10 A follow treatment outcomes,
survey Recommendation
and as an outcome measure for
instruments
clinical trials.
SPT is recommended for evalu-
ation of allergen sensitivities in
appropriately selected patients.
+++
SPT 8 B Recommendation The practitioner may decide
whether skin or in vitro sIgE
testing is best in an individual
patient.

4. Evaluation and diagnosis
Number Aggregate
Method of Recommendation
of listed grade of Interpretation Egyptian grading
evaluation level
studies evidence
Intradermal testing may be

Skin used to determine specific air-
++++
intradermal 17 B Option borne allergen sensitization for
testing individuals suspected of having
AR.
Serum tIgE is an option to as- +++

Serum tIgE 15 C Option
sess atopic status.
Serum sIgE testing is recom-

mended for evaluation of al-
lergen sensitivities in appro-
+++
Serum sIgE 7 B Recommendation priately selected patients. The
practitioner may decide wheth-
er skin or in vitro sIgE testing
is best in an individual patient.
Clinicians should perform and

interpret, or refer to a clinician
who can perform and interpret,
specific IgE (skin or blood) al-
Specific lergy testing for patients with
++++
Allergen B NR a clinical diagnosis of AR who
diagnosis do not respond to empiric treat-
ment, or when the diagnosis is
uncertain, or when knowledge
of the specific causative aller-
gen is needed to target therapy.
Correlation
Studies differ regarding the
between skin ++++
19 B — concordance of various allergy
and in vitro
testing methods.
testing
Nasal NPT has been employed for di-
+++
provocation 4 C — agnosis of occupational rhinitis
testing and LAR.
Nasal cytology is an investiga-
+++
Nasal cytology 4 C — tional tool, rather than diagnos-
tic.
Nasal histology is used for re-
search on the pathophysiology
Nasal Histology 11 B — of AR, but is not routinely used ++++
in clinical practice for the diag-
nosis of AR.
•AIT = allergen immunotherapy; AR = allergic rhinitis; BAT = basophil activation test; LAR = local allergic rhinitis; MQT = Modified Quantitative
Testing; NPT = nasal provocation testing; sIgE = antigen-specific immunoglobulin E; SPT = skin-prick test; tIgE = total immunoglobulin E.

5. Managment: A. Allergen avoidance and environmental control measures
Aggregate
Number of Egyptian
Allergen avoided grade of Recommendation level Interpretation
listed studies gradings
evidence
Clinicians may advise

avoidance of known al-
Allergen
lergens or may advise
avoidance and
environmental controls +++
environmental B Option
in patients with AR who
control
have identified aller-
measures
gens that correlate with
clinical symptoms.
Concomitant use of
acaricides, imperme-
able covers for bedding,
House dust +++
12 B Option and EC measures is an
mite
option for the treatment
of AR. “Air Purifiers” can
be used.
Combination of physical
measures (bait traps,
housecleaning) and ed- +++
Cockroach 11 B Option
ucation is an option for
AR management related
to cockroach exposure.
Pet avoidances, wash-

ing pets twice a week
+++
Pets 3 B Option and EC strategies are
an option for AR related
to pets.
Pollen and occupation-

al allergen avoidance
Pollen and
by EC strategies are an
occupational 3 B Option +++
option for the treatment
allergens
of AR. Air purifiers can
be used.
-Reduce Your Exposure

to Mold Spores Outside:
limit your outdoor activ-
ities when mold counts
are high. Wear a dust
mask.
Mold’s
D Option -Reduce Your Exposure +++
avoidance
to Mold Spores Inside:
Use central air condi-
tioning and “Air Purifi-
ers” Lower your indoor
humidity and Prevent
mold and mildew build
up inside the home.
•AR = allergic rhinitis; EC = environmental controls.

5. Management: B. Pharmacotherapy options for the treatment of AR
Number Aggregate
Egyptian
Medication of listed grade of Recommendation level Interpretation
Gradings
studies evidence
Newer-generation
(nonsedating) oral H1
Oral antihistamines are strongly ++++
21 A Strong Recommendation
H1 antihistamines recommended for the
treatment of AR.
Available data does not ++++

Oral adequately address the
6 B Strong Recommendation
H2 antihistamines question of benefit in the Against
treatment of AR.
Intranasal antihistamines
Intranasal may be used as first-line or ++++
44 A Recommendation
antihistamines second-line therapy for the
treatment of AR.
Due to the risks of oral

steroid use, along with
the availability of other ++++
Oral corticosteroids 9 B Recommend Against pharmacotherapy options,
Against
this therapy is not
recommended for routine AR
management.
Due to the risks of injectable

steroid use, along with
the availability of other ++++
Injectable pharmacotherapy options,
13 B Recommend Against
corticosteroids systemic or intraturbinate Against
injection of corticosteroids
is not recommended for the
routine treatment of AR.
INCS should be used as first-

++++
INCS 53 A Strong Recommendation line therapy in the treatment
of AR.
Oral decongestants Option for pseudoephedrine

++
9 B Option for short-term treatment of
pseudoephedrine AR symptoms.
Recommend against ++++

phenylephrine, as it has not
Phenylephrine Recommend Against
been shown to be superior against
to placebo.
Option for topical IND

use in the short-term not
more than 5 days for nasal
Topical decongestion. Use selective ++
4 B Option
decongestants forms e.g. oxymetazoline
or Zylometazoline. Chronic
use carries a risk of rhinitis
medicamentosa (RM)
LTRAs should not be used ++++

LTRAs 31 A Recommend Against as monotherapy in the
against
treatment of AR.

Number Aggregate
Egyptian
Gradings
studies evidence
DSCG may be considered

in the treatment of AR,
particularly for patients with ++
Cromolyn (DSCG) 22 A Option
known triggers who cannot
tolerate INCS. It is not a
common practice in Egypt.
IPB nasal spray may be

considered as an adjunct to
Intranasal INCS in PAR patients with
+
anticholinergic 14 B Option uncontrolled rhinorrhea.
(IPB)
Not used and not present in
the market.
Omalizumab is not approved ++++

Omalizumab 6 A No indication by the U.S. FDA for the
Against
treatment of AR alone.
Nasal saline is strongly rec-

++++
Nasal saline 12 A Strong recommendation ommended as part of the
treatment strategy for AR.
Probiotics may be consid-

ered in the treatment of AR. ++
Probiotics 28 A Option
It is not a common practice
in Egypt.
Clinicians may offer combi-

nation pharmacologic thera-
Combination py in patients with AR who ++++
A Option
therapy have inadequate response
to pharmacologic monother-
apy.
Option, particularly for acute

Combination: oral
exacerbations with a prima- +++
antihistamine and 21 A Option
ry symptom of nasal conges-
oral decongestant
tion.
Combination: oral
Combination equivocal over ++++
antihistamine and 5 B Option
either drug alone.
INCS
Combination is an option for

AR management, particular-
Combination: oral ly in patients with comorbid
+++
antihistamine and 13 A Option asthma who do not tolerate
LTRA INCS and are not well-con-
trolled on oral antihistamine
monotherapy.
Strong recommendation for

Combination: INCS
combination therapy when ++++
and intranasal 12 A Strong recommendation
monotherapy fails to control
antihistamine
AR symptoms.
In patients who wish to

avoid medications, acupunc-
ture many be suggested as a +
Acupuncture 15 B Option
possible therapeutic adjunct.
Not a common practice in
Egypt.

Number Aggregate
Egyptian
Gradings
studies evidence
Studies are inconclusive and

+
Honey 3 B No recommendation heterogeneous. Not a com-
mon practice in Egypt.
Multiple different herbs stud-

ied, with few studies for
each specific therapy. Re-
Herbal therapies — — No recommendation sults are inconclusive. +
Not a common practice in

Egypt.
•AR = allergic rhinitis; DSCG = disodium cromoglycate; FDA = Food and Drug Administration; INCS = intranasal corticosteroids; IND =
intranasal decongestants; IPB = ipratropium bromide; LTRA = leukotriene receptor antagonist; PAR = perennial allergic rhinitis; RM = rhinitis
medicamentosa.
5. Management: C. Surgery
Aggregate
Number of Recommendation Egyptian
Surgery grade of Interpretation
listed studies level Gradings
evidence
Surgical therapy: Whereas AR is

Turbinate reduction with
typically considered a medical
or without septoplasty
disease, surgical therapies are
may be considered in AR
sometimes offered. Surgical
patients who have failed
treatment of the septum, inferior
C Option medical management, +++
and/or middle turbinates, and
and have anatomic fea-
possibly vidian/posterior nasal
tures that explain symp-
neurectomy, may be considered
toms of nasal obstruc-
in both allergic and nonallergic
tion.
patients.

5. Management: D. Allergen immunotherapy (AIT) methods
Number Aggregate
Egyptian
Immunotherapy method of listed grade of Recommendation level Interpretation
grading
studies evidence
Strong recommenda-
tion for SCIT in pa-
tients unable to obtain
adequate relief from +++
SCIT 8 A Strong recommendation
pharmacotherapy and
those who would ben-
efit from secondary dis-
ease-modifying effects.
Strong recommenda-
tion for SLIT in pa-
tients unable to obtain
adequate relief from +++
SLIT 25 A Strong recommendation
pharmacotherapy. Its
cost and unavailability
currently limit its use in
Egypt.
Limited studies show

variable effectiveness,
along with adverse re- ++++
Trans/epicutaneous
4 B Recommend against actions. Trans/epicuta-
immunotherapy Against
neous immunotherapy
is not recommended
for AR treatment.
Pending additional
studies, ILIT may be
a viable option for AR
treatment in the clinical
ILIT 7 B Option ++
population. Not to be
used in Egypt except
after other studies con-
firm its benefits.
•AIT = allergen immunotherapy; AR = allergic rhinitis; ILIT = intralymphatic immunotherapy; SCIT = subcutaneous immunotherapy; SLIT =
sublingual immunotherapy.
6. AR-associated conditions
Number Aggregate
Diagnosis of listed grade of Interpretation Egyptian remarks
studies evidence
Clinicians should assess patients

Diagnosis of with a clinical diagnosis of AR for,
++++
associated C and document in the medical re-
conditions cord, the presence of the associat-
ed following conditions.
Asthma:
Asthma is associated with AR and ++++
Association with 7 C
NAR.
rhinitis
Asthma: Rhinitis AR and NAR are risk factors for ++++

13 C
as a risk factor developing asthma.
Asthma: Benefit +++

— — No specific recommendations.
of AR treatment
AR is thought to be a disease-mod- +
ARS 5 C
ifying factor for ARS.
Recurrent acute ++
2 D Data inconclusive.
rhinosinusitis

6. AR-associated conditions
Number Aggregate
Diagnosis of listed grade of Interpretation Egyptian remarks
studies evidence
Chronic
rhinosinusitis Conflicting evidence for/against an +
10 D
without nasal association.
polyps
Chronic
Conflicting evidence for/against an +++
rhinosinusitis 21 D
association.
with nasal polyps
AC is a frequently occurring comor- +++

Conjunctivitis 7 C
bidity of AR.
There is evidence for an association +++
AD 20 C
between AR and AD.
Food allergy and There is evidence for a link between ++

12 B
PFAS pollen allergy and PFAS.
Adenoid +++
11 C Data inconclusive.
hypertrophy
Otologic There is a causal role for AR in +++

7 C
conditions: ETD some cases of ETD.
Otologic
Relationship between AR and OTE +++
conditions: otitis 16 C
is unclear.
media
Otologic Evidence for an association is of

+
conditions: 8 C low grade, with substantial defects
Meniere’s disease in study design.
Low level evidence for an associa- ++++

Cough 9 C
tion between AR and cough.
There is some evidence for an as-

++
Laryngeal disease 18 C sociation between AR and laryngeal
disease.
Limited observational data suggests

a potential association between ++
EoE 13 C
aeroallergens and EoE pathogene-
sis.
Sleep disturbance Sleep disturbance is associated

20 B +++
and OSA with AR.
•AC = allergic conjunctivitis; AD = atopic dermatitis; AR = allergic rhinitis; ARS = acute rhinosinusitis; EoE = eosinophilic esophagitis; ETD =
Eustachian tube dysfunction; NAR = nonallergic rhinitis; OSA = obstructive sleep apnea; OTE = otitis media with effusion; PFAS = pollen-food
allergy syndrome.

AR: Allergic rhinitis.

ONSAH1: Oral nonsedating antihistamine H1.
NAH: Nasal antihistamine.
LRA: Leukotrienes receptor antagonists.
OAH: Intraocular antihistamine.

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Epistaxis: Adapted Egyptian Clinical Practice Guidelines

Rhinology Executive Manager: Ahmed Elfarouk,1 Mohamed Elsharnouby,9 Hossam Elsherif6
Assembly Board: Ibrahim Rezk Mohammed,10 Diaa Elhinnawi,11 Mohamed Rifaat Ahmed4
Ibrahim Abd-elshafy,2 Magda Abdellatif,12 Hesham El Adl,5 Ismail Elnashar,13 Hossam Elsissi,5 Amr Gouda,9 Anas Askora,9 Sayed
Kaddah,12 Mena Maher,9 Yaser Nour,14 Amr Rabie,9 Nassim Talaat,1 Mohamed Osama Tamoum,6 Ramez Reda17
Reviewers team: Ahmed Ragab,2 Ahmed Gamae,6 Magdy Eisa,6 Ahmed Anany,13 Samir Halim Khalil,15 Abdelzaher Tantawy,13
Abdelwahab Rakha,5 Ezzat Saleh,16 Tarek Abdelzaher Emara,13 Ramez Reda4
1
Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 4Otorhinolaryngology Department,
Faculty of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University,
6
Otorhinolaryngology Department, Faculty of Medicine/ Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams
University, 9Otorhinolaryngology Department, Faculty of Medicine/Ain Shams University, 10Otorhinolaryngology Department,
Faculty of Medicine/Sohag University, 11Otorhinolaryngology Department, Faculty of Medicine/ Suez Canal University,
12
Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar University 13Otorhinolaryngology Department, Faculty of
Medicine/ Zagazig University,14Otorhinolaryngology Department, Faculty of Medicine/ Alexandria University, 15Otorhinolaryngology
Department/ General Organisation of Teaching Hospitals and Institutes, 16Otorhinolaryngology Department, Faculty of Medicine/
Assuit University.
Introduction and background unjustified variations in care of patients with nosebleeds,

improve health outcomes, and minimize the potential harms
Epistaxis or bleeding from the nose is defined as acute of nosebleeds or interventions to treat nosebleeds.
haemorrhage from the nostril. Epistaxis can be divided into
2 categories, anterior bleeds and posterior bleeds, on the Methods
basis of the site where the bleeding originates. Epistaxis is
a frequent emergency department (ED) complaint and often Use of the simplest method to stop nosebleeds, reduce
causes significant anxiety in patients and clinicians. Epistaxis morbidity, protect airway, reduce need for blood products,
etiological causes can be divided into local causes, systemic improve patient satisfaction, allow for further assessment and
causes and idiopathic causes. Epistaxis is the most common management. Improve access to effective treatment options,
rhinological emergency seen in the emergency department raise awareness of effective treatment options, provide
accounted for approximately 1 in 30 visits to the ED and 77 effective and timely control of bleeding, reduce length of
out of a population of 100,000 nearly 60% of the population stay and overall cost for the patient, allow opportunity for
experience a nosebleed at least once. One-tenth of these shared decision making about methods more invasive than
patients eventually seek medical advice/intervention, and cautery to control nosebleed. The adaptation cycle passed
0.16% will need hospitalization. over: set up phase, adaptation phase (Search and screen,
assessment: Currency, Content and Quality and Decisions/
Scope and purpose selection) and finalization phase that include revision.
The purpose of this guideline is to identify quality Results

improvement opportunities in managing Epistaxis and to
create explicit and actionable recommendations to implement Ten guidelines were assessed by 3 experts rhinologists and
these opportunities in clinical practice. Specifically, the goals the International Consensus on Clinical Practice Guideline:
are to improve management of epistaxis to identify quality Nosebleed (Epistaxis) published in the January 2020 (The
improvement opportunities in the management of nosebleeds American Academy of Otolaryngology–Head and Neck
and to create clear and actionable recommendations to Surgery (AAO-HNS)8 had the highest scores as regards to
implement these opportunities in clinical practice. Specific the currency, contents and quality. It was graded GRADE by
goals of this guideline are to promote best practices, reduce 14 expert rhinologists and reviewed by 10 expert reviewers.
Grade Definition
We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but
Moderate +++
there is a possibility that it is substantially different
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the
Low ++
effect.
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the
Very Low +
estimate of effect
80 2021 (Volume 1) Pages: 80-86 Epistaxsis Guidelines

Accepted statements
Modified statements
Added statements
Grade of evidence by question type according to Oxford university
OCEBM
Grade level
Treatment Harm Diagnosis Prognosis
Systematic reviewb of
Systematic reviewb of cross
randomized trials, nested
Systematic reviewb of sectional studies with Systematic review of
A 1 case- control studies. Or
randomized trials consistently applied reference inception cohort studiesc
observational studies with
standard and blinding
dramatic effectb
Randomized trials or
Randomized trials or
observational studies cross sectional studies with
observational studies with
B 2 with dramatic effects consistently applied reference Inception cohort studiesc
dramatic effects or highly
or highly consistent standard and blinding
consistent evidence
evidence
Nonrandomized controlled
Non-consecutive studies,
Nonrandomized or cohart or follow-up study Cohort study, controlled arm
case- control studies, or
historically studies. (postmarketing surveillance) of Randomized trials case
studies with poor non-
C 3-4 Including case- with sufficient numbers to series or case-control studies
independent, or inconsistently
control studies and rule out a common harm, or poor – quality prognostic
observational studies case series , case-control. Or cohort study
Applied reference standard
historically controlled studies
D 5 Case report, mechanism based reasoning, or reasoning from first principles
X NA Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit over
harms
Definition of evidence-based recommendations according to American academy of pediatric

Recommendation and evidence qual- Description of Supporting evidencea Interpretation
ity
High-quality evidence RCT without important limitations or over- Can apply to most patients in most circum-
whelming evidence from observational studies stances without reservation
Moderate-quality evidence RCT without important limitations or strong Can apply to most patients in most circum-
evidence from observational studies stances without reservation
Low-quality evidence Observational studies/Case studies May change when higher-quality evidence
becomes available
Weak Recommendation
High-quality evidence RCT without important limitations or over- Best action may differ based on circum-
whelming evidence from observational studies stances or patients’ values
Moderate-quality evidence RCT without important limitations or strong Best action may differ based on circum-
evidence from observational studies stances or patients’ values
Low-quality evidence Observational studies\Case studies Other alternatives may be equally reason-
able
Insufficient Evidence is conflicting, of poor quality or Insufficient evidence to recommend for or
Lacking against
Epistaxsis Guidelines 2021 (Volume 1) Pages: 80-86 81

ARS guidelines statements
Strength of Strength
Level of recommendations after
evidence according to the adoption or
selected CPG adaptation
1.A stepwise A stepwise approach to epistaxis management is
High
management advocated: initial management, direct therapy, tamponade, Grade C Medium
++++
approach and vascular intervention.
First-line’ treatment can include combinations of direct
2.First line treatment Moderate
nasal compression, application of topical selective agonist Grade C Medium
in active nose bleed +++
nasal vasoconstrictors,
Cautery/coagulation of the bleeding site with (chemical
3.Prompt Moderate
cautery, electrocautery, or electrocoagulation) or nasal Grade C Medium
management +++
packing.
-At the time of initial contact, the clinician should distinguish

the epistaxis patient who requires prompt and emergency
ABCD management.
- If there is only minor active bleeding without airway

or hemodynamic issues, the patient may be assessed in
an ambulatory setting that has the clinical expertise and
supplies necessary to diagnose and control bleeding.
If active bleeding is not reported or seen but there is

concern for recurrence of severe bleeding, the clinician
should direct the patient to an emergency department or
hospital. High
4.Rapid ABC
Grade C Medium
assessment.
-Assess the patient severity of bleeding as they need ++++
promptint ervention through:
1. Bleeding duration 30 minutes over a 24-hour period
2.A history of hospitalization for nosebleed, prior blood

transfusion for nosebleeds, or recent episodes of nasal
bleeding
3. evidence of or suspicion for a prolonged or large volume

bleeding, bleeding from both sides of the nose or from the
mouth, or any signs of acute hypovolemia (ie, tachycardia,
syncope, orthostatic hypotension).
The clinician should treat active anterior epistaxis for pa-

tients in need of prompt management with firm sustained
compression to the lower third of the nose, with or without
the assistance of the patient or caregiver, for 5-10 minutes
or longer. Moderate
5.Nasal compression Grade C Medium
+++
If hemostasis is not achieved or leads to postnasal bleed-
ing, it should be discontinued, and an attempt made to
clear blood and visualize the site with suction, to identify
the bleeding site.
A. For patients in whom bleeding precludes identification
of a bleeding site despite nasal compression, the
clinician should treat ongoing active bleeding with nasal
packingunder its related clinical Setting.
B. nasal packing is anterior, posterior or both according to

the site of bleeding whether anterior or posterior.
C. The clinician should use resorbable packing for patients High

6.Nasal packs Grade C Medium
with a suspected bleeding disorder or for patients who are ++++
using anticoagulation or antiplatelet medications.
D. Once a pack is inserted, it is usually recommended that

it is left in place for 48 hours, necessitating admission
(specially for posterior nasal packing), although care at
home with packs has been described for anterior nasal
packing. Use prophylactic antistaph. Antibiotics during the
time of packing.

A. The clinician should educate the patient who undergoes
nasal packing about the type of packing placed, timing of
and plan for removal of packing (if not resorbable), post-
procedure care, and any signs or symptoms that would
7.Care during and Moderate
warrant prompt reassessment. Grade C Medium
after nasal packing +++
B. Following pack removal, it is imperative to examine the
nasal cavity, to exclude underlying abnormality and to
identify and manage the bleeding source if possible.
8.Topical
Topical selective vasoconstrictor agonist preparations
vasoconstrictor in Moderate
include 0.5% phenylephrine hydrochloride, or 0.05% Grade C Medium
minimal anterior +++
oxymetazoline solution and Xylometazoline 0.1%.
epistaxis
The clinician should document factors that increase the
frequency or severity of bleeding for any patient with a
nosebleed, including medical or family history of bleeding
Moderate
9.Risk factors disorders, drug use as anticoagulant or antiplatelet or Grade C Medium
+++
intranasal drug use, Nasal cannula oxygen use and CPAP
use (continuous positive airway pressure) specially in
COVID-19 patients.
10.Anterior The clinician should perform anterior rhinoscopy to identify
rhinoscopy to a source of bleeding after removal of any blood clot. The
Moderate
identify side of bleeding as well as whether predominantly anterior, Grade C Medium
+++
or posterior should be determined and localized point
location of bleeding bleeding or diffuse.
The clinician should perform, or should refer to a clinician
who can perform, nasal endoscopy to identify the site of
11.Examination
bleeding and guide further management in patients with High
using nasal Grade C Medium
recurrent nasal bleeding, despite prior treatment with ++++
endoscopy
packing or cautery, or with recurrent unilateral nasal
bleeding.
After patient stabilization and control of bleeding:
-A full blood count will facilitate assessment of blood loss

and shock
High
12.Investigations Grade B High
- coagulation profiles - ++++
A biochemistry profile may indicate circulatory effects

on renal function or the break-down products of a large
volume of ingested blood.
Angiography has an essential but infrequent role in
13.Advanced Very Low
excluding potentially fatal carotid aneurysms in trauma and Grade C Medium
investigation +
in cases of heavy postsurgical bleeding.
14.Appropriate The clinician should treat patients with an identified site of
interventions for bleeding with an appropriate intervention, which may include High
Grade B Medium
identified bleeding one or more of the following: topical vasoconstrictors, nasal ++++
site cautery, and moisturizing or lubricating agents.
-When nasal cautery is chosen for treatment, the clinician
should anesthetize the bleeding site and restrict application
of cautery only to the active or suspected site(s) of bleeding.

15.Nasal cautery or High
-Cautery/cogulation may be performed with a.Chemichals: Grade C Medium
coagulation ++++
topical administration of silver nitrate (25%-75%), chromic
acid, or richloroacetic acid, b. Electrocautery or ‘‘hot wire’’
thermal cautery.
C.Electrocoagulation with diathermy which is prefered.

A. The clinician should evaluate, or refer to a clinician
who can evaluate, candidacy for surgical arterial ligation
or endovascular embolization for patients with persistent
or recurrent bleeding not controlled by packing or nasal
cauterization.
B. EUA, examination under anesthesia and SPA,

sphenopalatine artery ligations are the first option of
16.Ligation and/
surgical treatment in such cases. High
or embolization for Grade C High
++++
persistent epistaxis C. AEA ligation has an essential role in traumatic or
postsurgical epistaxis, in which nasal or ethmoid bony
injury leads to bleeding beyond the SPA distribution.
D. Selective embolization of the maxillary or facial arteries

should be considered in cases where surgical ligation fails,
or is impossible because of anesthetic concerns or non-
availability.
17.Management
of life-threatening In the absence of life-threatening bleeding, the
bleeding in clinician should initiate first-line treatments prior to
patients using High
transfusion, reversal of anticoagulation, or withdrawal of Grade C High
anticoagulation and ++++
anticoagulation/ antiplatelet medications for patients using
antiplatelet these medications.
medications
18.Management
The clinician should assess, or refer to a specialist who
of recurrent
can assess, the presence of nasal telangiectasias and/or
nose bleeds with
oral mucosal telangiectasias in patients who have a history Very low
possible Hereditary Grade B High
of recurrent bilateral nosebleeds or a family history of +
hemorrhagic
recurrent nosebleeds to diagnose hereditary hemorrhagic
telangiectasia (HHT)
telangiectasia syndrome.
identification
The clinician should educate patients with nosebleeds and
19.Patient education their caregivers about preventive measures for nosebleeds, High
Grade B Medium
and prevention home treatment for nosebleeds, and indications to seek ++++
additional medical care.
The clinician should document the outcome of intervention
20.Nosebleed within 30 days or document transition of care in patients Very Low
Grade C Medium
outcomes who had a nosebleed treated with non-resorbable packing, +
surgery, or arterial ligation/embolization.
Refractory Acute Epistaxis will continue (usually slowly or
intermittently), despite all conservative measures, good
nasal packs, examination under anesthetic, and even
arterial ligations.
Evaluate the following:

21.Refractory Acute Very Low
-History of trauma, with or without anterior ethmoid Grade C Medium
Epistaxis +
laceration, or acarotid aneurysm?
-Role for further ligations of the bilateral sphenopalatine, or

anterior and posterior ethmoid arteries.
-Is Coagulopathic problems including drug-induced

coagulopathy.


References 5. Traboulsi H, Alam E, Hadi U. Changing Trends in the

Management of Epistaxis. Int J Otolaryngol. 2015.
1. Van Wyk FC, Massey S, Worley G, et al. Do all 2015:263987.
epistaxis patients with a nasal pack need admission?
A retrospective study of 116 patients managed in 6. Verillaud B, Robard L, Michel J, et al; SFORL
accident and emergency according to a peer reviewed Work-Group. Guidelines of the French Society of
protocol. J Laryngol Otol. 2007;121(3):222-7. Otorhinolaryngology (SFORL). Second-line treatment
of epistaxis in adults. Eur Ann Otorhinolaryngol Head
2. Barnes ML, Spielmann PM, White PS. Epistaxis: a Neck Dis. 2017;134(3):191-193.
contemporary evidence based approach. Otolaryngol
Clin North Am. 2012;45(5):1005-17. 7. Beck R, Sorge M, Schneider A, et al. Current
Approaches to Epistaxis Treatment in Primary and
3. Spielmann PM, Barnes ML, White PS. Controversies Secondary Care. Dtsch Arztebl Int. 2018;115(1-
in the specialist management of adult epistaxis: 02):12-22. doi:10.3238/arztebl. 2018.0012.
an evidence-based review. Clin Otolaryngol.
2012;37(5):382-9. 8. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice
Guideline: Nosebleed (Epistaxis). Otolaryngol
4. Rosenfeld RM, Shiffman RN, Robertson P; Department Head Neck Surg. 2020;162(1_suppl):S1-S38. doi:
of Otolaryngology State University of New York 10.1177/0194599819890327. PMID: 31910111.
Downstate. Clinical Practice Guideline Development
Manual, Third Edition: a quality-driven approach for 9. Tabassom A, Cho JJ. Epistaxis. [Updated 2020 Aug
translating evidence into action. Otolaryngol Head 8]. In: StatPearls [Internet]. Treasure Island (FL):
Neck Surg. 2013;148(1 Suppl):S1-55. StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK435997.

Cerebrospinal Rhinorrhea (CSF): Adapted Egyptian Clinical practice

guidlines
Rhinology Executive Manager: Ahmed Elfarouk,1 Mohamed Elsharnouby, Hossam Elsherif6
Assembly Board: Ismail Elnashar,10 Mostafa A. El Taher,11 Ashraf Elhosini,10 Tamer Orabi10
Grading Board: (In alphabetical order)
Ibrahim Abd-elshafy,2 Sameh Amin,12 Diaa Elhinnawi,13 Mohamed Fawwaz,4 Mohamed Gamea,14 Amr Gouda,9 Baliegh Hamdy,3
Islam R. Herzalla,10 Sayed Kaddah,15 Ashraf Khaled,4 Mohamed Qotb,12 Ahmad Ragab,2 Ramez Reda,4 Mohamed Osama Tamoum6
Reviewing Board: Yaser khafagy,5 Alaa Ghita,16 Ahmed Ali Ibrahim17
1
Ain Shams University, 9Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 10Otorhinolaryngology
Department, Faculty of Medicine/ Zagazig University 11Otorhinolaryngology Department, Faculty of Medicine/ Sohag University,
12
Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University, 13Otorhinolaryngology Department, Faculty of
Medicine/ Suez Canal University, 14Otorhinolaryngology Department, Faculty of Medicine/ Misr University for Science and
Technology, 15Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar University, 16Otorhinolaryngology Department,
Faculty of Medicine/ Military Medical Academy, 17Otorhinolaryngology Department, Faculty of Medicine/Alexandria University.
Summary finalization phase that includes revision.
These guidelines were adopted/adapted from the Results

International Consensus Statement on Allergy and
Rhinology: Endoscopic Skull Base Surgery (ICAR: ESBS), The guidelines were chosen and formulated by the
2019 which had the highest scores as regards currency, authors and graded by 13 experienced rhinologists and
content and quality. reviewed by three highly experienced reviewers.
Introduction and background The Grading of Recommendations Assessment,

Development and Evaluation (GRADE) approach was
CSF rhinorrhea, results from an osseous defect in the used to decision framework assessment.
skull base with an associated dural fistula. If untreated,
it can lead to serious complications. Many controversies High ++++: We are very confident that the true effect
exists in the management of CSF rhinorrhea. lies close to that of the estimate of the effect.
The purpose of this work is to search for the most suitable Moderate +++: We are moderately confident in the
guidelines to provide clinicians with best evidence effect estimate: the true effect is likely to be close to the
based medicine (EBM) practice in management of CSF estimate of the effect, but there is a possibility that it’s
rhinorrhea regarding diagnosis and treatment. Also, to substantially different
formulate these guidelines in a simplified algorithm trying
Low ++: Our confidence in the effect estimate is limited:
to solve controversies in the management in the best way
the true effect may be substantially different from the
that suits Egyptian circumstances.
estimate of the effect.
Methods
Very low +: We have very little confidence in the effect
The adaptation cycle passed over the setup phase, estimate: the true effect is likely to be substantially
the adaptation phase (search and screen assessment: different from the estimate effect.
currency, content, quality and decisions/ selection) and
Accepted statements
Modified statements
Added statements
Rhinorrhea (CSF) 2021 (Volume 1) Pages: 78-91 87

Traumatic and iatrogenic CSF leaks

aggregate grade Strength after
Statement Interaction Strength
of evidence adaptation
++++
Consideration for nonsurgical man- Option (Suggestion to make it as

1 agement within the first 7 days is fea- B recommendation as chance
sible in traumatic skull base injuries. of closure is high and risk of
meningitis is low during 1st
Non surgical week)
management Lumbar drains may shorten the inter-
2 val to traumatic CSF leak cessation B Option ++
during conservative management.
The evidence for acetazolamide in
3 traumatic or iatrogenic CSF leaks is B Option ++++
lacking.
There is a lack of evidence to support
Prophylactic
4 prophylactic antibiotics administration B Option +++
antibiotics
in patients with a traumatic CSF leak.
Non-iatrogenic (after conservative

measures fail) and iatrogenic trau-
Defects of the matic CSF (generally not treated con-
5 ethmoid roof servatively) leaks can be repaired en- B Recommendation ++++
and sphenoid doscopically with high success rates.
The transnasal endoscopic approach

to frontal sinus CSF leaks is safe and
Frontal sinus
6 effective in select patients, but may C Option ++++
defects
have higher rates of failure than other
locations.
88 2021 (Volume 1) Pages: 78-91 Rhinorrhea (CSF)

Spontaneous CSF rhinorrhea

The relationship between
There is a direct relationship
idiopathic intracranial B
between spontaneous CSF leaks
7 hypertension (IIH) Recommendation ++++
and IIH; most spontaneous leaks
and spontaneous CSF
represent a variant of IIH.
rhinorrhea.
After clinical examination, B2- ++

Confirmation of leak by transferrin and beta trace protein
8 NR Recommendation
Lab testing. are the initial preferred methods
of detection of CSF leaks.
The chronological order of the

investigations is:
-High resolution CT (HRCT), (non

invasive).
++++
9 Site of leak localization. NR
-Magnetic resonance imaging
Recommendation
(MRI) (Non invasive).
-CT cysternography with

intrathecal dye injection (Invasive)
if the above measures failed.
Perioperative lumbar drains are
Recommendation
not necessary for the successful
Role of perioperative ICP repair of most spontaneous CSF against except
management with lumbar leaks. Lumbar drains remain an in high risk cases
10 drains. B (option given the ++++
option for adjunctive measures
preponderance
such as administration of
of benefit over
intrathecal fluorescein or high-risk
harm).
cases.
Postoperative ICP management
should be considered in patients
Recommendation
with spontaneous CSF leaks and
for acetazolamide
elevated ICPs. Acetazolamide
with option for VP
Role of postoperative can be used as an effective C
shunt given the
11 ICP management with ICP-lowering medication with +++
preponderance of
acetazolamide or shunting. an option of CSF shunting
benefit over harm.
procedures in patients unable to
tolerate medical management or
with recalcitrantly elevated ICPs
or recurrent CSF leaks.
Reconstructive technique should
Technique of D
be left to the discretion of the No recommenda-
12 reconstruction and ++++
surgeon with consideration of tion
reconstruction materials.
defect location, size and etiology.
Intrathecal application is an
off-label use of fluorescein for
+++
which informed consent must
be obtained from the patient. Option
Recommendations are to inject
13 Intrathecal fluorescin. NR (Benefit is high
0.05 to maximally 0.1 ml per and risk is
10 kg body weight; in no case minimal according
however, more than 1.0 ml, not to most studies).
even in a massively overweight
patient must be applied.

The aggregate grade of evidence in the original guidelines was determined according to the following table: (based upon the guidelines from
the American Academy of Pediatrics Steering Committee on Quality Improvement and Managements (AAP SCQIM).7,8
Grade Research quality
A Well-designed randomized controlled trials

B Randomized controlled trials with minor limitations; overwhelming consistent evidence from observational studies
C Observational studies (case control and cohort design)
D Expert opinion; case report; reasoning from first principles
The following is an algorithm summarizing the statements
90 2021 (Volume 1) Pages: 78-91 Rhinorrhea (CSF)

References leaks. Am J Rhinol Allergy. 2017;31(6):48-56.
1. Psaltis A, Schlosser R, Banks C, et al. A Systematic 5. Sumaily I. Current Approach to Cerebrospinal

Review of the Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: Diagnosis and Management. J
Fluid Leaks. Otolaryngology-Head and Neck Surgery. Otolaryngol ENT Res: 2017;7(1):00191.
2012;147(2): 96–203.
6. Lund V, Stamberger H, NicolaI P, et al. European
2. Bedrosian J, Anand V, Schwartz T. The Endoscopic Position Paper on Endoscopic Management of
Endonasal Approach to Repair of Iatrogenic and Tumours of the Nose, Paranasal Sinuses and Skull
Noniatrogenic Cerebrospinal Fluid Leaks and Base. Rhinology, 2019: supplement 22.
Encephaloceles of the Anterior Cranial Fossa. World
Neurosurgery. 2014;82[6S]:S86-S94. 7. Wang E, Zanation A, Gardner P, et al. ICAR:
endoscopic skull-base surgery. International Forum
3. Sharma S, Kumar G, Bal J, et al. Endoscopic repair of Allergy & Rhinology. 2019;9(S3).
of cerebrospinal fluid rhinorrhoea. European Annals
of Otorhinolaryngology, Head and Neck diseases. 8. American Academy of Pediatrics Steering Committee
2016;133(3):187-90. on Quality Improvement and Management.
Classifying recommendations for clinical practice
4. Konuthula N, Khan M, Del Signore A, et al. A guidelines. Pediatrics. 2004;114:874-877.
systematic review of secondary cerebrospinal fluid

Chapter 3
Head and Neck
Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG Chapter 3: H & N
Early & Late Laryngeal Cancer: Adapted Egyptian Clinical Practice

Guidlines

Head and Neck Chief Manager: Mahmoud Abdelaziz6
Assembly Board: Mahmoud Abdelaziz,6 Islam Farid Abu Shady,9 Mahmoud El Bestar,1 Ahmad El Naggar,6 Mohamed El Rubaie,6 Yaser
Abdel Wahab Khalil,2 Abdelwahab Mohamed5
Ahmad Abdel Fattah,5 Ahmad Aboul Wafa,10 Ahmad Salama Abdelmeguid,5 Hazem M. Abdeltawab,1 Sherif Askar,11 Ahmad M. Elbatawi,1
Ahmed Ali Eldegwi,16 Ahmed S. Elhamshary,6 Mohamed Eltabbakh,12 Abdel Rahman Eltahhan,12 Ahmad Eltelety,1 Khaled Gamal,13
Mahmoud Hagras,1 Ibrahim Khaled,11 Elshaarawy Mousa,5 Mohammed Roushdy,10 Abdelraof Said,11 Emad Shehata,6 Mohamed Zahran14
Reviewing Board: Magid Elshennawy,1 Mohamed Elsharnouby,15 Hisham Abdel Fattah,14 Zakria Soliman16
1
Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/Minia University, 4Otorhinolaryngology Department, Faculty
of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology,
H&N Department, Faculty of Medicine/Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/
Cairo University,, 8 Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/Ain Shams University, 9Otorhinolaryngology,
Department, Faculty of Medicine/ Banha University, 10Otorhinolaryngology Department, Faculty of Medicine/ Assuit University,
11
Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 12Otorhinolaryngology Department, Faculty of Medicine/ Suez
Canal University, 13Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 14Otorhinolaryngology Department, Faculty
of Medicine/ Alxandria University, 15Otorhinolaryngology Department, Faculty of Medicine/ Menoufia University, 16Otorhinolaryngology
Department, Faculty of Medicine/ Military Medical Academy, 16Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar University.
Introduction and background and guide management, and promote judicious use of the
surgical and non-surgical management options available.
Laryngeal carcinoma is the most common site of malignancy
in the head and neck worldwide. The effects of the disease Methods
process and the treatment can have significant impact
on voice and swallow function and quality of life. Recent The adaptation cycle passed over: set up phase, adaptation
advances in the surgical and non-surgical management phase (Search and screen, assessment: Currency, Content
options are available. and Quality and Decisions/selection) and finalization phase
that include revision.
Scope and purpose
Results
The purpose of this guideline is to identify quality
improvement opportunities in assessment, diagnosis and Three guidelines were assessed by 7 experts Laryngologists
management of laryngeal cancer and to create explicit and the National Comprehensive Cancer Network (NCCN)
and actionable recommendations to implement these 2018 had the highest scores as regards to the currency,
opportunities in clinical practice. Specifically, the goals are contents and quality. It was graded GRADE by 19 expert
to improve diagnostic accuracy for laryngeal cancer, promote Laryngologists and reviewed by 4 expert reviewers.
Aggregate Grades of Evidence by original adopted guideline

Grade CEBM Level
A 1 Systematic reviewb of randomized trials

B 2 Randomized trials or observational studies
with dramatic effects or highly consistent
evidence
C 3-4 Nonrandomized or historically controlled
studies, including case-control and observa-
tional studies
D 5 Case reports, mechanism-based reasoning,
or reasoning from first principles
Aggregate Grades of Evidence by Question Type.a

Abbreviation: CEBM, Centre for Evidence-Based Medicine (Oxford).
a
Adapted from Howick and coworkers.
b
A systematic review may be downgraded to level B because of study limitations, heterogeneity, or imprecision.
92 2021 (Volume 1) Pages: 92-97 Laryngeal cancer

Chapter 3: H & N Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG
Categories of Evidence and Consensus according uniform NCCN consensus that the intervention is appropriate.
original adopted guideline
Category 2B: Based upon lower-level evidence, there is
Category 1: Based upon high-level evidence, there is NCCN consensus that the intervention is appropriate.
uniform National Comprehensive Cancer Network (NCCN)
consensus that the intervention is appropriate. Category 3: Based upon any level of evidence, there is major
NCCN disagreement that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is
Grade Definition
High
++++
++ effect.
+ of effect

Accepted statements
Modified statements
Added statements
Laryngeal Cancer guidelines statements
The larynx is divided into 3 regions: supraglottic, glottic,
and subglottic. The distribution of cancers is as follows:
1.Definition and 30% to 35% in the supraglottic region, 60% to 65% in
B 2A ++++
incidence the glottic region, and 5% in the subglottic region. The
incidence and pattern of metastatic spread to regional
nodes vary with the primary region.
More than 50% of patients with supraglottic primaries
present with spread to regional nodes because of an
abundant lymphatic network that crosses the midline.
Bilateral adenopathy is not uncommon with early-stage
supraglottic primaries. Thus, supraglottic cancer is often
locally advanced at diagnosis. In contrast, the lymphatic
2.Nodal metastasis B 2A ++++
drainage of the glottic is sparse and early-stage
primaries rarely spread to regional nodes. Because
hoarseness is an early symptom, most glottic cancer
is early stage at diagnosis. Thus, glottic cancer has an
excellent cure rate of 80% to 90%. Nodal involvement
adversely affects survival rates.
Multidisciplinary consultation is critical for laryngeal
3.Multidisciplinary cancer management because of the potential for loss
A 1 ++++
consultation of speech and, in some instances, for swallowing
dysfunction.
For patients with carcinoma in situ of the larynx,

recommended treatment options include: 1) endoscopic
4.CIS B 2A +++
removal (ie, stripping, laser), which is preferred; or 2) RT.
Meticulous follow-up is then mandatory.
Laryngeal cancer 2021 (Volume 1) Pages: 92-97 93

For early-stage glottic or supraglottic cancer, surgery or
RT have similar effectiveness, the choice of treatment
modality depends on anticipated functional outcome,
the patient’s wishes, reliability of follow-up, and general
medical condition. Transoral surgery (eg laser), offers a B 2A ++++
valid effective treatment option in selected cases.
Open partial laryngectomy as VPL and supraglottic

laryngectomy, are valid options in selected cases.
5.Early laryngeal
cancer Adjuvant treatment depends on the presence (or
absence) of adverse features. Adjuvant treatment for
selected patients with T1-2, N0 supraglottic cancer may
include re-resection if there are positive margins. For
selected patients with T1-3, N+ supraglottic disease, A 1 +++
re- resection may be attempted if negative margins are
feasible and can be achieved without total laryngectomy,
and if re-resection has the potential to change the
indication for adjuvant systemic therapy/RT.
Resectable, advanced-stage glottic and supraglottic
primaries are usually managed with a combined
modality approach. If treated with primary surgery, total
laryngectomy is usually indicated, although selected
B 2A ++++
cases can be managed with conservation surgical
techniques that preserve vocal function as supracricoid
laryngectomy. Pulmonary function tests should be
considered before surgery.
If total laryngectomy is indicated but laryngeal
preservation is desired, concurrent systemic therapy/
RT is recommended. When using systemic therapy/
RT, high-dose cisplatin is preferred (at 100 mg/m2 A 1 ++++
on days 1, 22, and 43). Induction chemotherapy with
management based on response is an option for all but
T1-2, N0 glottic cancer.
Definitive RT (without systemic therapy) is an option
for patients with T3, N0-1 disease who are medically
unfit or refuse systemic therapy. Surgery is reserved
for managing the neck as indicated, for those patients B 2A +++
whose disease persists after systemic therapy/RT or RT,
or for those patients who develop a subsequent loco
6.Late laryngeal regional recurrence.
cancer
Management of locally advanced, resectable glottic
and supraglottic cancers (in which total laryngectomy
is indicated but laryngeal preservation is desired) with 1
concurrent cisplatin and radiation .Concurrent RT and A +++
systemic therapy (eg, cisplatin 100 mg/m2 preferred)
is the recommended option for achieving laryngeal
preservation with Long-term follow-up (10 years).
For patients with glottic and supraglottic T4a tumors,

the recommended treatment approach is total
laryngectomy with thyroidectomy and neck dissection
A 2A ++++
as indicated (depending on node involvement) followed
by adjuvant treatment (RT, or systemic therapy/RT may
be considered).
For patients with glottic T4a laryngeal cancer,

postoperative observation is an option for highly
selected patients with good-risk features (eg, indolent
2A
histopathology). For selected patients with T4a tumors
B +++
who decline surgery, the NCCN Panel recommends:
1) considering concurrent chemoradiation; 2) clinical
trials; or 3) induction chemotherapy with additional
management based on response.

Follow-up examinations in patients treated from
laryngeal caner may need to be supplemented with
serial endoscopy or high-resolution, advanced radiologic
7.Follow up B 2A ++++
imaging techniques because of the scarring, edema,
and fibrosis that occur in the laryngeal tissues and neck
after high-dose radiation.


References term results of RTOG 91-11: a comparison of three

nonsurgical treatment strategies to preserve the
1. ZouhairA, AzriaD, CouckeP, et al. Decreased local larynx in patients with locally advanced larynx cancer.
control following radiation therapy alone in early- J Clin Oncol. 2013;31:845-852. Available at: http://
stage glotticcarcinoma with anterior commissure www.ncbi.nlm.nih.gov/pubmed/23182993.
extension. StrahlentherOnkol. 2004;180:84-
90. Available at: http://www.ncbi.nlm.nih.gov/ 7. Warner L, ChudasamaJ, Kelly CG, et al. Radiotherapy
pubmed/14762660. versus open surgery versus endolaryngealsurgery
(with or without laser) for early laryngeal squamous
2. Silver CE, BeitlerJJ, ShahaAR, et al. Current trends in cell cancer. Cochrane Database Syst Rev 2014:
initial management of laryngeal cancer: the declining Cd002027. Available at: https://www.ncbi.nlm.nih.
use of open surgery. Eur Arch Otorhinolaryngol 2009; gov/pubmed/25503538.
266:1333-1352. Available at: http://www.ncbi.nlm.
nih.gov/pubmed/19597837. 8. YooJ, LacchettiC, Hammond JA, et al. Role of
endolaryngealsurgery (with or without laser) versus
3. RodelRM, Steiner W, Muller RM, et al. Endoscopic radiotherapy in the management of early (T1)
laser surgery of early glottic cancer: involvement of glotticcancer: a systematic review. Head Neck 2014;
the anterior commissure. Head Neck 2009; 31:583- 36:1807-1819. Available at: https://www.ncbi.nlm.
592. Available at: http://www.ncbi.nlm.nih.gov/ nih.gov/pubmed/24115131.
pubmed/19132720.
9. Oxford Centre for Evidence-Based Medicine, OCEBM
4. HowickJ, Chalmers I, Glasziou, OCEBM Levels of Levels of Evidence Working Group. The Oxford 2011
Evidence Working Group. The Oxford 2011 levels of levels of evidence. http://www.cebm.net/index.
evidence. http://www.cebm.net/index.aspx?o=5653. aspx?o=5653. Published 2011. Accessed June 4,
2016.
5. Cooper JS, Zhang Q, PajakTF, et al. Long-term
follow-up of the RTOG 9501/intergroup phase III 10. Colevas, A Dimitrios, Sue S Yom, et al. ‘NCCN
trial: postoperative concurrent radiation therapy and guidelines insights: head and neck cancers, version
chemotherapy in high-risk squamous cell carcinoma 1.2018’, Journal of the National Comprehensive
of the head and neck. IntJ RadiatOncolBiolPhys Cancer Network. 2018;16:479-90.
2012; 84:1198-1205. Available at: http://www.ncbi.
nlm.nih.gov/pubmed/22749632. 11. Head and Neck Cancers Version 1.2018 — February
15, 2018. National Comprehensive Cancer Network
6. ForastiereAA, Zhang Q, Weber RS, et al. Long- (NCCN). NCCN.org.

Tonsillectomy: Adapted Egyptian Clinical Practice Guidlines

Assembly Board: Mohamed Elsalmawy,1 Mohamed Ekram,9 Tamer Azzam,10 Heba Abdel Rahem abo Elnaga,2 Mostafa Ammar,6
Islam farid Abu shady12
Ahmed Abdel Fattah,11 Hazem Abdel Tawab,1 Heba Abdel Rahem Abo Elnaga,2 Sherif Askar,13 Khaled Dahy,14 Ahmed M. El Batawi,1
Ahmed El Naggar,6 Ahmad Eltelety,1 Ibrahim Khaled,13 Yaser Khalil,2 Mohammed Roushdy,9 Emad Shehata,6 Mohamed Zahran15
Reviewers team: Ali Tawfik,5 Mohamed Hegazy,1 Abdellatif Elrashidy2
1
Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 4Otorhinolaryngology Department Faculty
Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Otorhinolaryngology,
Department, Faculty of Medicine/ Assuit University, 10Otorhinolaryngology Department, Faculty of Medicine/ Police Academy,
11
Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar University, 12Otorhinolaryngology Department, Faculty of Medicine/
Banha University, 13Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 14Otorhinolaryngology Department.
Faculty of Medicine/ Sohag University, 15Otorhinolaryngology Department, Faculty of Medicine/ Alxandria University.
Introduction and background To identify “watchful waiting policy” for recurrent throat
infection and when to offer tonsillectomy for recurrent throat
Adenotonsillectomy is the treatment of choice for otherwise infection with documentation and promote judicious use of
healthy children with obstructive sleep apnoea, with systemic antibiotic and analgesia after tonsillectomy.
improvement in 90% cases, including improvement in their
behaviour, growth and development. Methods
Tonsillectomy is one of the most commonly practiced The adaptation cycle passed over: set up phase, adaptation
operations in the field of otolaryngology and mostly it is phase (Search and screen, assessment: Currency, Content
offered for recurrent throat infection. For a long time, the and Quality and Decisions/selection) and finalization phase
only trial of value was that done by Paradise published in that include revision.
1984 and it is widely known and still used.
Results
Scope and purpose
Five guidelines were assessed by 6 experts Otolaryngologists
The purpose of this guideline is to identify quality and the International Consensus on Tonsillectomy 2021 had
improvement opportunities in the practice of tonsillectomy the highest scores as regards to the currency, contents and
and to create explicit and actionable recommendations in the quality. It was graded GRADE by 13 expert Otolaryngologists
clinical practice. and reviewed by 3 expert reviewers.
Aggregate Grades of Evidence by original adopted guidline

Grade CEBM Level
A 1 Systematic reviewb of randomized trials
Randomized trials or observational studies
B 2 with dramatic effects or highly consistent
evidence
Nonrandomized or historically controlled
C 3-4 studies, including case-control and
observational studies
Case reports, mechanism-based reasoning,
D 5
or reasoning from first principles
Aggregate Grades of Evidence by Question Type.a

Abbreviation: CEBM, Centre for Evidence-Based Medicine (Oxford).
a
Adapted from Howick and coworkers.
b
A systematic review may be downgraded to level B because of study limitations, heterogeneity, or imprecision.
98 2021 (Volume 1) Pages: 98-103 Guidlines for tonsillectomy in children

Original adopted guideline definitions for Evidence-Based Statements

Strength Definition Implied Obligation
A strong recommendation means that the benefits of
the recommended approach clearly exceed the harms
(or, in the case of a strong negative recommendation,
that the harms clearly exceed the benefits) and that Clinicians should follow a strong
the quality of the supporting evidence is high (grade recommendation unless a clear and
A or B).a In some clearly identified circumstances, compelling rationale for an alternative
strong recommendations may be based on lesser approach is present.
evidence when high-quality evidence is impossible to
obtain and the anticipated benefits strongly outweigh
the harms.
A recommendation means that the benefits exceed the
harms (or, in the case of a negative recommendation,
that the harms exceed the benefits) but the quality Clinicians should also generally follow
of evidence is not as high (grade B or C).a In some a, recommendation but should remain
Recommendation
clearly identified circumstances, recommendations alert to new information and sensitive to
may be based on lesser evidence when high-quality patient preferences.
evidence is impossible to obtain and the anticipated
benefits outweigh the harms.
Clinicians should be flexible in their
An option means that either the quality of evidence
decision making regarding appropriate
is suspect (grade D)a or well-done studies (grade A,
Option practice, although they may set bounds
B, or C)a show little clear advantage to one approach
on alternative patient preference should
versus another.
have a substantial influencing role.
American Academy of Pediatrics’ classification scheme.

a
Grade Definition
High
++++
Low
++
+ of effect

Accepted statements
Modified statements
Added statements
Guidlines for tonsillectomy in children 2021 (Volume 1) Pages: 98-103 99

Tonsillectomy guidelines statements
Clinicians should recommend watchful waiting for
1.Watchful waiting recurrent throat infection if there have been ≥7
for recurrent throat episodes in the past year,≥5 episodes per year in the A Strong recommendation ++++
infection past 2 years, or≥3 episodes per year in the past 3
years.
Clinicians may recommend tonsillectomy for recurrent
throat infection with a frequency of at least 7 episodes
in the past year, at least 5 episodes per year for 2
years, or at least 3 episodes per year for 3 years with
documentation in the medical record for each episode
2.Recurrent throat
of sore throat and ≥1 of the following: temperature
infection with B Option ++++
>38.3C (101F), cervical adenopathy, tonsillar
documentation
exudate, or positive test for group A beta-hemolytic
streptococcus.
Documentation should be clear from a specialist/

family physician that tonsillitis is the cause of fever.
Clinicians should assess the child with recurrent

throat infection who does not meet criteria in Key
Action Statement 2 for modifying factors that may
3.Tonsillectomy for
nonetheless favor tonsillectomy, which may include
recurrent infection A Recommendation +++
but are not limited to: multiple antibiotic allergies/
with modifying factors
intolerance, PFAPA (periodic fever, aphthous
stomatitis, pharyngitis, and adenitis) or history of ≥1
peritonsillar abscess.
Clinicians should ask caregivers of children with

obstructive sleep disordered breathing (oSDB) and
4.Tonsillectomy for
tonsillar hypertrophy about comorbid conditions that
obstructive sleep- B Recommendation ++++
may improve after tonsillectomy, including growth
disordered breathing
retardation, poor school performance, enuresis,
asthma, and behavioral problems.
Before performing tonsillectomy, the clinician should

refer children with obstructive sleep-disordered
breathing (oSDB) for polysomnography (PSG) if
5.Indications for
they are <2 years of age or if they exhibit any of B Recommendation +++
polysomnography
the following: obesity, Down syndrome, craniofacial
abnormalities, neuromuscular disorders, sickle cell B
disease, or mucopolysaccharidoses.
for polysomnography The clinician should advocate

for polysomnography (PSG) prior to tonsillectomy
for obstructive sleep-disordered breathing (oSDB)
in children without any of the comorbidities listed
in Key Action Statement 5 for whom the need for
tonsillectomy is uncertain or when there is discordance
between the physical examination and the reported
severity of oSDB.
6.Additional Although PSG is considered the gold standard for the
recommendations for B Recommendation +++
diagnosis of OSAS, it is expensive, labor intensive
olysomnography and not widely available in low and middle-income
countries. Simple‚ accessible and affordable OSAS
diagnostic tools are needed in resource-constrained
settings. Overnight oximetry is a widely accepted
and validated objective screening tool for diagnosing
OSAS, especially in more severe cases of OSAS. The
McGill Oximetry Score is widely used for grading OSAS
severity in children and has been validated against
PSG.
7.Tonsillectomy for Clinicians should recommend tonsillectomy for children
obstructive sleep with obstructive sleep apnea (OSA) documented by B Recommendation ++++
apnea overnight polysomnography (PSG).

Clinicians should counsel patients and caregivers and

8.Education regarding
explain that obstructive sleep-disordered breathing
persistent or recurrent B Recommendation +++
(oSDB) may persist or recur after tonsillectomy and
obstructive
may require further management.
The clinician should counsel patients and caregivers

regarding the importance of managing post
tonsillectomy pain as part of the perioperative
9.Perioperative pain
education process and should reinforce this counseling B Recommendation ++++
counseling
at the time of surgery with reminders about the need
to anticipate, reassess, and adequately treat pain
after surgery.
Strong
10.Perioperative Clinicians should not administer or prescribe Recommendation
antibiotics perioperative antibiotics to children undergoing A against ++
tonsillectomy.
Clinicians should administer a single intraoperative

11.Intraoperative Strong
dose of intravenous dexamethasone to children A ++++
steroids Recommendation
undergoing tonsillectomy.
Clinicians should arrange for overnight, inpatient

12.Inpatient
monitoring of children after tonsillectomy if they are
monitoring for
<3 years old or have severe obstructive sleep apnea B Recommendation ++++
children after
(OSA; apnea-hypopnea index [AHI] ≥ 10 obstructive
tonsillectomy
events/hour, oxygen saturation nadir <80%, or both).
13.Postoperative Clinicians should recommend ibuprofen,

Strong
ibuprofen and acetaminophen, or both for pain control after A ++++
Recommendation
acetaminophen tonsillectomy.
Clinicians must not administer or prescribe codeine, or Strong
14. Postoperative
any medication containing codeine, after tonsillectomy B Recommendation ++++
codeine
in children younger than 12 years. against
Clinicians should follow up with patients and/or
caregivers after tonsillectomy and document in the
medical record the presence or absence of bleeding
within 24 hours of surgery (primary bleeding) and
15a.Outcome bleeding occurring later than 24 hours after surgery
assessment for (secondary bleeding). C Recommendation ++++
bleeding
All patients with post tonsillectomy bleeding must be
admitted to hospital with monitoring of vital signs and
antibleeding measures and return to the operation
room if indicated.
Clinicians should determine their rate of primary

15b.Posttonsillectomy
and secondary post tonsillectomy bleeding at least C Recommendation ++++
bleeding rate
annually.


References OtorhinolaryngolRelatSpec. 2007;69:345-348.
1. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy 6. HowickJ, Chalmers I, Glasziou, OCEBM Levels of
for treatment of obstructive sleep apnoea in children. Evidence Working Group. The Oxford 2011 levels of
Arch Otolaryngol Head Neck Surg. 1995;121:525–30. evidence. http://www.cebm.net/index.aspx?o=5653.
2. Paradise JL, Bluestone CD, Colborn DK, et al. 7. Dhiwakar M, Clement WA, Supriya M, et al. antibiotics
Tonsillectomy and adenotonsillectomy for recurrent to reduce post-tonsillectomy morbidity. Cochrane
throat infections in moderately affected children. Database SystRev. 2012;(12):CD005607.
Pediatrics. 2002;110:7–15.
8. Sutters KA, Isaacson G. Posttonsillectomypain in
3. Erler I, Paditz E. Obstructive sleep apnea syndrome children. Am J Nurs. 2014;114:36-42.
in children: a state-of-the-art review. Treat Respir
Med. 2004;3:107–22. 9. Oxford Centre for Evidence-Based Medicine, OCEBM
Levels of Evidence Working Group. The Oxford 2011
4. AAP Steering Committee on Quality Improvement levels of evidence. http://www.cebm.net/index.
and Management. Policy statement: classifying aspx?o=5653. Published 2011. Accessed June 4,
recommendations for clinical practice guidelines. 2016.
Pediatrics. 2004;114:874-877.
10. Otolaryngology– Head and Neck Surgery 2019,
5. Mitchell RB, Kelly J. Outcomes and quality of Vol. 160 (1S) S1–S42 American Academy of
life following adenotonsillectomyfor sleep- Otolaryngology–Head and Neck Surgery Foundation
disordered breathing in children. ORL J 2018.

Thyroid Nodules: Adapted Egyptian Clinical Practice Guidelines

Assembly Board: Ahmad Eltelety,1 Ahmed Musaad Abd Elfattah,5 Ahmed S. Elhamshary,6 Mostafa Ammar6
Hazem M. Abdel Tawwab,1 Mahmoud Abdelaziz,6 Ahmed Abdel Fattah,9 Heba Abdel Rahem Abo Elnaga,2 Eslam Farid Abu Shady,10
Sherif Mohammad Askar,11 Khaled Dahy,12 Ahmed Mahmoud El Batawi,1 Ahmed El Naggar,6 Ibrahim Ahmed Khaled,11 Mohamed Abdel
Hakeem Khalifa,2 Yaser Khalil,10 Mohammed Mahmoud Roushdy,13 Emad Shehata,6 Mohamed Zahran14
Reviewing Board: Mohamed Naser ElSheikh,6 Mohamed Salah Hassouna,1 Mahmoud Fawzy Elbestar,1 Mohamed Mosleh1
1
Department, Faculty of Medicine/ Al Azhar University, 10Otorhinolaryngology Department, Faculty of Medicine/ Banha University,
11
Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 12Otorhinolaryngology Department, Faculty of Medicine/
Sohag University, 13Otorhinolaryngology Department, Faculty of Medicine/ Assuit University, 14Otorhinolaryngology Department, Faculty
of Medicine/ Alexandria University.
Thyroid nodules are frequently encountered during routine The adaptation cycle passed over: set up phase, adaptation
clinical practice. Numerous endocrine organizations have set phase (Search and screen, assessment: Currency, Content
clinical practice guidelines (CPG) in a trial to optimize the and Quality and Decisions/selection) and finalization phase
outcome of treating such disease while reducing morbidity that include revision.
and mortality. Clinical decision making differs from nation-
to-nation based on the policy makers perspectives on the Results
feasible assets and the legal arrangements.
Seven guidelines were assessed by four expert endocrine
Scope and purpose surgeons and the 2015 American Thyroid Association
Management Guidelines for Adult Patients with Thyroid
The purpose of this guideline is to provide evidence-based Nodules and Differentiated Thyroid Cancer had the highest
peer reviewed guidance to physicians involved with the care scores as regards to the currency, contents, and quality. It was
of patients with thyroid nodules. A guidance that is adapted graded by The Grading of Recommendations Assessment,
to the Egyptian practice regulations and meets the available Development and Evaluation (GRADE) approach to Decision
resources. frameworks (GRADE Working Group 2013) by 15 expert head
and neck surgeons and reviewed by 4 expert reviewers.
Table 1: The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision
frameworks (GRADE Working Group 2013)
Grade Definition
High
++++
++ effect.
+ of effect
Table 2: Recommendations statements

Accepted statements
Modified statements
Added statements
104 2021 (Volume 1) Pages: 104-111 Egyptian Guidelines on Thyroid Nodules

Table 3: Interpretation of The American College of Physicians’ Guideline Grading System (For the therapeutic interventions)
Table 4: Recommendations (for therapeutic interventions) based on strength of evidence
Egyptian Guidelines on Thyroid Nodules 2021 (Volume 1) Pages: 104-111 105

Table 5: Adapted/Adopted recommendations
Strength of
Grading after
Level of recommendation
Statement topic Action recommendation adaptation/
adoption
selected CPGs
Serum thyrotropin (TSH) should be measured during
Moderate Strong ++++
the initial evaluation of a patient with a thyroid nodule.
If the serum TSH is subnormal, a radionuclide
(preferably 123I) thyroid scan should be performed.
If the serum TSH is normal or elevated, a radionuclide
scan should not be performed as the initial imaging Moderate Strong ++++
evaluation.
Routine measurement of serum thyroglobulin (Tg) for

initial evaluation of thyroid nodules is not recommended.
The panel cannot recommend either for or against

Insufficient No
routine measurement of serum calcitonin in patients ++++
evidence Recommendation
with thyroid nodules.
Focal [18F]fluorodeoxyglucose positron emission

tomography (18FDG-PET) uptake within a
sonographically confirmed thyroid nodule conveys Moderate Strong ++++
an increased risk of thyroid cancer, and FNA is
recommended for those nodules =/> 1 cm.
Diffuse 18FDG-PET uptake, in conjunction with
The appropriate
sonographic and clinical evidence of chronic
laboratory Moderate strong ++++
lymphocytic thyroiditis, does not require further
and imaging
imaging of FNA.
evaluation for
patients with Thyroid sonography with survey of cervical lymph
clinically or nodes should be performed in all patients with known
incidentally or suspected thyroid nodules.
discovered thyroid
nodules Nodules should be classified according to the following
suspicion classification pattern:
High suspicion: Solid hypoechoic nodule or solid N/A N/A ++++

hypoechoic component of a partially cystic nodule with
one or more of the following features: irregular margins
(infiltrative, microlobulated), microcalcifications, taller
than wide shape, rim calcifications with small extrusive
soft tissue component, evidence of extrathyroid
extension (ETE).
Intermediate suspicion: hypoechoic solid nodule with

smooth margins without microcalcifications, ETE, or N/A N/A ++++
taller than wide shape.
Low suspicion: isoechoic or hyperechoic solid nodule,
or partially cystic nodule with eccentric solid areas,
N/A N/A ++++
without microcalcifications, irregular margins or ETE, or
taller than wide shape.
Very low suspicion: spongiform or partially cystic
nodules without any of the sonographic features
N/A N/A ++++
described in low, intermediate, or high suspicion
patterns.
Benign: purely cystic nodules (no solid component). N/A N/A ++++

Strength of Grading
Level of recommendation after
evidence according to the adaptation/
selected CPGs adoption
Ultrasonography
(US) for fine-needle FNA is the procedure of choice in the evaluation of thyroid
High Strong ++++
aspiration (FNA) nodules, when clinically indicated.
decision- making
Thyroid nodule diagnostic FNA is recommended for: Nodules
=/> 1 cm in greatest dimension with high suspicion sonographic Moderate Strong ++++
pattern.
Nodules =/> 1 cm in greatest dimension with intermediate
Low Strong ++++
suspicion sonographic pattern.
Nodules =/> 1.5 cm in greatest dimension with low suspicion
Recommendations Low Weak ++++
sonographic pattern.
for diagnostic FNA
of a thyroid nodule Thyroid nodule diagnostic FNA is not required for: Nodules that
based on sonographic Moderate Strong ++++
do not meet the above criteria.
pattern
Nodules that are purely cystic. Moderate Strong ++++
Nodules =/> 2 cm in greatest dimension with very low suspicion

sonographic pattern (spongiform). Observation without FNA is
N/A N/A ++++
the preferred option, while FNA should be considered only if
suspicious sonographic features develop.
Suspicious sonographic features develop. Thyroid nodule

FNA cytology should be reported using the diagnostic groups
outlined in the Bethesda System for Reporting Thyroid
cytopathology.
For a nodule with an initial nondiagnostic cytology result, FNA
should be repeated with US guidance and, if available, on-site Moderate Strong ++++
cytologic evaluation.
Repeatedly nondiagnostic nodules without a high suspicion
sonographic pattern require close observation or surgical Low Weak +++
excision for histopathologic diagnosis.
Surgery should be considered for histopathologic diagnosis if
the cytologically nondiagnostic nodule has a high suspicion
sonographic pattern, growth of the nodule (>20% in two Low Weak ++++
dimensions) is detected during US surveillance, or clinical risk
Role of FNA cytolo-
factors for malignancy are present.
gy interpretation in
patients with thyroid If the nodule is benign on cytology, further immediate
nodules High Strong ++++
diagnostic studies or treatment are not required.
If a cytology result is diagnostic for primary thyroid malignancy,

surgery is generally recommended.
For nodules with AUS/FLUS cytology, after consideration of
worrisome clinical and sonographic features, investigations
such as repeat FNA may be used to supplement malignancy
risk assessment in lieu of proceeding directly with a strategy N/A N/A +++
of either surveillance or diagnostic surgery. Informed patient
preference and feasibility should be considered in clinical de-
cision-making.
If repeat FNA cytology is not performed or inconclusive, either
surveillance or diagnostic surgical excision may be performed
N/A N/A +++
for an AUS/FLUS thyroid nodule, depending on clinical risk fac-
tors, sonographic pattern and patient preference.
Diagnostic surgical excision is the long-established standard of
care for the management of FN/SFN cytology nodules. Clini-
N/A N/A +++
cal and sonographic features, informed patient preference and
feasibility should be considered in clinical decision-making.
If the cytology is reported as suspicious for papillary carcinoma
(SUSP), surgical management should be similar to that of ma-
N/A N/A +++
lignant cytology, depending on clinical risk factors, sonographic
features and patient preference.
FDG-PET is not routinely recommended for the evaluation of
Moderate Weak ++++
thyroid nodules with indeterminate cytology.

Strength of Grading
When surgery is considered for patients with a solitary, cyto-
logically indeterminate nodule, thyroid lobectomy is the rec-
ommended initial surgical approach. This approach may be N/A N/A ++++
modified based on clinical or sonographic characteristics and/
or patient preference.
Because of increased risk for malignancy, total thyroidectomy
may be preferred in patients with indeterminate nodules that
are cytologically suspicious for malignancy, sonographically
suspicious, or large (>4cm), or in patients with familial thyroid Moderate Strong ++++
carcinoma or history of radiation exposure, if completion thy-
roidectomy would be recommended based on the indetermi-
nate nodule being malignant following lobectomy.
Patients with indeterminate nodules who have bilateral nod-
ular disease, those with significant medical comorbidities, or
those who prefer to undergo bilateral thyroidectomy to avoid
the possibility of requiring a future surgery on the contralateral Low Weak ++++
lobe, may undergo total or near-total thyroidectomy, assuming
completion thyroidectomy would be recommended if the inde-
terminate nodule proved malignant following lobectomy.
Patients with multiple thyroid nodules =/> 1 cm should be
evaluated in the same fashion as patients with a solitary nodule
=/> 1 cm, excepting that each nodule that is >1cm carries an Moderate Strong ++++
independent risk of malignancy and therefore multiple nodules
may require FNA.
When multiple nodules =/> 1 cm are present, FNA should be
performed preferentially based upon nodule sonographic pat- Moderate Strong ++++
tern and respective size cutoff.
If none of the nodules has a high or moderate suspicion sono-
graphic pattern, and multiple sonographically similar very low
or low suspicion pattern nodules coalesce with no intervening
Low Weak ++++
Appropriate normal parenchyma, the likelihood of malignancy is low and
operation for it is reasonable to aspirate the largest nodule (=/>2 cm) or
cytologically continue surveillance without FNA.
indeterminate thyroid
A low or low-normal serum TSH concentration in patients with
nodules
multiple nodules may suggest that some nodule(S) may be
autonomous. In such cases, a radionuclide (preferably 123I)
thyroid scan should be considered and directly compared
to the US images to determine functionality of each nodule Low Weak ++
=/> 1cm. FNA should then be considered only for those
isofunctioning or nonfunctioning nodules, among which those
with high suspicion sonographic pattern should be aspirated
preferentially.
Given the low false-negative rate of US-guided FNA cytology
and the higher yield of missed malignancies based upon
nodule sonographic pattern rather than growth, the follow-up
of thyroid nodules with benign cytology diagnoses should be Moderate Strong ++++
determined by risk stratification based upon US pattern.
Nodules with high suspicion US pattern: repeat US and US-

guided FNA within 12 months.
Nodules with low to intermediate suspicion US pattern: repeat
SU at 12-24 months. If sonographic evidence of growth (20%
increase in at least two nodule dimensions with a minimal
increase of 2 mm or more than a 50% change in volume) or Low Weak ++++
development of new suspicious sonographic features, the FNA
could be repeated or observation continued with repeat US,
with repeat FNA in case of continued growth.
Nodules with very low suspicion US pattern (including
spongiform nodules): the utility or surveillance US and
assessment of nodule growth as an indicator for repeat FNA Low Weak +++
to detect a missed malignancy is limited. If US is repeated, it
should be done at > 24 months.
If a nodule has undergone repeat US-guided FNA with a
second benign cytology result, US surveillance for this nodule Moderate Strong ++++
for continued risk of malignancy is no longer indicated.

Strength of Grading
Routine TSH suppression therapy for benign thyroid nodules in
iodine sufficient populations is not recommended.
High Strong ++++
Though modest responses to therapy can be detected, the
potential harm outweighs benefit for most patients.
Individual patients with benign, solid or mostly solid nodules
should have adequate iodine intake. If inadequate dietary
intake is found or suspected, a daily supplement (containing
150 g iodine) is recommended.
Surgery may be considered for growing nodules that are benign
after repeat FNA if they are large (>4cm), causing compressive Low Weak ++++
or structural symptoms, or based upon clinical concern.
Patients with growing nodules that are benign after FNA
should be regularly monitored. Most asymptomatic nodules
Low Strong ++++
demonstrating modest growth should be followed without
intervention.
Recurrent cystic thyroid nodules with benign cytology should
be considered for surgical removal or percutaneous ethanol
injection (PEI) based on compressive symptoms and cosmetic Low Weak ++++
concerns. Asymptomatic cystic nodules may be followed
conservatively.
A) FNA of clinically relevant thyroid

nodules should be performed in euthyroid and Moderate Strong ++++
hypothyroid pregnant women.
For women with suppressed serum TSH levels that persist

beyond 16 weeks gestation, FNA may be deferred until after
pregnancy and cessation of lactation. At that time, a radionuclide
N/A N/A ++++
scan can be performed to evaluate nodule function if the serum
TSH remains suppressed, however radioiodine scan should be
avoided during pregnancy and Lacation.
PTC discovered by cytology in early pregnancy should be
monitored sonographically. If it grows substantially before
24-26 weeks gestation, or if US reveals cervical lymph nodes
that are suspicious for metastatic disease, surgery should be Low Weak ++++
considered during pregnancy. However, if the disease remains
stable by midgestation, or if it is diagnosed in the second half
of pregnancy, surgery may be deferred until after delivery.

Fig 1: Algorithm of adapted ECPGs for management of thyroid nodules. TSH: Thyroid stimulating hormone; FNA: Fine needle aspiration; AUS/
FLUS: Atypia of undetermined significance or follicular lesion of undetermined significance; FN/FSN: Follicular neoplasm or suspicious for a
follicular neoplasm.

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and management of thyroid nodules. Head & neck. settings. Head & neck. 2020;42(8):1746-1756.

Dysphonia: Adapted Egyptian Clinical Practice Guidlines

Assembly Board: Emad Shehata,6 Mahmoud Abdelaziz,6 El Shaahrawy Kamal5
Ahmed Abdelfatah,9 Ahmed Abdelmeguid,5 Hazem Abdeltawab,1 Eslam Farid Abu Shady,10 Ahmed El-Batawi,1 Ahmed S. Elhamshary,6
Ahmed Elnaggar,6 Ahmad Eltelety,1 Khaled Gamal,11 Mohamed Rabie,12 Mohammed Roshdy,12 Ashraf Yakoot,13 Mohamed Zahran14
Reviewing Board: Maged Elshenawy,1 Medhat Heshmat,6 Ashraf Elhamshary,10 Zakria Soliman13
1
of Medicine/Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology
Department/ Al-Azhar University, 10Otorhinolaryngology Department. Faculty of Medicine/ Banha University, 11Otorhinolaryngology
Department, Faculty of Medicine/ Sohag University, 12Otorhinolaryngology Department, Faculty of Medicine/Assiut University,
13
Otorhinolaryngology Department. Faculty of Medicine/ Alexandria University, 14Otorhinolaryngology Department, Faculty of Medicine/
Military Medical Academy, 13Otorhinolaryngology Department, Faculty of Medicine/ Military Medical Academy, 14Otorhinolaryngology
Department, Faculty of Medicine/ Alexandria University.
Introduction and background practice guidelines for dysphonia and to implement

it with continuous process of development and
Dysphonia is defined as any altered vocal quality, pitch, improvement in the next editions.
loudness, or vocal effort that impairs communication as
assessed by a clinician, and/or affects quality of life as • These goals were made to improve the quality of care for
self-perceived by the patient. Dysphonia is a common our patients suffering from dysphonia based on the best
symptom for a wide variety of diseases, it is estimated that available evidence, and supported by expert consensus
at least 30% of the people experience dysphonia once per to evaluate this evidence, and finally reviewed by 4
life. Sometimes dysphonia is an early symptom of serious experts to fill the evidence gaps.
pathology (like cancer), moreover it affects much the human
ability to communicate with others. Methods
Goals The adaptation cycle passed over: setup phase, adaptation

phase (search, screen, assessment, currency, content,
• To improve the diagnostic accuracy of different causes quality, decision/ selection) and finalization phase that
of dysphonia. include revision.
• To promote early detection of cancer larynx. Results
• To diminish common malpractices usually done during Many review articles, and practice consensuses and guidelines
management of dysphonia by GBs and young ENT were assessed by 3 experts in larynx, head and neck surgery
doctors. and the last update of clinical practice guideline: Hoarseness
(Dysphonia) (2018 Update) developed by the American
• To establish the appropriate indications of surgical and Academy of Otolaryngology - Head and Neck Association
non-surgical interventions to manage dysphonia. foundation (AAO-HNSF) was the only full guideline detected
for all causes of dysphonia and had the highest scores
• To create high quality, easy applicable, cost benefit
regarding the currency, contents and quality.
System used for grading: The grading of recommendations, assessment, development and evaluation (GRADE) approach
to decision frameworks (GRADE working group 2013)
High
The graders have a lot of confidence that the true effect lies close to that of the estimated effect.
++++
Moderate The graders have a moderate confidence in the estimated effect: The true effect is likely to be close to the
+++ estimated effect, but there is a possibility that it is substantially different.
Low The graders have a limited confidence in the estimated effect: The true effect might be substantially different
++ from the estimated effect.
Very low The graders have a very little confidence in the estimated effect: The true effect is likely to be substantially
+ different from the estimated effect.
112 2021 (Volume 1) Pages: 112-115 Dysphonia

Egyptian clinical practice guidelines (CPG) Recommendations
Level of evidence Grade of strength

and level of after adaptation
Statement topic Action Recommendation
confidence in the by the national
evidence graders
Dysphonia is identified as:
any altered vocal quality, pitch,
C
1.Identification loudness, or vocal effort that
of dysphonia by impairs communication as assessed Recommendation ++++
High level of
clinician. by a clinician and/or affects quality confidence
of life as self-perceived by the
patient.
Clinicians should assess the patient
C
2.Identifying the with dysphonia by specific history
underlying cause and physical examination for Recommendation ++++
High level of
of dysphonia. underlying causes of dysphonia, and confidence
factors that modify management.
Clinicians should identify the
patient with suspected history,
and/or serious sign(s) denoting
possibility of serious condition
3.Identifying causing the dysphonia. These
the dysphonia include but are not limited to; B
as a symptom history of tobacco abuse, history
Strong Recommendation ++++
for serious of malignancy, professional voice High level of
condition (serious user, recent history of endotracheal confidence
dysphonia). intubation, surgery or trauma to
neck or head or chest, concomitant
stridor and or respiratory distress
and or aspiration and presence of
concomitant neck mass.
Clinicians should perform or refer
the patient for visualization of
B
the larynx to assess the cause
4.Escalation of
of dysphonia; immediately in Strong recommendation ++++
care High level of
suspected serious dysphonia, and confidence
after 4 weeks for non-serious
persistent dysphonia.
Clinicians may perform or refer

C
the patient for visualization of the
5.Indirect
larynx at the first visit or early at
laryngoscopy and High level of Option. +++
any time in a patient with dysphonia
dysphonia evidence but in large
regardless its cause. (suspected observational study
serious dysphonia is excluded).
Clinicians should not ask for

C
computed tomography (CT) or
6.Imaging magnetic resonance imaging (MRI) Recommendation Against ++++
High level of
for patients with dysphonia prior to confidence
visualization of the larynx.
Clinicians should not prescribe

anti-reflux medications routinely to
treat isolated dysphonia, or based
7a.Medications B
on symptoms alone suggesting
and dysphonia;
suspected gastroesophageal Recommendation Against +++
Anti-reflux Medium level of
reflux disease (GERD) or
medication confidence
laryngopharyngeal reflux (LPR),
without positive signs obtained
from the visualization of the larynx.
Clinicians should not routinely B

7b.Medications
prescribe corticosteroids for
and dysphonia; Recommendation Against ++++
patients with dysphonia prior to High level of
Corticosteroid
visualization of the larynx. confidence
A
7c.Medications Clinicians should not routinely
and dysphonia; prescribe antibiotics to treat ++++
High level of Against
Antimicrobial dysphonia. confidence
Dysphonia 2021 (Volume 1) Pages: 112-115 113

Level of evidence Grade of strength

and level of after adaptation
confidence in the by the national
evidence graders
Clinicians should advocate for
surgery as a therapeutic option
for patients with dysphonia with
conditions necessary to be biopsied
such as suspected malignancy, or
B
8.Surgical lesions amenable to improvement
interventions and by surgical intervention like; Recommendation ++++
High level of
dysphonia symptomatic benign vocal fold confidence
lesions that do not respond
to conservative management
which includes and not limited
to (cyst, polyp, or severe glottic
insufficiency).
Clinicians should advocate voice
9a.Voice therapy A
therapy for patients with dysphonia
and dysphonia;
from a cause amenable to voice Strong Recommendation ++++
(advocating for High level of
therapy like; (nodules, mild Glottic
voice therapy) confidence
insufficiency).
9b.Voice therapy C
Clinicians should perform or refer
and dysphonia;
to visualization of larynx, before Recommendation ++++
laryngoscopy prior High level of
prescribing voice therapy.
to voice therapy confidence
Clinicians should inform patients C
10.Education/ with dysphonia about control/
Recommendation ++++
prevention preventive measures (voice High level of
instructions). confidence
Clinicians should document
resolution, improvement, or C
11.Outcomes and worsened symptoms of dysphonia
Recommendation +++
follow-up or change in QOL among patients high level of
with dysphonia after treatment or confidence
observation.
114 2021 (Volume 1) Pages: 112-115 Dysphonia

References Oxford 2011 levels of evidence. http://www.cebm.

net/index.aspx?o=5653. Published 2011.
1. Zeitels SM, Casiano RR, Gardner GM, et al.
Management of common voice problems: committee 13. Shiffman RN, Michel G, Rosenfeld RM, et al. Building
report. Otolaryngol Head Neck Surg. 2002;126:333- better guidelines with BRIDGE-Wiz: development
348. and evaluation of a software assistant to promote
clarity, transparency, and Implementability. J Am Med
2. Johns MM. Update on the etiology, diagnosis, and Inform Assoc. 2012;19:94-101.
treatment of vocal fold nodules, polyps, and cysts.
Curr Opin Otolaryngol Head Neck Surg. 2003;11:456- 14. Thomas JP, Zubiaur FM. Over-diagnosis of
461. laryngopharyngeal reflux as the cause of hoarseness.
Eur Arch Otorhinolaryngol. 2013;270:995-999.
3. Sulica L, Behrman A. Management of benign vocal
fold lesions: a survey of current opinion and practice. 15. Cohen SM, Kim J, Roy N, et al. Prescribing patterns
Ann Otol Rhinol Laryngol. 2003;112:827-833. of primary care physicians and otolaryngologists in
the management of laryngeal disorders. Otolaryngol
4. Royal College of Speech and Language Therapists. Head Neck Surg. 2013;149:118-125.
Clinical voice disorders. http://almacengpc.dynalias.
org/publico/ Clinical_Guidelines%20Speech%20 16. Rosenfeld RM, Shiffman RN, Robertson P. Clinical
Therapists.pdf. Published. 2005. practice guideline development manual, third
edition: a quality-driven approach for translating
5. Rubin JS, Sataloff RT, Korovin GS. Diagnosis and evidence into action. Otolaryngol Head Neck Surg.
Treatment of Voice Disorders. 3rd ed. San Diego, CA: 2013;148(1):S1-S55.
Plural Publishing Inc. 2006.
17. Govil N, Rafii BY, Paul BC, et al. Glucocorticoids for
6. Hopkins C, Yousaf U, Pedersen M. Acid reflux vocal fold disease: a survey of otolaryngologists. J
treatment for hoarseness. Cochrane Database Syst Voice. 2014;28:82-87.
Rev. 2006;(1):CD005054.
18. Smith MM, Abrol A, Gardner GM. Assessing delays
7. Rosenthal LHS, Benninger MS, Deeb RH. Vocal fold in laryngeal cancer treatment. Laryngoscope.
immobility: a longitudinal analysis of etiology over 20 2016;126:1612-1615.
years. Laryngoscope. 2007;117:1864-1870.
19. Reveiz L, Cardona Zorrilla AF, Ospina EG. Antibiotics
8. Smith-Bindman R, Miglioretti DL, Larson EB. for acute laryngitis in adults. Cochrane Database Syst
Rising use of diagnostic medical imaging in a large Rev. 2015;(2):CD004783.
integrated health system. Health Aff (Millwood).
2008;27:1491-1502. 20. Cohen SM, Kim J, Roy N, et al. Delayed otolaryngology
referral for voice disorders increases health care
9. Schwartz SR, Cohen SM, Dailey SH, et al. CPG: costs. Am J Med. 2015;128:426.e11-e18.
dysphonia guideline. Otolaryngol Head Neck Surg.
2009;14:S1-S31. 21. Cohen SM, Kim J, Roy N, et al. Change in diagnosis
and treatment following specialty voice evaluation:
10. Johns MM 3rd, Sataloff RT, Merati AL, et al. Shortfalls a national database analysis. Laryngoscope.
of the American Academy of Otolaryngology—Head 2015;125:1660-1666.
and Neck Surgery’s clinical practice guideline:
hoarseness (dysphonia). Otolaryngol Head Neck 22. Stachler RJ, Francis DO, Schwartz SR, Damask CC,
Surg. 2010;143:175-180. Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel
RR, Reavis CCW, Smith LJ, Smith M, Strode SW,
11. Howick J, Chalmers I, Glasziou; OCEBM Levels Woo P, Nnacheta LC. Clinical Practice Guideline:
of Evidence Working Group. The Oxford 2011 Hoarseness (Dysphonia) (Update). Otolaryngol
levels of evidence. http:// www.cebm.net/index. Head Neck Surg. 2018 Mar;158(1_suppl):S1-S42.
aspx?o=5653. Published. 2011. doi: 10.1177/0194599817751030. Erratum in:
Otolaryngol Head Neck Surg. 2018;159(2):403.
12. Oxford Centre for Evidence-Based Medicine. The
PMID: 29494321. (main reference).
Dysphonia 2021 (Volume 1) Pages: 112-115 115

Chapter 4
Audiovestibular
Medicine
Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG Chapter 4: Audiovestibular
Medicine
Pure-Tone Air-Conduction and Bone-Conduction Threshold Audiometry
with and without Masking: Adapted Egyptian Clinical Practice Guidelines

Audiology Chief Manager: Tarek Ghannoum7
Audiology Executive Manager: Iman El-Danasoury9
Assembly board: Trandil El Mehallawi,10 Nashwa Nada,10 Mai ElGohary11
Rafeek Mohamed Abdelkader,12 Adel Abdel Maksoud,9 Abeir Dabbous,7 Iman Eladawy,13 Mohammed El Badry,12 Iman El-Danasoury,9 Tarek
El Dessouky,14 Wafaa El Kholi,9 Reham Elshafei,15 Amira El Shennawy,7 Nahla Gad,16 Nagwa Hazzaa,9 Naema Ismail,13 Nadia Kamal,9 Enaas
Kolkaila,10 Radwa Mahmoud,17 Salwa Mahmoud,11 Soha Mekki,16 Iman Mostafa,14 Mona Mourad,18 Abir Omara,11 Mohammed Salama,19 Enaas
Sayed19
Reviewing Board: Salah Soliman,9 Sameh Farid,7 Ossama Sobhy,18 Gihan Elzarei13
1
Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Department, Faculty of Medicine/Menoufia
University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 4Otorhinolaryngology Department, Faculty of Medicine/
Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology Department, Faculty
of Medicine/ Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Audiovestibular Unit, Otorhinolaryngology Department, Faculty of
Medicine/ Ain Shams University, 10Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Tanta University, 11Audiovestibular
Unit, Otorhinolaryngology Department/ Hearing and Speech Institute, 12Audiovestibular Unit, Otorhinolaryngology Department, Faculty of
Medicine/ Minia University, 13Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar University,14Audiovestibular
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Bani-Suef University, 15Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Fayoum University, 16Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University,
17
Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Banha University, 18Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Alexandria University, 19Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Assiut
University.
Introduction and background opportunities in clinical practice.
Pure tone audiometry air conduction and bone conduction Methods

are basic and common practice for hearing assessment.
Different methods are encounter during doing PTA. Here The adaptation cycle passed over: Set up phase,
we apply general guidelines for the audiologist that they adaptation phase (Search and screen, assessment:
should follow in order to reach the ideal results. Currency, Content and Quality and Decisions/selection)
and finalization phase that include revision.
Scope and purpose
Results
This document is aimed at practitioners working within
audiology. It describes procedures suitable for routine Ten guidelines were assessed by three audiovestibular
clinical use with adults and older children and may not be medicine experts. The “Pure-tone air- conduction and
appropriate for certain populations (eg. younger children bone-conduction threshold audiometry with and without
or adults with learning difficulties). The purpose of this masking” the recommended procedure by BSA (2017) had
guideline is to identify quality improvement opportunities the highest scores as regards to the currency, contents
when doing the hearing assessment using PTA air and quality. It was graded by 23 audiovestibular medicine
conduction and bone conduction and to create explicit consultants and reviewed by four expert reviewers.
and actionable recommendations to implement these
Grade Definition
High
++++
Low
++
+ of effect
116 2021 (Volume 1) Pages: 116-124 Pure Tone Audiometry

Chapter 4: Audiovestibular Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG
Medicine
Accepted statements
Modified statements
Added statements
Strength
Strength of
Level of after
Statement topic Action recommendation recommendation
evidence adoption or
according to BSA
adaptation
Audiometer,transducers and response buttons SHALL be Strong
D ++++
clean and Calibrated (refer to section VIII). Recommendation
I. Equipment and Ambient noise SHOULD not exceed the levels permitted Strong
D ++++
test environment (35dB (A)) measured by the sound level meter. Recommendation
The subject SHALL not be able to see or hear the tester Strong
D ++++
adjust the audiometer controls. Recommendation
Audiometry SHALL be
preceded by otoscopic examination Otoscopic
examination (Findings recorded, including the presence Strong
D ++++
of wax and ear canal collapse). Occluding wax shall be Recommendation
removed prior to audiometry and use insert earphone in
II. Preparation of the case of ear canal collapse.
test subjects And
full history taking
Subject SHALL be asked about any exposure to loud Strong
D ++++
noise during the previous 24 hours. Recommendation
Subjects SHALL be asked if they have tinnitus and if they Strong

D ++++
have better hearing in one ear. Recommendation
Remove any hearing aids, also any glasses, headwear
or earrings that may obstruct the correct placement
of the transducers, cause discomfort or affect sound
D Recommendation ++++
transmission. Wherever possible, hair, scarves etc,
SHOULD not be allowed to sit between the ear and the
transducer.
Instructions
SHALL give clear information about the task.
The patient responds to the faintest sound he/she hears. Strong

D ++++
Recommendation
“Whatever the sound, and no matter how faint the
sound, press the button as soon as you think you hear it,
and release it as soon as you think it stops.”
Subject’s response
III. Air-conduction * The subject’s response to the test tone SHOULD clearly
audiometry indicate when the test tone is heard and when it is no
longer heard. Response mode may be verbal, raising
D Recommendation +++
hands or push button. But the latter is the preferred
method.
Naïve patients may find it difficult to use push buttons.

Alternatively, raising hand may be much easier.
*When testing younger children, adults with learning
difficulties or subjects with attention difficulties a more Strong
D ++++
engaging response method may be required, and, if so, Recommendation
this SHALL be recorded.
Earphones (three main types of transducers can
Strong
be used supra, circum aural or insert earphones D ++++
Recommendation
The tester SHALL fit the earphones.
The subject SHOULD be instructed not to hold them. D Recommendation ++++
The sound opening of the supra-aural earphones SHALL Strong
D ++++
be aligned with the ear canal entrance. Recommendation
Pure Tone Audiometry 2021 (Volume 1) Pages: 116-124 117

Medicine
Strength
Strength of
Level of after
according to BSA
adaptation
Test order D Not Reported ++++
Start with the better-hearing ear (according to the

subject’s account) and at 1000 Hz. Next, test 2000 Hz,
4000 Hz, 8000 Hz, 500 Hz and 250 Hz in that order.
Then, for the first ear only, retest at 1000 Hz.
Mid frequencies may be required in presence of > 20dB NR Not Reported ++++
difference between two adjacent octave frequencies
in frequeny range (250-8000 Hz) (Modified from ASHA
2005).
Testing 3000 Hz and 6000 Hz may be required in cases D Recommendation ++++
of high-frequency hearing loss, tinnitus and suspicion of
retrocochlear pathology
Initial familiarization
III. Air-conduction Present a tone of 1000 Hz that is clearly audible (e.g. at

audiometry 40 dB HL for a normally hearing subject or approximately
30 dB above the estimated threshold for a subject with
D Not Reported ++++
a hearing impairment, but never more than 80 dB HL).
If there is no response, increase in 10-dB steps until a
response occurs. If the tone is still inaudible at 80 dB HL,
increase 5-dB steps until a response occurs, taking care
to monitor the subject for discomfort.
Method for finding threshold 1. Following a
satisfactory positive response, reduce the level of the
tone in 10-dB steps until no further response occurs.
2. Increase the level of the tone in 5-dB steps until a
response occurs. 3. After the first response using an
ascending approach, decrease the level by 10 dB and
begin another ascending 5-dB series until the subject D Not Reported ++++
responds 4. Again decrease the level by 10 dB and
increase by 5 dB until the subject responds at the same
level on two out of two, three or four (i.e. 50 % or more)
responses on the ascent. This is the hearing threshold
level. Proceed to the next frequency, starting at a clearly
audible level (e.g. 30 dB above the adjacent threshold).
1. Industrial audiometry: requires testing at 500 Hz,
1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz, 6000 Hz and
8000 Hz.
2. Subjects with short attention spans, and some

elderly subjects: in these cases, it may be
appropriate to test fewer frequencies with use of
longer test tones or alternative response methods.
3. Subjects with tinnitus: If the subject is unable to

IV. Variants in meth- perform an accurate test at some frequencies due
ods to an inability to distinguish between their tinnitus Strong
D ++++
and the test tone, then a frequency-modulated or recommendation
warble tone may be used as a stimulus.
The use of pulsed tones and narrow-band noise is

not advised due to calibration and perception
problems.
4. Exaggerated thresholds: published variations

in technique may help with this (e.g. Cooper &
Lightfoot, 2000).
5. Pulsed ascending technique may be adopted in
certain patients, such as non-organic HL, elderly
and inattentive.
Variations in technique SHALL be recorded.

Medicine
Strength
Strength of
Level of after
according to BSA
adaptation
The bone vibrator is normally initially placed over the
mastoid prominence of the worse hearing ear (as
defined by the a-c thresholds averaged between 500 Hz
and 4000 Hz), with the required area of the vibrator in Strong
D ++++
contact with the skull. Recommendation
It SHALL be placed as near as possible behind the pinna

without touching it and without resting on hair.
The vibrator SHALL be held firmly in place by means
V. Bone conduction Strong
of a headband that holds it against the skull with the D ++++
audiometry Recommendation
required static force.
The procedure is similar to the AC audiometery. The
+++
canal MUST NOT be occluded at test frequencies below
3000 Hz, as this may artificially improve b-c thresholds
due to the ’occlusion effect ‘. D Recommendation
Tested ear SHOULD be occluded with ear plug when ++++

testing 4000 Hz b-c.
Narrow Band Masking noise SHOULD be used. D Recommendation ++++
Cross-hearing and masking
Rule 1
Masking is needed at any frequency where the difference

between the left and right not-masked a-c thresholds
is 40 dB or more when using supra- or circum-aural ++++
earphones or 55 dB when using insert earphones.
Rule 2
Masking is needed at any frequency where the not- D Not Reported

masked b-c threshold is better than the air-conduction
++++
threshold of either ear by 10 dB or more.
Rule 3
Masking will be needed where the b-c threshold of one

ear is more acute by 40 dB or more (if supra or circum-
aural earphones have been used) or 55 dB or more (if ++++
insert earphones have been used) than the not-masked
VI. Masking
a-c threshold attributed to the other ear.
Procedure for masking (plateau-seeking method for
masking).
Re-establish hearing threshold in the test ear by

presenting the tone and seeking the response without ++++
masking noise to remind the subject what to listen for.
Introduce masking noise to the non-test ear. The initial

level of masking SHOULD be the effective masking level
which is equal to the tonal threshold level of that ear at D Recommendation ++++
that frequency.
using increments of 10 dB in masking noise, until you

have at least four measurements (including the initial
starting point) and until three successive measurements ++++
yield the same tonal threshold. You may be unable
to obtain this plateau due to maximum level of the
audiometer being reached or because the subject finds
the masking noise uncomfortable.

Medicine
Strength
Strength of
Level of after
according to BSA
adaptation
Masking during bone-conduction testing
-An insert earphone SHOULD be used to deliver masking

noise to the non-test ear for b-c testing, for subject
comfort and for the advantages of high transcranial
transmission loss, measurements yield the same tonal
threshold. A supra-aural or circumaural earphone can be
used if there is no alternative.
-You may be unable to obtain this plateau due to maximum

level of the audiometer being reached or because the
subject finds the masking noise uncomfortable; in either
case mark as unreached.
-When three successive levels of masking yield the same

tonal threshold, or one threshold is no more than 5 dB
different from the other two, this is the ‘plateau’. The
mode (i.e. the threshold which occurs 2/3) of the three
hearing threshold levels at plateau is taken as the correct
hearing threshold of the test ear and no further masking
is required. Withdraw the masking noise and plot the
hearing threshold level on the audiogram.
-In subjects with tinnitus and hyperacusis, extra care
SHOULD be taken when using high levels of masking
noise, as this can exacerbate the tinnitus and worsen
hyperacusis. In some cases, it may be appropriate not
to perform masking
• Hearing threshold level can be plotted graphically
on an audiogram form. The aspect ratio SHOULD
be fixed at 20 dB:1 octave in all cases to ease
interpretation.
• Air-conduction symbols SHOULD be connected with
continuous straight lines; bone-conduction symbols D Recommendation ++++
SHOULD be joined with broken lines.
• If no response occurs at the maximum output level
of the audiometer, a downward arrow SHOULD be
drawn, attached to the corner of the appropriate
symbol. These symbols SHOULD not be connected
VII. Recommended
with the line to symbols representing measured
format and
thresholds.
symbols
(ASHA, 1990)

Medicine
Strength
Strength of
Level of after
according to BSA
adaptation
Descriptor Average hearing threshold levels (dB HL)

(ASHA, 2015).
NR Not Reported ++++
Five audiometric descriptors are given According to

ASHA, 2015 but in contrary to ASHA 2015, we adopt the
average of pure tone hearing threshold at frequencies
(250Hz, 500 Hz, 1KHz, 2KHz, and 4KHz) instead of
250Hz to 2KHz.
We also clarify that as described previously by Northern

and Downs (2002) that 15 dB HL as the upper limit for
normal hearing for children between 2 and 18 years of
age.
b) The configuration, or shape, of the hearing

loss refers to the degree and pattern of hearing loss
across frequencies.
VIII. Descriptor
Average hearing For example, a hearing loss that only affects the high
threshold levels tones would be described as a high-frequency loss.
(dB HL)
On the other hand, if only the low frequencies were
affected, the configuration would show poorer hearing
for low tones and better hearing for high tones. Some
hearing loss configurations are flat, indicating the same
amount of hearing loss for low and high tones (ASHA,
2015).
Moreover, if there is V dip at certain frequency, it

SHOULD be described.
Quoted from Schlauch, R. S., & Nelson, P. B. (2009)
For the purposes of this document, in determining the

five-frequency average value of hearing loss, if at any
frequency no response is obtained due to the severity of Strong
D ++++
the loss, this reading SHALL be given a value of 130 dB recommendation
HL. Any hearing threshold level lower (better) than 0 dB
HL SHALL be given the value 0 dB HL.

Medicine
Strength
Strength of
Level of after
according to BSA
adaptation
Stage A: routine checking and subjective tests: SHOULD
be carried out in daily and weekly manner.
Stage B: periodic objective tests are objective tests
which ideally SHOULD be performed every 3 months.
Stage C: basic calibration tests They will only be required
IX. Calibration
when a serious error or fault occurs, or when, after a
long period of time, it is suspected that the equipment
may no longer be performing fully to specifications. It D Not Reported ++++
may be advisable to submit equipment for a Stage C
check after, for example, five years’ use if it has not
received such a test in that time in the course of repair.
During The terrible COVID 19 outbreak, we adapt the
Guidelines that were published with AIHHP, BAA, BSA &
BSHAA , 2021 updated June 2021.
The following are the main points that should be followed

during the pandemics:
Apply triage system to determine which patient will be

suitable for face to face appointment
A) Questions you should ask to triage for

Covid-19 symptoms
Do you or anyone in your household/bubble:
I. have coronavirus?
II. have a new continuous cough?
III. have a high temperature (37.8oC or over?)
IV. have a loss or change in your sense of smell or taste?
Have you or any member of your household/bubble been

told to self-isolate after travel from a high-risk country or
contact from test and trace?
X. Guidelines of PTA
in outbreaks: B) During an appointment the following must be
observed:
• Best practice hand hygiene
• The use of Type II R facemasks for staff and

patients (if tolerated) is required.
• Physical Distancing of 2 meters remains best

practice unless providing clinical care. If this is not
possible the use of physical barriers as agreed with
local infection prevention should be considered.
• Best Practice respiratory hygiene (‘catchit,binit,killit’)

and avoiding touching your face with your hands is
required.
C) After an appointment the following should be

observed:
• Leave enough time to doff any PPE, to clean high touch

areas a patient has been in contact with, and to prepare
for the next patient.
No statements were described in BSA, 2017 as how to

deal in highly infectious circumstances as in COVID 19.

Medicine

Medicine
References New York: Lippincott Williams & Wilkins. 2002.
1. Boothroyd A, Cawkwell S. Vibrotactile thresholds in 13. British Society of Audiology. Pure tone air and bone
pure tone audiometry.J Acta Otolaryngol. 1970;69: conduction threshold audiometry with and without
381-387. masking and determination of uncomfortable
loudness levels. 2004.
2. Lightfoot GR. Air-borne radiation from bone
conduction transducers. Br J Audiol. 1979;13:53-56. 14. The Health & Safety Executive: Controlling Noise
at Work. The Control of Noise at Work Regulations.
3. Bell I, Goodsell S, Thornton ARD. A brief 2005. Guidance on Regulations. Crown.
communication on bone conduction artifacts. Br J
Audiol. 1980;14:73-75. 15. Schlauch RS., & Nelson PB. Pure tone evaluation. In
Handbook of Clinical Audiology. Lippincott Williams &
4. Shipton MS, John AJ, Robinson DW. Air-radiated Wilkins. 6th Edition. 2009:30-49.
sound from bone vibration transducers and its
implications for bone conduction audiometry. Br J 16. British Society of Audiology. Recommended
Audiol. 1980;14:86-99. Procedure: Determination of uncomfortable loudness
levels. British Society of Audiology www.thebsa.org.
5. American Speech-Language-Hearing Association. uk. 2009.
Guidelines for audiometric symbols. ASHA. 1990;32
(Suppl. 2)25-30. 17. Margolis RH, Eikelboom RH, Johnson C et al. False
air-bone gaps at 4 kHz in listeners with normal
6. Lightfoot GR, Hughes JB. Bone conduction errors at hearing and sensorineural hearing loss. Int J Audiol.
high frequencies: implications for clinical and medico- 2013;52:526-532.
legal practice. J Laryngol Otol. 1993;107:305-308.
18. Schünemann H, Brożek J, Guyatt J, et al. GRADE
7. Fagelson M, Martin FN. Sound pressure in the external handbook 2013. https://gdt.gradepro.org/app/
auditory canal during bone-conduction testing. J Am handbook/handbook.html.
Acad Audiol. 1994;5:379-383.
19. American Speech-Language-Hearing Association.
8. Harkrider AW, Martin FN. Quantifying air-conducted Type, degree, and configuration of hearing loss.
acoustic radiation from the bone-conduction vibrator. Audiology Information Series. 2015;10802-10803.
J Am Acad Audiol. 1998;9:410-416.
20. British Society of Audiology Recommended
9. Munro KJ, Agnew N. A comparison of inter-aural Procedure: Ear Examination. British Society of
attenuation with the Etymotic ER-3A inserts earphone Audiology 2016;www.thebsa.org.uk.
and the Telephonics TDH-39 supra-aural earphone.
Br J Audiol. 1999;33:259-262. 21. British Society of Audiology. Recommended
Procedure: Recommended Procedure, Pure-tone
10. Coper J, Lightfoot G. A modified pure tone audiometry air-conduction and bone-5 conduction threshold
technique for medico-legal assessment. Br J Audiol. audiometry with and without masking. 2017. British
2000;34:37-45,782. Society of Audiology. www.thebsa.org.uk.
11. Lightfoot GR. Audiometer calibration: interpreting 22. Audiology & Otology Guidance during COVID-19
and applying the standards. Br J Audiol. 2000;34:311- Pandemic. 2021, AIHHP, BAA, BSA & BSHAA British
316. Society of Audiology Procedure for Processing
Documents. British Society of Audiology. www.
12. Northern JL, Downs MP. Hearing in Children. 5th ed.
thebsa.org.uk.

Medicine
Tympanometry: Adapted Egyptian Clinical Practice Guidelines

Audiology Chief Manager: Tarek Ghannoun7
Assembly board: Enaas Kolkaila,10 Mostafa Elrefaie10
Mohamed Abdelghaffar,11 Rafeek Mohamed Abdelkader,12 Abeir Dabbous,7 Iman Eladawy,13 Mona El Akkad,14 Mohamed El-Badry,12 Iman
El-Danasoury,9 Tarek ElDessouky,15 Wafaa El Kholi,9 Trandil El Mehallawi,10 Reham Elshafei,14 Amira El Shennawy,7 Enaas Hassan,16
Nagwa Hazzaa,9 Naema Ismail,13 Nadia Kamal,9 Rabab Koura,15 Radwa Mahmoud,17 Salwa Mahmoud,18 Soha Mekki,19 Iman Mostafa,15
Mona Mourad,20 Nashwa Nada,10 Abir Omara,18 Mohamed Salama16
Hesham Sami,12 Hesham Taha,9 Somia Tawfik9
Reviewing Board: Hesham Kozou,20 Rasha Elkabarity,9 Hosam Sanyelbhaa21
1
of Medicine/Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/Mansoura University, 6Otorhinolaryngology
Department, Faculty of Medicine/ Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Dep. Faculty of Medicine/ Cairo University,
8
Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Ain Shams University, 10Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/
Tanta University, 11Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 12Audiovestibular
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 13Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Al Azhar University,14Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Fayoum
University, 15Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Tanta University,16 Audiovestibular Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Assiut University, 17Audiovestibular Unit, Otorhinolaryngology Department, Faculty
of Medicine/ Banha University,18Audiovestibular Unit, Otorhinolaryngology Department/ Hearing and Speech Institute, 19Audiovestibular
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 20Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Alexandria University, 21Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Menoufia
University.
Introduction and background a nominal probe frequency of 226 Hz for subjects whose
corrected age is equal to or greater than 6 months (i.e. at
Tympanometry is a testing methodology that is used to least 6 months from the child’s due date), and 1000 Hz for
evaluate the function of the middle ear. It provides a graphic subjects below 6 months corrected age.
representation of the relationship of air pressure in the
external ear canal to impedance (resistance to movement) Methods
of the ear drum and middle ear system. This impedance
measurement examines the acoustic resistance of the middle The adaptation cycle passed over: set up phase, adaptation
ear. If the eardrum is hit by a sound, part of the sound is phase (Search and screen, assessment: Currency, Content
absorbed and sent via the middle ear to the inner ear while and Quality and Decisions/selection) and finalization phase
the other part of the sound is reflected. that include revision.
Scope and purpose Results
Its purpose is to describe recommended procedures for Three guidelines were assessed by two audiovestibular
conducting tympanometry as a mean of analyzing middle-ear medicine experts and the British Society of Audiology,
function for subjects of all ages, from birth to adulthood. The Recommended Procedure: Tympanometry, published in 2013
recommendations are deemed suitable for routine clinical and reviewed in 2018, had the highest scores as regards
measurements applicable to most types of instruments to the currency, contents and quality. It was graded by 30
measuring aural acoustic impedance/ admittance using audiovestibular medicine consultants and reviewed by three
expert reviewers.
Grade Definition
High
++++
++ effect.
+ estimate of effect.
Tympanometry 2021 (Volume 1) Pages: 125-130 125

Medicine
Accepted statements
Modified statements
Added statements
Statement Level of recommendations after
Action recommendation
topic evidence According to the adoption or
1.1. The tympanometer and probe tip shall be clean (i.e.

free from dust and dirt and in compliance with local
infection control standards). Tympanometers shall Not Reported Recommendation ++++
meet the performance and calibration requirements
of BS EN 60645–5.
1.Equipment 1.2. Calibration: The calibration of the instrument

shall be checked daily with the probe fitted to an
appropriate cavity such as the one supplied by the
manufacturer. The performance of the instrument Not Reported Recommendation ++++
shall also be checked on an ear known to produce
a normal, peaked tympanogram (e.g. to ensure the
pump is operational and its tube is not blocked).
1.3. Before examination, the subject (or the person

responsible for the subject) should be asked if
he/she currently has any ear-related symptoms
(including discomfort, pain and discharge), Not Reported Optional +
is currently being treated for any ear-related
problems or has previously had surgery involving
2.Subject the ears.
preparation
1.4. The subject should be seated comfortably and
should remain as still as possible during the test.
1.5. Young children may need to be held by an

appropriate adult, which should be the person Not Reported Optional +
responsible for the child.
1.6. Tympanometry should be preceded by otoscopic

examination to ensure that there are no
3.Otoscopic contraindications to continue. Otoscopy in
examination neonates is only intended as a general inspection
of the outer ear for obvious signs of disease,
blockage or malformation.
1.7. Testing should proceed only with informed
4.Informed consent (e.g. verbally) from the subject or
Not Reported Recommendation ++
consent person responsible for the subject and if it is the
judgement of the tester that it is safe to do so.
1.8. The examiner should explain, and where necessary
5.Subject in- Weak
demonstrate, the procedure to the subject and/or Not Reported +
structions Recommendation
person responsible for the subject.
126 2021 (Volume 1) Pages: 125-130 Tympanometry

Medicine
6.1 Subjects with age over 6 months, using a

226-Hz probe tone is recommended:
• Fit a clean tip of suitable size and shape to

the probe and straighten the ear canal by
gently pulling the pinna.
• Point the probe in the direction of the

tympanic membrane to avoid the risk of
occluding the probe aperture, for example
against the wall of the canal.
• A slow rate of change of pressure (50 daPa

s–1 or less) should be used but with young
children it may be beneficial to use a faster
sweep, sacrificing some accuracy for speed
of operation.
• In the absence of other requirements,

tracking should commence at +200 daPa
and end once the peak, if it exists, has been
clearly recorded.
• On automatic systems a lower limit of about

–300 daPa, depending on instrument, should
normally be selected but occasionally it may
6.Test be necessary to go to –600 daPa in search
procedures of a peak.
• In cases of normal tympanograms, tracking

should stop at –200 daPa for adults and –300
daPa for children to minimise discomfort.
• When testing adults and children on the

same equipment, all test parameters should
be checked and set appropriately prior to
testing.
• If an unexpected result is obtained the test

should be repeated in its entirety, that is,
by removing the probe, inspecting the ear,
checking the probe to ensure it is not blocked,
for example with wax, and re-testing.
• Unexpected results should not be accepted

without verifying that they are repeatable
and running a calibration check of the probe
in the test cavity and performing biologic
calibration.
• After tympanometry has been completed

the probe tip should be removed and all
contaminated tips shall be disposed of or
cleaned as per local policy.

Medicine
6.2 Subjects with a corrected age under 6 months

using a 1000-Hz probe tone
• Fit a clean tip of suitable size and shape to

the probe and straighten the ear canal (e.g.
by gently pulling the pinna downwards and
outwards).
• Point the probe in the direction of the

tympanic membrane to avoid the risk of
sealing the tip against the wall of the canal.
• Movement of the infant and crying can result

in a false peak in the tympanogram. The
baby does not need to be asleep but should
definitely be resting quietly during the test.
• The direction of pressure change should

++++
be from positive to negative and the range
should be at least from +200 daPa to –400
daPa (and preferably–600daPa).
• A fast screening mode speed of up to 600daPa

s–1 should be used.
• Traces should usually be repeated, if possible,

to check that the result is repeatable and not
due to artefacts such as baby movement.
It is especially important to retest any ear
with an abnormal or difficult-to-interpret
tympanogram.
• After tympanometry has been completed

the probe tip shall be removed and all
contaminated tips shall be disposed of or
cleaned as per local policy.
7.1.Tympanometric results do not identify pathology uniquely
7.Results and and should be interpreted in the context of other information
NR Recommendation ++++
reporting from the complete test battery being conducted and with
particular regard to the otoscopic findings and history.

Medicine

Medicine
References Society of Audiology. Berkshire (United Kingdom):
British Society of Audiology, 2-20. 2013. Reviewed
1. Mona M., Jack Roush, Judith Gravel, et al. Audiologic in 2018.
Guidelines for the Assessment of Hearing in Infants
and Young Children. August, 2012. 3. College of Audiologists and Speech-Language
Pathologists of Ontario. 2018.
2. Recommended Procedure: Tympanometry, British

Medicine
Auditory Brainstem Response (ABR) Testing in Babies: Adapted Egyptian
Clinical Practice Guidelines

Scientific Board: Ashraf Khaled,4 Mohamed Ghonaim,5 Mahmoud Abdel Aziz,6 Tarek Ghannoum,7 Mahmoud Youssef8
Assembly board: Mona Mourad,10 Yasmine Hamza,11 Mai EL Ghazaly10
Alaa Abou Setta,12 Abeir Dabbous,7 Mohamed El Badry,14 Iman El-Danasoury,9 Tarek ElDessouky,13 Mai El Gohary,15 Trandil El Mahalawy,16
Reham Elshafie,17 Amira El Shennawy,7 Heba Ghannoum,18 Tarek Ghannoum,7 Enas Hassan,19 Nadia Kamal,9 Radwa Mahmoud,20
Salwa Mahmoud,15 Iman Mostafa,13 Nashwa Nada,16 Abir Omara,15 Mohamed Salama,20 Hesham Samy,14 Somia Tawfik9
Reviewing Board: Nagwa Hazzaa,9 Naema Ismail,20 Soha Mekki21
1
of Medicine/ Bani-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology
Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Audiovestibular Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 10Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Alexandria University, 11Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ University of
California, Irvine, 12Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Bani-Suef University, 13Audiovestibular
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Suez Canal University, 14Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Minia University, 15Audiovestibular Unit, Otorhinolaryngology Department/ Hearing and Speech
Institute, 16Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Tanta University, 17Audiovestibular Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University, 18Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Helwan University, 19Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Assuit
University, 20Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Banha University, 21Audiovestibular Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Al Azhar University, 22Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Zagazig University.
Introduction and background specific information is required. It aims to define criteria

by which to identity a ‘clear response’, ‘response absent’
Effective and consistent hearing measurement in babies is or ‘inconclusive’ response when performing ABR testing
important for early intervention. Auditory Brain Response in babies. This to ensure uniform standards that can be
(ABR) is used to identify an accurate estimate of hearing achieved by those using this procedure.
thresholds at different frequencies. It is important
to ensure good quality recordings of ABR waveforms Methods
which are obtained using earphones, inserts and bone-
conduction transducers. As universal hearing screening The adaptation cycle passed over: set up phase,
is being implemented in EGYPT, there is a growing need adaptation phase (Search and screen, assessment:
to unify testing parameters and improve data reporting. Currency, Content and Quality and Decisions/selection)
Scope and purpose
Results
These guidelines aim at the achievement of the
uniformity of the equipment set up, improvement in Ten guidelines were assessed by three audiovestibular
test performance and waveform interpretation. These medicine experts and the British Society of Audiology
guidelines are for the use of ABR in assessing hearing 2019 had the highest scores as regards to the currency,
in babies up to a corrected age of 12 weeks. Frequency- contents and quality. It was graded by 20 audiovestibular
medicine consultants and reviewed by three experts.
Grade Definition
High
++++
++ effect.
+ estimate of effect
Auditory Brainstem Response (ABR) Testing in Babies 2021 (Volume 1) Pages: 131-137 131
Medicine
Accepted statements
Modified statements
Added statements
ABR guidelines statements
Strength of
Strength of
evidence after
According to BSA
Adopt/adapt
1.Patient
preparation
Threshold ABR tests should be performed in a sound-
proofed room or environment which meets the same stan-
1.1.Test dards as PTA. D Strong ++++
environment Recommendation
Levels of electrical interference should be sufficiently low
such that the signal baseline is not adversely affected.
1.2.Precautions
All local procedures should cover hygiene upon use of
against cross- D Recommendation ++++
equipment and electrodes.
infection
Sedation is not necessary in babies under 12 weeks of age
and considered in babies under 12 months of age only in ++++
1.3.Sedation exceptional circumstances. Sleep deprivation, feeding, Dia- D Recommendation
per change in most situations will lead to natural sleep and
lessen activity
Skin should be gently wiped with (wet) gauze , Caution with
abrasive materials .Appropriate options: cleaning stick with D ++++
soft cotton material.
D
Single use disposable electrodes. Recommendation ++++
1.4.Choice of
electrodes &
application The impedance, as measured between each electrode pair
should be under 5000 ohms and similar across electrodes.
The ABR system must not be switched on or off with the Strong
D ++++
patient attached. Recommendation
2.Stimulus ++++
Strong
parameters Alt polarity to minimize the stimulus artifact. D
Recommendation
C-R clicks when CM collection is needed ++++

2.1.Polarity
Click: 100μs
Strong
2.2.Timing Tone pip: 2 -1-2 cycles or 5-cycle Blackman D Recommendation ++++
Option
Narrow band (pip-like) chirps (NB chirp)
D Strong
2.3.Rate Rates 45.1-49.1/s ++++
Recommendation
0.5, 1, 2 or 4kHz.
Thresholds may be measured for at least two frequency

2.4.Frequency audiometric regions: Strong
D ++++
Specific ABR Recommendation
Low frequency thresholds using 0.5khz.
High frequency thresholds using TP / TB 2 , 4 khz or clicks.
132 2021 (Volume 1) Pages: 131-137 Auditory Brainstem Response (ABR) Testing in Babies
Medicine
Strength of
Strength of
evidence after
According to BSA
Adopt/adapt
Should be able to deliver a stimulus up to 140dBSPL peak

(107dBnHL for clicks) without distortion.
3.TRANSDUCER Supra-aural or insert earphones (e.g. type ER-3A) Strong
D ++++
Recommendation
3.1.Earphones Insert phones should not be used > maximum levels given
in (BSA, HNSP 2013).
Supra-aural earphones should be centered over the ear

canal to avoid collapse of ear canal due to excess pressure.
Should be able to deliver a stimulus up to 60dBnHL
(50dBnHL at 0.5 kHz) without waveform distortion.
Placement: on mastoid 1 finger’s width above the

electrode + finger pressure on BC vibrator. Strong ++++
3.2.Bone
D Recommendation
vibrator Placement on temporal bone posterior to the upper part of Option
pinna if it gets close to electrode.
Effective level of stimulus changes with age (BSA,NHSP2013)

may be used.
4. Data
Relaxed and sleeping baby is important.
collection and
analysis
4.1.Amplifier ±3 to ±10μVg peak-to-peak.
artifact
rejection level
++++
Low frequency 30Hz- 50Hz.
4.2.Amplifier
filters
High frequency 1500Hz. D Recommendation ++++
4.3.Use of Recommendation
Smoothing of averaged waveform 50-1000Hz Notch filter D ++++
digital filters (Against)
4.4.Window Click, NB chirp & 2kHz / 4kHz tone pip: 20ms.
length & D Recommendation ++++
averaging 0.5kHz / 1kHz tone pip: 25 ms.
Number of sweeps averaged per replication:
1500 -2000 click & NB chirp, or 2000- 3000 for TP ABR D Recommendation
If response is clear stop averaging.
Wave V upwards Strong

Recommendation
4.5.Display Ensure small waveforms near threshold are visible D ++++
Recommendation
Automatic display gain. (Against)
Medicine
Strength of
Strength of
evidence after
According to BSA
Adopt/adapt
Masking of the contralateral ear when stimulus level is

high to cross to the other cochlea and produce a response.
Strong
Consider masking when stimuli are at or above the Recommendation
following levels (in dBnHL) for babies of 0 to 8 weeks
corrected age assuming the other ear is normal.
D ++++
4.6.Masking Trans- Click 0.5kHz 1kHz 2kHz 4kHz
ducer
Supra 65 75 75 65 75
Aural
Insert 60 75 75 70 75
Option
BC 20 15 15 25 20
Visual interpretation. Strong

Recommendation
Replication of waveforms
Decision criteria for the result at each stimulus level
CR: clear response present
RA: Response absent, or
Inc: Inconclusive
Criteria for CR
Strong
High correlation between replications, waveforms should
Recommendation
show the expected characteristics of amp, latency &
morphology.
4.7.Criteria for The size/amplitude of the response as judged from the ++++
accepting the wave III/V should be a minimum of 40nV and at least 3 D
presence of a times the background noise level.
response
The waveform should be judged over the whole time
window excluding any stimulus artifact.
Waveforms should be compared with those at other stimulus

levels to confirm that they follow the expected changes with
stimulus level.
Strong
Criteria for RA the waveforms must be appropriately flat, Recommendation
no evidence of a response and the average gap (noise)
between a pair of optimally superimposed waveforms
should be less than or equal to 25nV.
If the result does not meet the criteria for either a (CR)
or (RA), the result should be marked as inconclusive (Inc).
Inconclusive waveforms should not contribute to the Strong

derivation of threshold. Recommendation
Medicine
Strength of
Strength of
evidence after
According to BSA
Adopt/adapt
ABR threshold is defined in (BSA, NHSP 2013) as the lowest

level at which a clear response (CR) is present, with a
response absent (RA) 5 - 10dB below threshold, under good
recording conditions.
5.Threshold Alternately criteria for ABR response & threshold: may be D ++++
Strong
defined as visual and graphic reproducibility of responses for
5.1.Definition of recommendation
all intensity i/o function were threshold is the reproducible
ABR threshold
response at the lowest stimulus intensity attained. I/O
intensity may start at low stimulus levels unless there are
good reasons to do otherwise .stimulus level may change
in10db steps .Larger steps may be better in some occasions
according to babies ‘ sleep.
Results should be clearly marked using the symbols ‘=’, D Strong ++++
‘≤’ or ‘<=’, and ‘>’ in addition to the descrip- Recommendation
tive statements, when important rehabilitation decisions
are made
’= ’ means clear response at threshold
(CR at 5-10dB above & RA 5-10db below).
‘<=’ means CR at threshold but not tested below this level.
5.2.Reporting ‘>’ means RA at 80dB, but not tested above this level.
thresholds
(including those If no ‘confirmatory’ CR is obtained at 5 or 10dB above Recommendation
which are not threshold,
gold standard)
report threshold = lowest CR obtained.
If no CR is obtained above a RA result,
report threshold > highest RA
If an RA response is obtained but not within 10dB of the

lowest CR.
report threshold as <=lowest CR and > highest RA.
Subjective stage A listening check using 50/sec RR

6.Calibration D Recommendation ++++
Reference equivalent SPL for clicks and tone pips.
Weekly check
7.Artifacts
Blocked stimulus run and compare to a normal waveform
Recording &
system checks If artifacts in the response are observed: determine source
– contact manufactures.
Medicine
Medicine
References Hearing Screening Programme. Version 6 (Wales)
October 2013 adapted from version. 2013;3:1.
1. NHSP Clinical Group. “Check List for Daily and
monthly Function Check of Auditory Brainstem 5. Protocol for auditory brainstem response-based
Response systems (stage A check).” 2008. audiological assessment (ABRA) Version 2016.02.
h t t p s : / / w w w. m o u n t s i n a i . o n . c a / c a r e / i n fa n t-
2. American Academy of Audiology. (AAA). Audiologic hearing-program/documents/protocol-for-auditory-
guidelines for the assessment of hearing in infants brainstem-response-2013-based-audiological-
and young children. Retrieved July 26, 2017, assessement-abra.
from https://audiologyweb.s3.amazonaws.com/
migrated/201208_AudGuideAssessHear_youth. 6. Year 2019 Position Statement: Principles and
pdf_5399751b249593.36017703.pdf .2012. Guidelines for early Hearing Detection and
Intervention Programs. The Joint Committee on
3. BRITISH SOCIETY OF AUDIOLOGY (NHSP). infant hearing. 2019.
Guidelines for the early audiological assessment and
management of babies from the Newborn Hearing 7. BRITISH SOCIETY OF AUDIOLOGY. Recommended
Screening Programme, Version. 3.1. 2013.(online). Procedure auditory Brainstem Response (ABR)
Testing in Babies. 2019(Online).Available from: www.
4. Guidelines for the early audiological assessment and thebsa.org.uk.
management of babies referred from the Newborn
Medicine
Newborn Hearing Screening: Adapted Egyptian Clinical Practice
Guidelines

Scientific Board: Ashraf Khaled,4 Mohamed Ghonaim,5 Mahmoud Abdel Aziz,6 Tarek Ghannoum,7 Mahmoud Youssef8
Assembly board: Soha Mekki,10 Abir Omara,11 Salwa Mahmoud11
Rafeek Mohamed Abdelkader,12 Adel Abdel Maksoud,9 Abeir Dabbous,7 Mohamed El-Badry,12 Iman El-Danasoury,9 Tarek ElDessouky,13 Mai
El Gohary,11 Reham Elshafei,14 Amira El Shennawy,7 Nahla Hassan,10 Nagwa Hazzaa,9 Naema Ismail,15 Enaas Kolkaila,16 Rabab Koura,13 Radwa
Mahmoud,17 Nashwa Nada,16 Mohamed Salama,18 Hesham Samy,12 Hesham Taha,9 Somaia Tawfik9
Reviewing Board: Mona Mourad,19 Nadia Kamal,9 Trandil ElMehallawi16
1
Otorhinolaryngology Deptartment, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Deptartment, Faculty of Medicine/ Menoufia
University, 3Otorhinolaryngology Deptartment, Faculty of Medicine/ Minia University, 4Otorhinolaryngology Deptartment, Faculty of Medicine/
Beni-Suef University, 5Otorhinolaryngology Deptartment, Faculty of Medicine/Mansoura University, 6Otorhinolaryngology Deptartment, Faculty of
Medicine/ Tanta University, 7Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/ Cairo University, 8Phoniatrics
Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/ Ain Shams University, 9Audiovestibular Medicine Unit, Otorhinolaryngology
Deptartment, Faculty of Medicine/ Ain Shams University, 10Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/
Zagazig University, 11Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment/ Hearing and Speech Institute, 12Audiovestibular Medicine
Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/Minia University, 13Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment,
Faculty of Medicine/ Bani-Suef University, 14Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/ Fayoum
University, 15Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/ Al Azhar University, 16Audiovestibular
Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/ Tanta University, 17Audiovestibular Medicine Unit, Otorhinolaryngology
Deptartment, Faculty of Medicine/ Banha University, 18Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/
Assuit University, 19Audiovestibular Medicine Unit, Otorhinolaryngology Deptartment, Faculty of Medicine/ Alexandria University.
Introduction and background goal is recommended.
Newborn hearing screening is the standard of care in Methods

hospitals nationwide. The primary purpose of newborn
hearing screening is to identify newborns who are likely The adaptation cycle passed over: Set up phase,
to have hearing loss and who require further evaluation. A adaptation phase (Search and screen, assessment:
secondary objective is to identify newborns with medical Currency, Content and Quality and Decisions/selection)
conditions that can cause late-onset hearing loss and to and finalization phase that include revision.
establish a plan for continued monitoring of their hearing
Results
status.
Ten guidelines were assessed by three audiovestibular
Scope and purpose
medicine experts and the American Speech and Hearing
Hearing screening no later than (1) month of age, Association Newborn Hearing Screening Program
appropriate audiological evaluation no later than (3) Guidelines 2018 had the highest scores as regards the
months of age, Early intervention no later than (6) months currency, contents and quality. It was graded by 21
of age and Family counseling (1.3.6 goal). Recently 1.2.3 audiovestibular medicine consultants and reviewed by
three experts.
Grade Definition
++++
++
+ of effect.

Accepted statements
Modified statements
Added statements
138 2021 (Volume 1) Pages: 138-144 Newborn hearing screening

Medicine
NHS Guidelines statements
Strength of Strength of
Level of recommendations recommenda-
Evidence according to the tion after
selected CPG Adopt/adapt
Audio-vestibular medicine physicians by virtue
of academic degree, clinical training, and license
1. Roles and
to practice are qualified to provide guidance, NR Not Reported ++++
responsibilities
development, implementation, and oversight of
newborn hearing screening programs.
A screener can be a nurse.
2. Screener role and Screeners should be well trained and competent NR Not Reported ++++
characteristics to use the technology and protocol specific to
the screening program.
Universal newborn hearing screening (UNHS)
programs typically include: awareness and
education materials; hearing screening protocols
3. General considerations NR Not Reported ++++
and a process for communicating screening
results; a follow-up system and a quality
assurance.
Newborns in the well-baby nursery are screened
as close to hospital discharge as possible and
prior to 1 month of age.
4. Timing of Screening
Newborns who have initially passed a hearing
screening are rescreened if readmitted to the
hospital in the first month of life or if risk factors
for hearing loss develop.
5. Testing Environment Screening can be done in a nursery or a quiet
room with the infant resting quietly or sleeping. NR Not Reported ++++
A sound booth is not needed.
A newborn must pass the screening in both

ears during one session for screening to be
considered a “pass’’.
If the newborn does not pass in one ear, both

ears must be rescreened.
6. Pass/Refer Indications If the newborn passes the screening or the

rescreening and has no risk factors for late-onset NR Not Reported ++++
or progressive hearing loss, then the screening
is complete.
If the newborn passes the screening or the

rescreening and has risk factors for late-onset
or progressive hearing loss, then it will be very
important to monitor the newborn’s hearing
during early childhood.
Auditory brainstem response (ABR) and

otoacoustic emissions (OAEs) are appropriate
7. Technology NR Not Reported ++++
physiologic calibrated measures for screening
the newborn population.
OAEs only for well newborns. (Protocol “1” see
below).
8. Protocols Combined ABR&OAE for NICU & high risk NR Not Reported ++++
registered newborns. (Protocol “2” see below).
*(JCIH. 2019)
Identification of children with either missed
newborn, late-onset, or progressive hearing loss,
regardless of the presence or absence of high-
9. Detection of late onset risk indicators at birth. NR Not Reported ++++
hearing loss
Developmental milestones, hearing skills, and
speech and language milestones should be
monitored.
Newborn hearing screening 2021 (Volume 1) Pages: 138-144 139

Medicine
Strength of Strength of
Level of recommendations recommenda-
Evidence according to the tion after
selected CPG Adopt/adapt
Newborn hearing screening documentation.
Can include the recording of screening results

into the medical record, electronic health record,
10. Documentation discharge summary, or Early Hearing Detection NR Not Reported +++
and Identification (EHDI) data system.
Screening results must be provided to the family

and the newborn’s physician.
Parent/guardian awareness and education
begins before an infant is screened.
11. Counseling and Educational materials can be provided orally or NR Not Reported ++++
education written included in patient education packets, in
culturally appropriate preferred language of the
family.
Medical physicians and nurses play a major role
12. Loss to follow in the care of infants who do not pass or do not
up (LTF)/loss to receive a newborn hearing screening, helping NR Not Reported ++++
documentation (LTD) families understand the EHDI process and
encouraging prompt follow-up.
Ongoing efforts to improve EHDI systems so that
13. System issues babies who do not pass their newborn hearing NR Not Reported ++++
screening are not LTF or LTD.
Various quality indicators and benchmarks

can be used to evaluate quality assurance
and performance relative to screening and
diagnosis.
Benchmark of newborns who complete screening

(by 1 month) is 95%.
Benchmark for the referred cases for diagnostic

14. Program evaluation audiologic evaluation is 4%.
and quality assurance
Benchmark of newborns who did not pass the
screening and went for comprehensive diagnostic
audiologic evaluation by 3 months is 90%.
Benchmark of infants obtaining amplification
within 1 month of hearing loss confirmation for
families choosing that option is 95%.
Evaluation of the program by complete data

collection.*ASHA (2018).
NHS program committee including: Decision

makers, Administrators, information technology
15. Laws and Regulations NR Not Reported ++++
personnel (IT), AVM physicians are responsible
for program laws and regulations.
According to each university fund &raising
16. Program funding NR Not Reported ++++
facilities.
*ASHA 2018: American Speech- Language –Hearing Association, Newborn hearing screening.
*JCIH 2019: Joint Committee on Infant Hearing: position statement: Principles and Guidelines for early hearing detection and intervention.

Medicine

Medicine

Medicine

Medicine
References 6. Italian Guidelines Newborn hearing screening protocol in
Tuscany region Italian journal of pediatrics. 2017.
1. World health organization (WHO): Newborn and infant
hearing screening current issues and guiding principles for 7. American speech language hearing association (ASHA)
action. 2009. Guidelines: Newborn Hearing Screening. 2018.
2. Belgium Guidelines: Newborn hearing screening in Belgium: 8. Astralian Guidelines: Queensland Health Screening Protocols
a consensus recommendation on risk factors BMC Pediatrics. and Guidelines 2019, https://www.childrens. health.qld.
2015. gov.au/chq/our-services/community- health-services/
healthy-hearing- program/screening/ 2019.
3. Malaysian Guidelines: Ministry of health, Malaysia. 2015.
9. German Guidelines: Newborn and infant screening- facing
4. Malawian Guidelines: Setting up a Newborn Hearing globally growing numbers of people suffering from disabling
Screening Programme in a Low-Income Country: Initial hearing loss International Journal of Neonatal screening
Findings from Malawi, International Journal of Neonatal 2019.
screening. 2017.
10. Joint Committee on Infant Hearing (JCIH) Guidelines: Year
5. Indian Guidelines: Consensus Statement of the Indian 2019 Position Statement: Principles and Guidelines for Early
Academy of Pediatrics on Newborn Hearing Screening The Hearing Detection and Intervention Programs The journal
national consultation meeting for developing IAP guidelines of early hearing detection and intervention. 2019.
on neuro-developmental disorders. 2017.

Medicine
Benign Paroxysmal Positional Vertigo (BPPV): Adapted Egyptian Clinical
Practice Guidelines

Assembly board: Nagwa Hazzaa,9 Mohamed El Badry,10 Nahla Gad,11 Lamees El-Amragy9
Adel Abdel Maksoud,9 Abeir Dabbous,7 Iman El Adawi,12 Iman El-Danasoury,9 Tarek ElDessouky,13 Mai El Gohary,14 Wafaa El Kholy,9 Trandil
El Mehallawi,15 Enas El Sayed,16 Reham Elshafei,17 Amira El Shennawy,7 Naema Ismail,12 Enaas Kolkaila,15 Rabab Koura,13 Salwa Mahmoud,14
Radwa Mahmoud,18 Soha Mekki,11 Iman Mostafa,13 Mona Mourad,19 Abir Omara,14 Mohamed Salama,16 Hesham Sami,10 Hesham Taha,9 Somia
Tawfik,9 Ragaey Youssef13
Reviewers: Mohamed Shabana,7 Alaa Abou Setta,20 Hossam A.Ghaffar21
1
Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 2Otorhinolaryngology Department, Faculty of Medicine/ Menoufia
University, 3Otorhinolaryngology Department, Faculty of Medicine/Minia University, 4Otorhinolaryngology Department, Faculty of Medicine/
Bani-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 6Otorhinolaryngology Department, Faculty
of Medicine/Tanta University, 7Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Audiovestibular Unit, Otorhinolaryngology Department, Faculty of
Medicine/ Ain Shams University,10 Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 11Audiovestibular
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 12Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Al Azhar University, 13Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Bani-Suef University,
14
Audiovestibular Unit, Otorhinolaryngology Department/ Hearing and Speech Institute, 15Audiovestibular Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Tanta University, 16Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Assiut University,
17
Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University,18Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Banha University, 19Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Alexandria
University, 20Audiovestibular Unit, Otorhinolaryngology Department, Faculty of Medicine/ Suez Canal University, 21Audiovestibular Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Helwan University.
Introduction and background maneuvers. The target patient for the guideline is aged ≥18
years with a suspected or potential diagnosis of BPPV.
Benign paroxysmal positional vertigo (BPPV) is a very common
cause for dizziness and vertigo in the general population. It is Methods
estimated that over one third of dizzy patients referred to a
dizziness clinic have BPPV. Many maneuvers were proposed for The adaptation cycle passed over: set up phase, adaptation
treatment of BPPV. Persistent symptoms for unresolved BPPV phase (Search and screen, assessment: Currency, Content and
after successful maneuver or atypical pattern of nystagmus Quality and Decisions/selection) and finalization phase that
should raise the index of suspicion include revision.
Scope and Purpose Results
The primary purposes of this guideline are to improve the quality Four guidelines were assessed by four audiovestibular medicine
of care and outcomes for BPPV by improving the accurate and experts and the American Academy of Otolaryngology—Head
efficient diagnosis of BPPV, reducing the inappropriate use of and Neck Surgery Foundation (2017) had the highest scores as
vestibular suppressant medications, decreasing the inappropriate regards to the currency, contents and quality. It was graded by
use of ancillary testing such as radiographic imaging, and 25 audiovestibular medicine consultants and reviewed by three
increasing the use of appropriate therapeutic repositioning expert reviewers.
Grade Definition
++++
Moderate We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there
Low Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
++
Very Low We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate
+ of effect
Benign Paroxysmal Positional Vertigo (BPPV) 2021 (Volume 1) Pages: 145-150 145
Medicine
Accepted statements
Modified statements
Added statements
Levels of evidence
Grade CEBM
Treatment Harm Diagnosis Prognosis
Level
Systematic reviewa Systematic reviewa of

of randomized trials, nested cross-sectional studies
Systematic reviewa of Systematic reviewa of
A 1 with consistently applied
randomized trials case control studies, or inception cohort studiesb
observational studies with reference standard and
blinding
dramatic effect
Randomized trials or Randomized trials or Cross-sectional studies
observational studies with observational studies with with consistently applied
B 2 Inception cohort studiesb
dramatic effects or highly dramatic effects or highly reference standard and
consistent evidence consistent evidence blinding
Nonconsecutive studies; Cohort study, control
Nonrandomized controlled
case-control studies; arm of a randomized
cohort or follow-up study
Nonrandomized or historically or studies with poor, trial, case series, or
(postmarketing surveillance)
controlled studies, including nonindependent, or case-control studies;
C 3-4 with sufficient numbers to
case-control and observational inconsistently applied poor-quality prognostic
rule out a common harm;
studies reference standards cohort study
case-series, casecontrol, or
historically controlled studies
D 5 Case reports, mechanism-based reasoning, or reasoning from first principles
Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit
X n/a
over harm
Adapted from Howick and coworkers (2015).

Abbreviation: CEBM, Oxford Centre for Evidence-Based Medicine.
aA systematic review may be downgraded to level B because of study limitations, heterogeneity, or imprecision.
bA group of individuals identified for subsequent study at an early uniform point in the course of the specified health condition or before the
condition develops.
146 2021 (Volume 1) Pages: 145-150 Benign Paroxysmal Positional Vertigo (BPPV)
Medicine
BPPV Action Statements
Statement topic Egyptian Recommendation
Clinicians should diagnose posterior semicircular canal
BPPV when vertigo associated with torsional, up beating
1.Diagnosis nystagmus is provoked by the Dix-Hall pike maneuver,
of posterior performed by bringing the patient from an upright to Strong
B
semicircular canal supine position with the head turned 45° to one side Recommendation ++++
BPPV and neck extended 20° with the affected ear down. The
maneuver should be repeated with the opposite ear
down if the initial maneuver is negative.
If the patient has a history compatible with BPPV and the
2.Diagnosis of
Dix-Hallpike test exhibits horizontal or no nystagmus,
lateral (horizontal)
the clinician should perform, or refer to a clinician who B Recommendation
semicircular canal
can perform, a supine roll test to assess for lateral ++++
BPPV
semicircular canal BPPV.
Clinicians should differentiate, or refer to a clinician who
3.Differential
can differentiate, BPPV from other causes of imbalance, C Recommendation
diagnosis
dizziness, and vertigo. ++++
Clinicians should assess patients with BPPV for factors
that modify management ,by the recommended
4.Modifying factors repositioning maneuvers, including impaired mobility C Recommendation +++
or balance, central nervous system disorders, a lack of
home support, and/or increased risk for falling.
5.Radiographic Clinicians should not obtain radiographic imaging in a Recommendation
C ++++
testing patient who meets diagnostic criteria for BPPV. (against)
Clinicians should not order laboratory vestibular testing
in a patient who meets diagnostic criteria for BPPV
in the absence of additional vestibular signs and/or
Recommendation
6.Vestibular testing symptoms inconsistent with BPPV that warrant testing. C +++
(against)
Also if recurrence or persistence of complaint after
repositioning according to history & exam or in the
presence of atypical nystagmus.
Clinicians should treat, or refer to a clinician who can
7.Repositioning treat, patients with posterior canal BPPV with a canalith
Strong
procedures as initial repositioning procedure. Epley’s or Semont’s are A ++++
Recommendation
therapy (a) equivocally effective for posterior canal BPPV. Semont’s
is recommended in cupulolithiasis than Epley’s.
8.Repositioning The barbecue roll maneuver or Gufoni maneuver appear
procedures as initial moderately effective for the geotropic form of lateral C Recommendation +++
therapy (b) semicircular canal BPPV.
Clinicians may not routinely recommend post procedural
postural restrictions after canalith repositioning
procedure for posterior canal BPPV. Post procedural
Strong
9.Post procedural postrural restriction might be recommended in
A Recommendation
restrictions selected cases as in failure (or repeated failure) of
(against) +++
the repositioning maneuvers, recurrent cases, or cases
associated with other vestibular pathology as MD or
vestibular Migraine.
1-2 sessions would resolve the condition in 87-100% of ++++
10.Number of CRP
patients. A minority would require a 3ed trial. Otherwise C Recommendation
repetitions
persistent BPPV is suspected.
Clinicians should start with CRP (or modified) even
11.If there is
in those patients who are very obese; have severe
difficulty in
cervical or lumber discs; or upon patient’s preference.
performing C Recommendation ++++
In the latter case patients should be instructed to
successful
avoid activities that may increase the risk of falls until
maneuver
symptoms resolve.
Clinicians may offer observation with follow up only if
there is difficulty in performing successful maneuver
12.Observation as
after trials in some patients as : very obese; severe C Recommendation ++++
initial therapy
cervical or lumber discs; or upon patient’s preference
not to repeat the maneuver.
Medicine
Statement topic Egyptian Recommendation
VR should be considered an option in the treatment of
BPPV rather than a recommended first-line treatment
modality. Home based Brandt-Daroff exercises is
indicated in patients with persistent dizziness or
Vestibular
imbalance after successful CRP or patients who refuse B Option
rehabilitation
CRP.A more comprehensive customized VR program is ++++
indicated in patients with other vestibular pathology
or with comorbid impairments that require balance
rehabilitation specially in elderly.
Clinicians should not treat BPPV with vestibular
suppressant medications such as antihistamines and/
Recommendation
or benzodiazepines. Exceptions: Prior to CRP in patients
Medical therapy B ++++
with severe nausea and/or vomiting, or patients (against)
previously manifested severe nausea and/or vomiting
during testing.
Clinicians should reassess patients within an initial
period of observation following the canalith repositioning
Outcome
procedure ( 40 minutes up to one week) to document D Option
assessment
resolution, need for repetition of CRP session or ++++
persistence of symptoms.
Clinicians should evaluate, or refer to a clinician who
Evaluation of can evaluate, patients with persistent symptoms for
C Recommendation ++++
treatment failure unresolved BPPV and/or underlying peripheral vestibular
or central nervous system disorders.
Clinicians should educate patients regarding the impact

Patient Education of BPPV on their safety, the potential for disease C Recommendation ++++
recurrence, and the importance of follow-up.
Medicine
Medicine
References 11. Cakir BO, Ercan I, Cakir ZA, et al. What is the true
incidence of horizontal semicircular canal benign
1. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo? Otolaryngol Head
paroxysmal positional vertigo. Arch Otolaryngol. Neck Surg. 2006;134:451-454.
1980;106:484-485.
12. Phillips JS, FitzGerald JE, Bath AP. The role of
2. Brandt T, Steddin S, Daroff RB. Therapy for benign the vestibular assessment. J Laryngol Otol.
paroxysmal positioning vertigo, revisited. Neurology. 2009;123:1212-1215.
1994;44:796-800.
13. Breverna MV, Bertholon BP, Brand TC, et al. Benign
3. Gordon CR, Shupak A, Spitzer O, et al. Nonspecific paroxysmal positional vertigo: Diagnostic criteria.
vertigo with normal otoneurological examination: the Consensus document of the Committee for the
role of vestibular laboratory tests. J Laryngol Otol. Classification of Vestibular Disorders of the Bárány
1996;110:1133-1137. Society Journal of Vestibular Research 2015;25:105–
117.
4. Kentala E, Pyykkö I. Vertigo in patients with benign
paroxysmal positional vertigo. Acta Otolaryngol 14. Howick, J, Chalmers, I, Glasziou; OCEBM Levels of
Suppl. 2000;543:20-22. Evidence Working Group. The Oxford 2011 levels of
evidence. http://www.cebm.net/index.aspx?o=5653.
5. Oghalai JS, Manolidis S, Barth JL, et al. Unrecognized
Accessed October 22, 2015.
benign paroxysmal positional vertigo in elderly
patients. Otolaryngol Head Neck Surg. 2000;122:630- 15. McDonnell MN, Hillier SL. Vestibular rehabilitation for
634. unilateral peripheral vestibular dysfunction. Cochrane
Database Syst Rev. 2015;(1):CD005397.
6. Casani AP, Vannucci G, Fattori B, et al. The treatment
of horizontal canal positional vertigo: our experience 16. Takao I, Noriaki T, Tetsuo I, et al. Classification,
in 66 cases. Laryngoscope. 2002;112:172-178. diagnostic criteria and management of benign
paroxysmal positional vertigo. Committee for
7. Cohen HS, Kimball KT. Treatment variations on the
Standards in Diagnosis of Japan Society for Equilibrium
Epley maneuver for benign paroxysmal positional
Research Auris Nasus Larynx. 2017;44:1–6.
vertigo. Am J Otolaryngol. 2004;25:33-37.
17. Bhattacharyya N , Gubbels SP , Schwartz SR , et al.
8. Gamiz MJ, Lopez-Escamez JA. Health-related
Clinical practical guidelines : Benign paroxysmal
quality of life in patients over sixty years old with
positional vertigo (update).Otolaryngology– Head
benign paroxysmal positional vertigo. Gerontology.
and Neck Surgery 2017, Vol. 156(3S) S1–S47.Clinical
2004;50:82-86.
Practice Guideline: Benign Paroxysmal Positional
9. Prokopakis EP, Chimona T, Tsagournisakis M, Vertigo (Update); AAO-HNS Otolaryngol Head Neck
et al. Benign paroxysmal positional vertigo: 10- Surg. 2017;156(3_suppl): S1-S47.
year experience in treating 592 patients with
18. Pérez-Vázquez P, Franco-Gutiérrez V, Soto-Varela
canalith repositioning procedure. Laryngoscope.
A, et al. Practice Guidelines for the Diagnosis and
2005;115:1667-1671.
Management of Benign Paroxysmal Positional
10. White J, Savvides P, Cherian Net al. Canalith Vertigo. Otoneurology Committee of Spanish
repositioning for benign paroxysmal positional Otorhinolaryngology and Head and Neck Surgery
vertigo. Otol Neurotol. 2005;26:704-710. Consensus Document Acta Otorinolaringol Esp.
2018;69(6):345-366.
Chapter 5
Phoniatrics
Late Language Emergence & Autism Spectrum Disorders
Chapter 5: Phoniatrics Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG
Late Language Emergence / Language Delay Language Disorders / Autism

Spectrum Disorders: Adapted Egyptian Clinical Practice Guidelines
Scientific Board: Ashraf Khaled,4 Mahmoud Abdel Aziz,5 Mohamed Ghonaim,6 Tarek Ghanoum,7 Mahmoud Youssef8
Phoniatrics Manager: Mahmoud Youssef8
Phoniatrics Executive Manager: Dalia Mostafa9
Assembly Board: Dalia Mostafa Osman,9 Yossra Abdel Naby Sallam,10 Rehab Abd ElHafeez Zaytoun,11 Ahmed Ali AbdelMonem12
Ahlam El Adawy,17 Ahmed Ali,12 Aisha Fawzy,9 Asmaa El Dessouky,18 Aya Sheikhany,9 Azza Abdel Aziz,13 Dalia Mostafa,9 Essam
Aref,16 Hemmat El Baz,15 Iman El Roubi,13 Mahmoud Youssef,8 Nervana Hafez,8 Omayma Afsah,15 Rasha Safwat,9 Rehab Zaytun,11
Safaa El Sady,8 Salwa Ahmed,14 Youssra Sallam10
Reviewing Board: Hossam El Dessouky,9 Sahar Shohdi,9 Azza Adel Aziz9
1
Medicine/Menoufia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 4Otorhinolaryngology
Department, Faculty of Medicine/Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Tanta University,
6
Otorhinolaryngology Department, Faculty of Medicine/Mansoura University, 7Audiovestibular Unit, Otorhinolaryngology
Ain Shams University, 9Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 10Phoniatrics
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Al-Azhar University, 11Phoniatrics Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Fayoum University, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/
Beni-Suef University, 13Phoniatrics Unit, Otorhinolaryngology Department/Hearing and Speech Institute, 14Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Banha University, 15Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Mansoura University, 16Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Assiut
University, 17Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 18Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Menoufia University.
Introduction and background Currency, Content and Quality and Decisions/

selection) and finalization phase that include revision.
Late language is diagnosed when language development
skills are below age expectations. On the other hand,
Autism spectrum disorder is a neurodevelopmental Results
disorder characterized by social communication deficits,
along with restricted, repetitive behaviors. Children, with Three guidelines for language delay and five guidelines
such difficulties, are expected to be at risk for developing for language disorders & autism spectrum disorders)
literacy, social and academic difficulties if left untreated. were assessed by 4 experts in phoniatrics and the ASHA
Thus, it is crucial to properly evaluate and intervene Practice Portal (2014; regularly updated) had the highest
such children; each according to his/her areas of need scores as regards to the currency, contents and quality.
and strength, using proper evaluation & therapeutic It was graded GRADE by 18 expert phoniatricians and
techniques. reviewed by 3 expert reviewers.
The purpose of this guideline Explanation of Levels of Evidence and Grades of

Recommendation:
The purpose of this guideline is to identify quality
improvement techniques that can be used in assessing • Level A Evidence: Strong evidence;
and intervening children having language delay and / recommendations are consistently and strongly
or disorders including those having Autism Spectrum supported by two or more studies that met the
Disorders in order to create explicit and actionable criteria for adequate evidence about efficacy and had
recommendations that could be, accordingly, implemented at least moderate applicability to the topic
in clinical practice. The goals are specifically to promote
• Level B Evidence: Moderate evidence;
evaluation techniques, improve diagnostic accuracy,
recommendations are supported by at least one
and ensure efficient use of rehabilitation methods in a
study that met criteria for adequate evidence about
systematic manner.
efficacy and had at least moderate applicability to the
Methods topic
The adaptation cycle passed over: set up phase, • Level C Evidence: Limited evidence;
adaptation phase (Search and screen, assessment: recommendations are supported by at least one
study that met criteria for adequate evidence about
Late Language Emergence & Autism Spectrum Disorders 2021 (Volume 1) Pages: 151-170 151
Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG Chapter 5: Phoniatrics
efficacy and had at least minimally acceptable ◊ The unique set of personal and cultural circumstances,
applicability to the topic values, priorities, and expectations identified by your
client and their caregivers
• Level D Evidence: Panel consensus opinion (either
D1 or D2 based on the criteria below): The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) approach to
◊ Level D1 Evidence: Panel consensus opinion based Decision frameworks (GRADE Working Group 2013) 3.
on information not meeting criteria for adequate
evidence about efficacy on topics where a systematic Grade Definition
review of the literature was done
High ++++
◊ Level D2 Evidence: Panel consensus opinion on
topics where a systematic literature review was not We are very confident that the true effect lies close to that
done of the estimate of the effect.
Evidence-based practice (EBP) is the integration Moderate +++

of
We are moderately confident in the effect estimate: the
• Clinical expertise/expert opinion true effect is likely to be close to the estimate of the effect,
but there is a possibility that it is substantially different
◊ The knowledge, judgment, and critical reasoning
acquired through your training and professional Low ++
experiences
Our confidence in the effect estimate is limited: the true
• Evidence (external and internal) effect may be substantially different from the estimate of
the effect.
◊ The best available information gathered from the
scientific literature (external evidence) and from data Very Low +
and observations collected on your individual client
We have very little confidence in the effect estimate: the
(internal evidence)
true effect is likely to be substantially different from the
• Client/patient/caregiver perspectives estimate of effect.
Accepted statements
Modified statements
Added statements
152 2021 (Volume 1) Pages: 151-170 Late Language Emergence & Autism Spectrum Disorders
Guidelines for Late Language Emergence
Strength of the
Strength Average grad-
Statement Level of recommendation
Action Recommendations after Adapta- ing for review-
Topic Evidence according to the
tion/adoption ers
selected CPG
1-Relevant case history, includes family’s

concerns about the child’s speech and lan-
guage; birth, medical, and developmental
history; history of middle ear infections;
Case history Not present Not Reported ++++ High ++++ High
family history of late language emergence
or other language difficulties; language his-
tory and proficiency for children who are du-
al-language learners.
2-If motor/ neurological problems are re-

ported by parents or observed during the
Not present Not Reported ++++ High ++++ High
initial interview or screening, a referral for
neurological examination will be needed.
3-If syndrome features are suspected, a re-

ferral for genetic testing should be consid- Not present Not Reported ++++ High +++Moderate
ered and discussed with parents.
4-Psychometric and neurodevelopment as-

sessments must be considered*.
5-If feeding and/or swallowing problem is

suspected (including drooling, choking at-
tacks, feeding difficulties, repeated attacks
of chest infections), etc.; a referral for nec- Not present Not Reported ++++ High ++++ High
Referrals essary instrumental assessment techniques
based on case and relevant therapeutic methods must be
history report considered.
6-Audiological assessment is crucial in the

assessment process of any child presenting
with language delay and/or disorder (includ-
ing Autism Spectrum Disorder) in order to
rule out the existence of any hearing impair-
ment*.
7-Electroencephalography can be recom-

mended in certain cases particularly for chil-
dren with history of absence (pyknolepsy)
and/or convulsions.
8-Brain imaging can be considered in chil-
dren with history of serious head trauma;
Not present Not Reported ++++ High +++Moderate
followed by loss of consciousness and/or
vomiting.
N.B.
*Psychiatric consultation can be considered in children with severe Attention Deficit Hyperactivity Disorders / Autism Spectrum disorders.
**Audiological assessments can include central auditory testing in school-aged children; referred for language difficulties & language-based
learning disabilities.
Strength of
recommenda- Strength after
Statement Level of Evi- Average grading
Action Recommendations tion according Adaptation/
Topic dence for reviewers
to the select- adoption
ed CPG
Medical/ 9- A child with a severe speech/language

Level D2 evidence
health delay should receive a comprehensive
(clinical expertise)
referrals health assessment to identify or rule out Not Reported +++ Moderate ++++ High
ASHA evidence
whenever medical conditions that might be related to
map
indicated the delay.
10-It is important that the phoniatrician

uses screening and assessment tools that
provide the most representative sample of
Screening Not Present Not Reported +++ Moderate ++++ High
the child’s behaviors across a range of peo-
ple and activities within the child’s natural
environments.
11-Pre-assessment planning involves one or

more professionals who meet with the child
and family to gather information and plan
the upcoming assessment. Common goals
Pre-as-
for planning include identifying what the Boone, H., &
sessment Not Reported +++ Moderate +++ Moderate
family needs and wants from the assess- Crais, E. R. (2001)
Planning
ment process, the roles that family mem-
bers (and caregivers) would prefer to take
in the assessment, and the child’s areas of
strength and need.
12-Assessment is accomplished using a va-

riety of measures and activities, including
Dollaghan, C.
both standardized and non-standardized
(2004). Evi-
measures, as well as formal and informal
Assessment dence-based
assessment tools. Phoniatricians have Not Reported ++++ High ++++ High
Measures practice in com-
the obligation to ensure that standardized
munication disor-
measures used in assessment show robust
ders
psychometric properties that provide strong
evidence of their quality.
Raaijmakers MF,
Dekker J, Dejon-
13-For each individual, assessment must ckere PH & Zee
take into account the body functions and J van der (1995)
structures, activity (e.g. communication Evidence Level III B
Assessment
++++ High ++++ High
components skills), participation (e.g. functional use of Raaijmakers MF, RCSLT
language) and contextual factors (environ- Dekker J & De-
mental and personal factors). jnckere PH (1998)
Evidence Level III
(RCSLT)
Oral
mechanism 14-Assessment includes oral mechanism ex-
examination amination (structure, power function and
Not Present Not Reported ++++ High ++++ High
& speech programming) and speech sound assess-
sounds as- ment
sessment
Strength of the
Strength Average
recommenda-
Statement after Ad- grading
Action Recommendations Level of Evidence tion according
Topic aptation/ for review-
to the selected
adoption ers
CPG
15-Following initial assessment,

a differential diagnosis should be
formed, taking into account all
the available information in order
to exclude the existence of any Professional consensus (RCSLT)
associated hearing impairment, for the part NOT underlined only.
Differential autism spectrum disorder or social The rest has been suggested and
Not Reported ++++ High ++++ High
Diagnosis communication disorder, dyspraxia the whole modified statement
(verbal, oral ± motor), co-morbid was subjected to consensus
attention deficit hyperactivity dis- panel scoring
order, cognitive delay, global devel-
opmental delay or central auditory
processing difficulties and learning
disabilities.
16-Screening and assessment re-

sults are interpreted within the
context of a child’s overall devel-
Interpreta- opment and in collaboration with Not Present Not Reported ++++ High ++++ High
tion of results family members and with other
professionals as appropriate.
• Glogowska M,
Campbell R, Peters
T J, Roulstone S &
17-A clear explanation of the be-
Enderby P ( 2001)
havior/disorder will be offered to
Evidence Level III
the individual and their family, with
Sharing re-
written information to reinforce Not Reported ++++ High ++++ High
sults • Langhorne P &
this. Pollock A (2002)
Evidence Level III
Pollack MR & Disler
PB (2002) Evidence
Level IV(RCSLT)
18- For bilingual children, appro-

Special con- priate assessment in all languages
+++
siderations in is necessary to differentiate be- Not Present Not Reported ++++ High
Moderate
bilingualism tween a linguistic difference and a
true communication disorder.
19- In most bilingual cases, the

use of standardized tests alone is
Special con-
not sufficient and cannot be used +++ +++
siderations in Not Present Not Reported
to decisively determine the pres- Moderate Moderate
bilingualism
ence or absence of a communica-
tion disorder.
20- A severe speech/language de-

lay can be indicated by no words
at 18 months; fewer than 30 words
at 24 months; or no word combi-
nations at 36 months. However, it
Identification
should be noted that at 18 months, Level B evidence
of severe +++ +++
the condition mentioned above Not Reported
speech/lan- Moderate Moderate
can be considered as language ASHA evidence map
guage delay
delay but not necessarily severe as
some children catch up, to some
extent with their peers, provided
that they are given the family is
given the appropriate counselling
Strength of the
recommenda- Strength after Average
Statement Level of Evi-
Action Recommendations tion according Adaptation/ grading for
Topic dence
to the selected adoption reviewers
CPG
21- Children who continue to have poor lan-

guage abilities below chronological age expec-
Identifi-
tations (by late preschool or school age) that Archibald, L.
cation of
cannot be explained by other factors (e.g., low M., & Gath-
Specific Not Reported +++ Moderate +++Moderate
nonverbal intelligence, sensory impairments, ercole, S. E.
Language
or autism spectrum disorder) may be identi- (2007).
Impairment
fied at that point as having Specific Language
Impairment.
22-Management will be planned, based on the

results of information gathering/assessment
and consequent hypothesis formation and un-
Hypothesis
derstanding of the theoretical frameworks rel- Not Present Not Reported ++++ High ++++ High
formation
evant to the behavior/disorder and knowledge
of the different approaches to intervention/
management.
23-A management plan, with provisional

timescales, will be drawn up in consultation
Manage- with the individual. It will be shared with their John A (1998)
ment Plan- caregiver and other professionals and will de-
ning & Goal tail the aims, objectives and expectations of Evidence Level
Setting intervention/management. Goals should be IV
identified relating to the individual’s activity,
participation and well-being.
24-For children between 18 and 36 months Level B

with a speech/language delay and no other evidence
Initiation
apparent developmental issues, speech-lan- Not Reported ++++ High +++ Moderate
of therapy
guage treatment should be initiated; whether ASHA evidence
direct / indirect methods. map
25-When no other developmental delays or

disabilities have been identified or are sus-
Indirect
pected, the typical course for a late talker,
interven- Not Present Not Reported ++++ High ++++ High
less than 2 years, is regular monitoring or
tion
monitoring combined with indirect language
stimulation.
Roles and
Responsibilities
of Speech-Lan-
26- Because young children (less than 2 guage Pathol-
years) learn through familiar, natural activities, ogists in Early
Interven- it is important for the phoniatrician to provide Intervention:
tion for information that promotes the parents’ and/or Guidelines. Ad
young other caregivers’ abilities to implement com- Hoc Commit-
children munication-enhancing strategies during those tee on the
everyday routines, creating increased learning Role of the
opportunities and participation for the child. Speech-Lan-
guage Pathol-
ogist in Early
Intervention.
Strength of
the recom- Strength
Average
Statement mendation after Ad-
Action Recommendations Level of Evidence grading for
Topic according to aptation/
reviewers
the selected adoption
CPG
27- When language delays persist over time, or

are present with other identified or suspected
delays or disabilities (e.g., intellectual disabilities,
Direct inter- autism spectrum disorder, hearing impairment),
vention direct speech and language services are indicat-
ed; the phoniatrician coordinates services with
other professionals working with the child. Family
participation is very important.
Intervention 28-Speech and language intervention can include

to promote working on phonology, semantics, morphology
various ineffi- and syntax, pragmatics (including narration), and Not present Not Reported ++++ High ++++ High
cient language literacy (+ other intervention methods used in
skills written language disorders/learning disabilities*)
* Please refer to learning disabilities adapted guideline and its recommendations.
Strength of
the recom- Strength
Average
mendation after Ad-
Statement Topic Action Recommendations Level of Evidence grading for
according to aptation/
reviewers
CPG
29-Within an appropriate context & when-

ever indicated, consideration needs to be
given to the development of the child’s:
Phonological system
Phonological processes
Intelligibility Professional C
Management
consensus
of phonology
Phonetic system RCSLT ++++ High ++++ High
& articulation (For the sections
problems Phonetic errors NOT underlined)
Self-monitoring
Pre-literacy skills
Literacy skills
Prosody & resonance
Tallal P, Stark RE &

Management 30-The phoniatrician should consider the Mellits ED (1985) B +++
of Processing child’s ability to process speech as a critical Evidence Level IIa ++++ High
Moderate
problems skill for speech and language development. (RCSLT)
RCSLT)
31-The multidisciplinary team may include
an audiologist, early childhood general and
special education teachers and interpreter
(if needed), neurodevelopmental pediatri-
cian, occupational therapist, physical ther-
Multidisciplinary apist and school psychologist, phoniatrician, +++
Not Present Not Reported ++++ High
team qualified speech & language therapist ± Moderate
childcare providers, educational diagnos-
ticians, educational therapists, reading
specialists, social workers, child and devel-
opmental psychologists, pediatric neurolo-
gists, and child psychiatrists.
Strength of
the recom-
Strength after Average
Statement mendation
Action Recommendations Level of Evidence Adaptation/ grading for
Topic according to
adoption reviewers
the selected
CPG
32-It is essential that all the professionals

Multidisci- involved in the multidisciplinary team have
plinary team the capacity to collaborate effectively and
collectively.
33-It is essential that all the professionals
involved in the multidisciplinary team possess
knowledge of typical and atypical patterns of
Multidisci- development in the domains of cognition; Not present Not Reported ++++ High ++++ High
plinary team communication; emergent literacy; and
motor, sensory, and social-emotional
functioning.
34-Augmentative or alternative communica-
Augmen-
tion methods may be considered as a tempo- (Lüke, 2014; Romski
tative &
rary means of communication for late talkers, et al., 2010; Wright, +++ Mod-
Alternative Not Reported ++++ High
particularly in severe cases. Research shows Kaiser, Reikowsky, & erate
Communica-
that use of AAC may aid in the development Roberts, 2013).
tion
of natural speech and language
35-Augmented input is based on the con- Binger, C., & Light, J.
cept that language input provides a model (2006)
for language development. This approach
can lead to increased symbol comprehension Drager, K. D. R.,
in young AAC* users and in users with se- Postal, V. J., Carrou-
vere cognitive or intellectual disabilities, as lus, L., Castellano,
well as increased symbol comprehension and M., Gagliano, C., &
Augmented
production. Augmented input—also called Glynn, J. (2006). Not Reported ++++ High ++++ High
input
“natural aided language” or “aided language
modeling”—is a receptive language training Goossens’, C., Crain,
approach in which the communication part- S. S., & Elder, P.
ner provides spoken words along with AAC* (1992)
symbols during communication tasks (e.g.,
partner points to the AAC* symbols while si- Harris, M., & Reichle,
multaneously talking). J. (2004)
* AAC=Augmentative & Alternative Communication.
Strength of
the recom- Strength
Average
Statement Level of Evi- mendation after Ad-
Action Recommendations grading for
Topic dence according to aptation/
reviewers
CPG
Professional
36-Management aims and objectives must be reviewed
consensus
Reflective regularly and frequently. If anticipated progress is not ++++
(RCSLT) for the Not Reported ++++ High
Practice achieved the therapeutic intervention should be re- High
sections NOT
viewed.
underlined
37-Outcomes of therapy should be routinely measured,

reflecting the range of interventions delivered and the Professional C
Evaluation of ++++
aims agreed for therapy (every 3-6 months; provided consensus ++++ High
outcome High
that the child regularly & consistently attends his/her (RCSLT) RCSLT
previously scheduled sessions).
B-Guidelines for Autism Spectrum Disorders
Strength of the
Strength Average
recommenda-
Statement Level of Evi- after Adap- grading
Action Recommendations tion according
Topic dence tation/adop- for review-
to the selected
tion ers
CPG
1-If the child exhibits warning signs of autism External scientific

spectrum disorder, the child, regardless of age, evidence
Referral should receive a referral for “a communication and Not Reported ++++ High ++++ High
language assessment by a phoniatrician possibly ASHA evidence
specifying with rehabilitation if necessary”. map
2-According to the DSM-5, individuals who meet American Psychi-

Diagnostic the specified criteria are given the diagnosis of “au- atric Association.
Statistical tism spectrum disorder (ASD)” with one of three (2013): Diagnos-
Manual-V levels of severity. tic and statistical Not Reported ++++ High ++++ High
manual of mental
(DSM-V) N.B. DSM-5 reflect a number of changes from disorders (5th
those in the DSM-IV. ed.).
3-Current findings suggest that ADOS [Autism Di-

agnostic Observation Scale] is best for not miss-
ing children who have ASD and is similar to CARS
[Childhood Autism Rating Scale] and ADI-R [Au-
tism Diagnostic Interview - Revised] in not falsely External scientific
diagnosing ASD in a child who does not have ASD. evidence +++ Moderate
ADOS has acceptable accuracy in populations with +++ Mod-
Diagnosis Not Reported
a high prevalence of ASD. However, overdiagnosis erate
ASHA evidence
is likely if the tool is used in populations with a low- map
er prevalence of ASD. This finding supports current
recommended practice for ASD diagnostic tools to
be used as part of a multi-disciplinary assessment,
rather than as stand- alone diagnostic instruments.
Strength of
the recom-
Strength
mendation Average
Statement after Ad-
Action Recommendations Level of Evidence according grading for
Topic aptation/
to the reviewers
adoption
selected
CPG
Baron-Cohen S, Allen J & Gillberg
C (1992) Evidence Level III
McArthur D & Adamson LB (1996)
4-An evaluation of the individual’s Evidence Level III
B
Joint attention ability to direct and maintain shared
++++ High ++++ High
evaluation attention with another individual Mundy P, Sigman M & Kasari
RCSLT
should be completed. CA (1990) Evidence Level III
Charman T (1998) Evidence Level
IV Trevarthen C & Aitken KJ
(2001) Evidence Level IV (RCSLT)
5-An evaluation of the individual’s
Evaluating Pascualvaca DM, Fantie BD,
readiness and ability to focus and
the child’s Papageorgiou M & Mirsky AF B
shift attention will be made. This is
readiness to (1998)Evidence Level III Cooper ++++ High ++++ High
the baseline for determining which
focus and shift J, Moodley M & Reynell J (1978) RCSLT
type of intervention and manage-
attention Evidence Level IV (RCSLT)
ment would be appropriate.
6-It is recommended that all
members of the Assessment
Team consider the individual’s
behavioral presentation and needs
Assessment Clinical expertise Not +++ Mod-
in comparison to other individuals of ++++ High
considerations ASHA evidence map Reported erate
the same gender, and be aware of
how [autism spectrum disorder] ASD
may manifest diferently in males and
females”
Dawson G, Meltzoff AN, Osterling
J, Rinaldi J & Brown E
(1998) Evidence Level III
Wing L & Gould J (1979) Evidence
Level III
Wimpory DC, Hobson RP, Williams
7-It is essential to make a qualitative
Assessment JM & Nash S (2000) Evidence Level
assessment of the individual’s social B
of the child’s III +++ Mod- +++Mod-
interaction skills in a variety of social
social Interac- Frith U (1989) Evidence Level IV erate erate
settings such as a school, nursery or RCSLT
tions Happe F (2001)
day center.
Evidence Level IV
Baron-Cohen S, Wheelwright
S, Cox A, Baird G, Charman T,
Swettenham J, Drew A & Doehring
P (2000)
Evidence Level IV
8-It is recommended that all mem-

bers of the Assessment Team con-
sider racial, ethnic, and/or socioeco- Clinical expertise
Assessment Not +++ Mod-
nomic background of the individual ++++High
considerations Reported erate
and how cultural factors may influ- ASHA evidence map
ence the assessment of autism spec-
trum disorder (ASD) concerns. “
Strength of
the recom- Strength
State- Average
Level of mendation after Ad-
ment Action Recommendations grading for
Evidence according to aptation/
Topic reviewers
CPG
9-Depending on the individual’s age and abilities, the

phoniatrician typically assesses:
Receptive language
Comprehen-
Expressive language +++
sive assess- Not Present Not Reported ++++ High
Literacy skills Moderate
ment
Social communication
Conversational skills
Speech prosody
10-Comprehensive assessment for ASD* typically includes

structured, reliable and valid tests (until standardized as-
sessment tools for the Egyptian culture is available) that
Comprehen-
should be culturally and linguistically appropriate, and if ++++
sive assess- Not Present Not Reported ++++ High
the norming sample is not representative of the individual High
ment
assessed, the standard scores should be viewed with cau-
tion; depending on the differences in the Arabic accents
and dialects across different regions in Egypt).
11-When possible, parent checklists should be provided in

++++
Checklists their native language to obtain the most accurate infor- Not Present Not Reported ++++ High
High
mation.
*ASD=Autism Spectrum Disorder
Strength of the Strength

Average
Statement Level of recommendation after Ad-
Action Recommendations grading for
Topic Evidence according to the aptation/
reviewers
selected CPG adoption
12-Observation of the individual in everyday social

settings with others. Criterion-referenced assessments
Naturalistic +++ +++
may be used during naturalistic observations to docu- Not present Not Reported
observation Moderate Moderate
ment an individual’s functional use of language across
social situations.
13-Dynamic Assessment seeks to identify an individ-

ual’s skills as well as his or her learning potential. Dy-
Dynamic +++
namic assessment is highly interactive and emphasiz- Not Present Not Reported ++++ High
assessment Moderate
es the learning process over time. It can be used in
conjunction with standardized assessments.
Evaluation 14-Assessment may also include evaluation of the po-

of potential tential benefit of using augmentative and alternative +++
benefit of communication (AAC) to facilitate functional improve- Moderate
using AAC* ments
Differential 15-It is important to differentiate between Autism
Diagnosis Spectrum Disorder and social communication disorder. +++
ASD** vs. Phoniatricians will be instrumental in making this dif- Moderate
SCD*** ferential diagnosis.

**ASD=Autism Spectrum Disorder.
***SCD=Social Communication Disorder.
Strength of
the recom- Strength Average
Statement Level of mendation after Ad- grading
Action Recommendations
Topic Evidence according aptation/ for re-
to the se- adoption viewers
lected CPG
16-As part of the ongoing assessment process, dynamic
assessment procedures can be used to identify the skills that
Ongoing +++
an individual has achieved, those that may be emerging, and Not present Not Reported ++++ High
assessment Moderate
the contextual supports that enhance communication skills
(e.g., AAC* or modeling).
17-The similarities in communication and socialization symp-
toms between hearing impairment and ASD** populations, Gray, C.,
along with the possibility of dual diagnosis, can present chal- White, A. L., &
lenges for differential diagnosis. An audiologic assessment is McAndrew, S.
conducted when hearing loss and/or ASD** are suspected. (2002)
Audiological Suggestions for assessing hearing in individuals with these Brueggeman, +++
assessment Not Reported ++++ High
and other challenging behaviors include, for example, min- P. M. (2012) Moderate
in ASD** imizing distractions in using the individual’s primary/pre-
ferred language form , increasing the individual’s familiarity Davis, R., &
with assessment procedures prior to testing, allowing the Stiegler, L.
individual to touch and explore earphones; considering the (2010, April
need for auditory brainstem response (ABR) testing when 27)
behavioral audiometry is not possible.
**ASD=Autism Spectrum Disorder.
Strength of the
recommendation Strength
Statement Level of Average grading for
Action Recommendations according to the after Adap-
Topic Evidence reviewers
selected guide- tation
line
18-Diagnostic evaluation may include ge-
netic testing, particularly if there is a fami-
ly history of intellectual disability or genet-
Genetic +++
ic conditions associated with ASD* (e.g., Not present Not Reported ++++ High
Testing Moderate
fragile X, tuberous sclerosis) or if the child
exhibits physical features suggestive of a
possible genetic syndrome.
19-Diagnostic evaluation may metabol-
ic testing, if the child exhibits symptoms
Metabolic such as lethargy, cyclic vomiting, pica, or +++
Not present Not Reported ++++ High
testing seizures. Moderate
20-The phoniatrician’s role includes incor-

porating a family perspective into the as-
sessment, effectively eliciting information Marcus, L. M.,
Conveying
from families about their concerns, beliefs, Kunce, L. J., +++
information Not Reported ++++ High
skills, and knowledge in relation to the in- & Schopler, E. Moderate
to parent
dividual being assessed. It is important to (2005)
convey information to families clearly and
empathetically.
21-Phoniatricans will need to advocate for
inclusion of language intervention for indi-
Language
viduals diagnosed with ASD* and ensure +++
interven- Not present Not Reported ++++ High
that individuals with ASD* also receive a Moderate
tion
diagnosis of language disorder, when they
meet the criteria.
*ASD=Autism Spectrum Disorder.
Strength of
the recom- Strength
Average
Statement mendation after Ad-
Action Recommendations Level of Evidence grading for
Topic according to aptation/
reviewers
CPG
22-Regardless of the presence or absence

of difficulties acquiring the form and con-
Language tent of language, all individuals with ASD
intervention are eligible for speech-language pathology
services due to the pervasive nature of the
social communication impairment.
23-Social communication intervention can

Social com- have moderate effectiveness in increas- External scientific
munication ing early social communication outcomes evidence Not Reported ++++ High ++++ High
intervention (e.g., joint attention, synchronous engage- ASHA evidence map
ment).
Gilchrist, A., Green, J.,

Cox, A., Burton, D., Rutter,
Interven- 24-It is important to provide intervention M., & Le Couteur, A.
tion for to address the gap between cognitive po- (2001)
high-func- tential and social adaptive functioning. As
Mueller, E., Schuler, A. L., Not Reported ++++High ++++ High
tioning indi- high-functioning individuals with ASD pose
Burton, B., & Yates, G.
viduals with particular challenges both for identification
(2003)
ASD and for determining eligibility for services.
Tsatsanis, K. D., Foley, C.,
& Donehower, C. (2004)
Verbal-based
25-The use of verbal-based intervention
intervention
(i.e., focused play intervention) and aug-
& Augmen-
mentative and alternative communication External scientific
tative &
(i.e., Picture Exchange Communication evidence (Limited
Alternative Not Reported ++++ High ++++ High
Systems [PECS]) improve spoken and evidence) ASHA
Communica-
non-verbal communication in minimally evidence maps
tion
verbal children with autism spectrum dis-
order.
Augmen- 26-Augmentative and alternative com-

tative & munication can be considered an evi-
Alternative External scientific
dence-based practice for supporting so-
Communica- evidence
cial-communication skills in individuals Not Reported ++++ High ++++ High
tion with autism spectrum disorder or intellec- ASHA evidence maps
tual disabilities and complex communica-
tion needs.
Important 27-It is preferable not to recommend
recommen- computer-based instructions and video
dation modeling in the Egyptian culture for fear
that these might be overused / misused by Not present Not Reported ++++ High ++++ High
parents and caregivers; thereby increasing
the echolalia and deteriorating the child’s
social communication skills.
Recom- 28-It is important to advice the parents
mendations and caregivers to reduce , or preferably,
regarding totally eliminate whenever possible) the
watching child’s exposure to iPad, cell phones, com-
television puters, etc. in a systematically-planned
& using cell manner and to try to replace these activi-
phones and ties with more interactive, communicative-
iPad ly-enriching ones.
Strength of the Strength Average

Statement recommendation after Ad- grading
Action Recommendations Level of Evidence
Topic according to the aptation/ for re-
selected CPG adoption viewers
The 2002 ASHA Work
Group on AIT, after
reviewing empirical
29-Sensory integration therapies are used ASHA’s position research in the area to
Auditory/ to treat integration dysfunction in one or statement “ Auditory date, concludes that AIT
Sensory more sensory systems. Treatments can Integration Training”, has not met scientific
++++ High ++++ High
Integration include physical exercise, sensory/tactile -The 2002 ASHA standards for efficacy
Training stimulation, and auditory integration train- Work Group on AIT, that would justify its
ing (Berard, 1993). (ASHA, 2004) practice by audiologists
and speech-language
pathologists” (ASHA,
2004).
Applied 30-Applied behavior analysis (ABA) pro-
External scientific
Behavior grams are moderately effective in improving
evidence Not Reported ++++ High ++++ High
Analysis socialization skills in children with autism
ASHA evidence map
(ABA) spectrum disorder.
31-Early intensive behavioral intervention

(EIBI) is an effective treatment for children
Early
diagnosed with autism spectrum disorders External scientific
Intensive
(ASD) with suggested gains in the areas of evidence +++
Behavioral Not Reported ++++ High
adaptive behavior, IQ*, communication, so- (Weak evidence) Moderate
Interven-
cialization, and daily living skills, with the ASHA evidence map
tion
largest gains made in IQ and the smallest
in socialization”.
IQ= Intelligent Quotient.
Strength of the Strength Average

recommendation after Ad- grading
Statement Topic Action Recommendations Level of Evidence
according to the aptation/ for re-
selected CPG adoption viewers
32-Cognitive Behavioral Therapy (CBT)

is an intervention approach with the un-
Cognitive Be- derlying assumption that an individual’s
+++ Mod- +++Mod-
havioral Therapy behavior is mediated by maladaptive Not present Not Reported
erate erate
(CBT) patterns of thought or understanding
and that change in thinking or cognitive
patterns can lead to changes in behavior.
External
33-Parent-implemented interventions scientific
Parent-mediated
are likely to result in meaningful im- evidence ++++
or implemented Not Reported ++++ High
provements in communication for chil- ASHA High
intervention
dren with ASD*. evidence
map
34-Parent-implemented [functional com- External scientific

Parent-imple- munication training] FCT is suggested evidence
mented Functional to produce meaningful reductions in + Clinical perspective ++++
Not Reported ++++ High
Communication challenging behavior and these chang- ASHA evidence map High
Training es tend to generalize to other situations
and maintain over time.
*ASD = Autism Spectrum Disorder.
Strength of
the recom-
Strength Average
mendation
after Ad- grading
Statement Topic Action Recommendations Level of Evidence according
aptation/ for re-
to the
adoption viewers
selected
CPG
35-Peer-mediated or implemented treat-
ment approaches incorporate peers as com-
Peer- implemented munication partners for children with ASD* Not ++++ ++++
Not Present
Treatment in an effort to minimize isolation, provide Reported High High
effective role models, and boost communi-
cation competence.
36-The use of generalization-promotion
++++
Familiar-person strategy (e.g., having a familiar person de- External scientific
Not High ++++
mediated treat- liver intervention, teaching across various evidence
Reported High
ment stimuli and responses) can support success- ASHA evidence map
ful generalization.
37-Interventions delivered by teaching staff External scientific
Teaching staff-me- in an inclusive preschool setting can be ef- evidence Not ++++ +++
diated intervention fective in improving outcomes for young ASHA evidence Reported High Moderate
children with ASD”. map
38-Social communication treatment ap- Adams, C., Lockton, E.,
Social communica- proaches and frameworks are designed to Freed, J., Gaile, J., Earl, Not ++++ ++++
tion interventions increase social skills, using social group set- G., McBean, K., Green, J., Reported High High
tings and other platforms. Vail, A., & Law, J. (2012)
Strength of
the recom- Strength
Average
mendation after Adap-
Statement Topic Action Recommendations Level of Evidence grading for
according to tation/adop-
reviewers
the selected tion
CPG
External scientific
39-Social groups can positively
Group Social Skills evidence
affect social knowledge in youth Not Reported +++ Moderate ++++ High
Intervention ASHA evidence
with ASD.
map
40-Social story interventions can External scientific

Social story inter- have a positive impact on the so- evidence
Not Reported +++ Moderate +++ Moderate
vention cial interaction of students with ASHA evidence
autism spectrum disorder. map
41-Effective transition planning

involves the student as an active,
respected participant of the team Wehman, P.
Transition panning as well as his/her family, who Not Reported +++ Moderate ++++ High
(2006)
can provide valuable information
about the student’s needs.
42-Teachers and other school
personnel can successfully imple-
Functional commu- ment functional communication External scientific
nication training in training to increase appropriate evidence ASHA Not Reported ++++ High ++++ High
school-age children communication in school-aged evidence map
children having autism spectrum
disorders.
43-A peer mentor can serve as a
role model and source of social
skills information and feedback
Role of peers in so- (Lawrence, Alleckson,
in social settings providing op- Not Reported +++ Moderate ++++ High
cial skills modeling & Bjorklund, 2010)
portunities for social involvement
and the development of friend-
ships.
Strength of
Reviewers’
the recom-
Strength average score
mendation
Statement Topic Action Recommendations Level of Evidence after Adap- for strength
according to
tation of recommen-
the selected
dations
CPG
44-In addition to determining the type of
speech and language treatment that is op-
timal for children with social communication
Service delivery disorders, phoniatricans consider other ser- Not present +++ ++++
Not Reported
options vice delivery variables—including format, Moderate High
provider, dosage, and timing—that may im-
pact treatment outcomes.
45-Generalization and maintenance of in-

tervention outcomes are of paramount
Generalization and
importance in achieving socially significant National Research ASHA Practice ++++ ++++
maintenance of
outcomes as they invite higher rates of ini- Council (2001) Portal High High
intervention
tiation and generalization and enhance the
ecological validity of the intervention.
External scientific
evidence
46-The telehealth* component of the inter- A Systematic
vention or assessment have high levels of Search and Review ASHA +++ +++
Telehealth*
program acceptability and parent satisfac- of the Literature Evidence Map Moderate Moderate
tion. Sutherland, R.,
Trembath, D., et al.
(2018)
*telehealth = telepractice.
Flowcharts

**SCD = Social Communication Disorder.
***ADHD = Attention Deficit Hyperactivity Disorder.
****CAPD=Central Auditory Processing Disorder.
N.B.:ASD = Autism Spectrum Disorder.
References 5. https://www.asha.org/Practice-Portal/Clinical-
Topics/Autism/ American Speech-Language-Hearing
1. Royal College of Speech & Language Therapists Clinical Association. 2014, gets regularly updated.
Guidelines (RCSLT): British Library Cataloguing in
Publication Data, Speechmark Publishing Ltd. 2005. 6. https://www.asha.org/Practice-Portal/Clinical-Topics/
Late-Language-Emergence/American Speech-
2. Missouri Autism Guidelines Initiative: Autism Spectrum Language-Hearing Association, 2014, gets regularly
Disorders: Guidance to Evidence-based Practice. 2012. updated.
3. NICE Guideline for Recognition: Referral, Diagnosis 7. https://www.asha.org/Practice-Portal/About/. 2014,
and Management of Adults on the Autism Spectrum. gets regularly updated.
National Clinical Guideline Number 142, National
Collaborating Centre for Mental Health commissioned by 8. https://www.asha.org/Practice-Portal/Clinical-Topics/
the National, Institute for Health & Clinical Excellence, Spoken-Language-Disorders/. 2014, gets regularly
The British Psychological Society & The Royal College of updated.
Psychiatrists. 2012.
9. Clinical Guidelines, Speech Therapy, Version 1: evicore
4. KCE: Management of Autism in Children and Young Healthcare innovative solutions, American Medical
People: A Good Clinical Practice Guideline, KCE Report. Association. 2019.
2014.
Childhood Apraxia of Speech (CAS): Adapted Egyptian Clinical Practice

Guidelines

Phoniatrics Chief Manager: Mahmoud Youssef8
Assembly Board: Hemmat Mostafa Baz10
Aisha Fawzy Abdel Hady,9 Reham Abdelwakil,11 Salwa Ahmed,12 Ahmed Ali,13 Azza Abdel Aziz Azzam,14 Mohammed Darweesh,15
Ahlam Abdel Salam Nabieh El-Adawy,16 Dalia Mostafa Osman,9 Asmaa El Dessouky Rashad,17 Amal Saeed,18 Yossra Salam19
Reviewing Board: Eman Ezat,17 Elham Magdy,18 Zienab Khalaf20
1
Otorhinolaryngology Dep. Faculty of Medicine/Cairo University, 2Otorhinolaryngology Dep. Faculty of Medicine/Menoufia Univer-
sity, 3Otorhinolaryngology Dep. Faculty of Medicine/Minia University, 4Otorhinolaryngology Dep. Faculty of Medicine/Beni-Suef
University, 5Otorhinolaryngology Dep. Faculty of Medicine/Tanta University, 6Otorhinolaryngology Dep. Faculty of Medicine/
Mansoura University, 7Audiovestibular Unit, Otorhinolaryngology Dep. Faculty of Medicine/Cairo University, 8Phoniatrics Unit,
Otorhinolaryngology Dep. Faculty of Medicine/ Ain Shams University, 9Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of
Medicine/Cairo University, 10Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of Medicine/ Mansoura University, 11Phoniatrics
Unit, Otorhinolaryngology Dep. Faculty of Medicine/Assuit University, 12Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of
Medicine/Banha University, 13Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of Medicine/Beni-Suef University, 14Phoniatrics
Unit, Otorhinolaryngology Dep. /Hearing and Speech Institute, 15Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of Medicine/
Tanta University, 16Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of Medicine/Sohag University, 17Phoniatrics Unit, Otorhi-
nolaryngology Dep. Faculty of Medicine/Menoufia University, 18Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of Medicine/
Zagazig University, 19Phoniatrics Unit, Otorhinolaryngology Dep. Faculty of Medicine/Al-Azhar University, 20Phoniatrics Unit, Oto-
rhinolaryngology Dep. Faculty of Medicine/Minia University.
Introduction and background easy to install & understand, compatibility and testability.
Childhood apraxia of speech (CAS) is a neurological childhood Selection of the best & most appropriate guideline was based
(pediatric) speech sound disorder in which the precision and on highest scores which was Guideline I: American Speech-
consistency of movements underlying speech are impaired Language and Hearing Association Childhood-Apraxia-of-
in the absence of neuromuscular deficits (e.g. abnormal Speech (Practice Portal) (2019)
reflexes, abnormal tone). CAS may occur as a result of
known neurological impairment, in association with complex The adaptation cycle passed through the following steps: set
neurobehavioral disorders of known and unknown origin, or up phase, adaptation phase (search and screen, assessment,
as an idiopathic neurogenic speech sound disorder. currency, content, quality and decisions/selection and
finalization phase that included revision.
The core impairment in planning and/or programming
spatiotemporal parameters of movement sequences results Results
in errors in speech sound production and prosody.
The chosen guideline based on the highest scores regarding
To date, there are no available CAS-specific standardized currency, content and quality was graded by 11 phoniatricians
screening tools. In addition, CAS may not be identified during and reviewed by 3 Expert reviewers (Phoniatricians).
screening because the diagnosis sometimes results from
Explanation of Levels of Evidence and Grades of
observations made over the course of treatment
Recommendation
Scope and purpose
Level A: Body of research evidence can be trusted to guide
The aim of the clinical practice guidelines (CPG) is to practice
provide Phoniatricians and Clinicians with explicit statements
Level B: Body of research evidence can be trusted to guide
and recommendations regarding clinical assessment &
practice in most situations
management of CAS that are based on the current evidence.
They can assist in the clinical decision-making process Level C: Body of research evidence provides some support
by providing information on what is considered to be the for recommendation
minimum best practice.
Level D: Body of research evidence is weak
Methods
Good Practice Point (GPP): Recommendation is based on
It was searched for the best evidence-based guidelines. Five expert opinion or consensus
Guidelines were selected. The guidelines selected were then
scored regarding credibility, observability, relative advantage,
Childhood Apraxia of Speech 2021 (Volume 1) Pages: 171-187 171

Grade Definition
++++
Moderate We are moderately confident in the effect estimate: the true effect is likely to
+++ be close to the estimate of the effect, but there is a possibility that it is substan-
tially different
Low ++ Our confidence in the effect estimate is limited: the true effect may be sub-
stantially different from the estimate of the effect.
Very Low We have very little confidence in the effect estimate: the true effect is likely to be substantially different
+ from the estimate of effect
Accepted statements
Modified statements
Added statements
CAS recommendations statements
Average
Statement Level of recommendation after ad-
Action of recommendation grading for
topic evidence according to the aptation/
reviewers
1- Childhood apraxia of speech (CAS) is a neurolog-
ical childhood (pediatric) speech sound disorder in
which the precision and consistency of movements ++++ +++
Level B Strong
underlying speech are impaired in the absence of High Moderate
neuromuscular deficits (e.g. abnormal reflexes, ab-
Definition normal tone).
2- The core impairment in planning and/or pro-
gramming spatiotemporal parameters of movement ++++ ++++
Strong
sequences results in errors in speech sound produc- High High
tion and prosody.
1-estimates of CAS are unreliable due to the

++++ ++++
inconsistency of diagnostic guidelines, lack of Level B Strong
High High
Prevalence adequately validated diagnostic tools.
2-These same factors may also play a role in the +++ +++
frequent over identification of CAS by clinicians Moderate Moderate
1-Inconsistent errors on consonants and vowels in
repeated productions of syllables or words.
2- Lengthened and disrupted coarticulatory transi-

++++
tions between sounds and syllables. Level A Strong ++++
Signs and High High
Symptoms
3- Inappropriate prosody, especially in the realiza-
tion of lexical or phrasal stress. The frequency of
these and other signs may change depending on
task complexity, age of the child, and severity of
symptoms.
4- As in children with other speech disorders, co-oc-
curring language and literacy problems can be pres-
ent, including:
• Delayed language development.

++++ ++++
• Expressive language problems, such as word
High High
order confusion and grammatical errors.
• Problems learning to read, spell, and write;

and
• Problems with social language/pragmatics.
172 2021 (Volume 1) Pages: 171-178 Childhood Apraxia of Speech

Average
reviewers
5- Co-occurring nonspeech sensory and motor
problems can also be present include:
• Gross and fine motor delays.
• Motor clumsiness.
++++ ++++
GPP
• Oral apraxia. High High
• Limb apraxia.
• Feeding difficulties; and abnormal orosensory

perception (hyper- or hyposensitivity in the
oral area).
1.CAS can be congenital, or it can be acquired
during speech development. Both congenital and
acquired CAS can occur.
2.As an idiopathic neurogenic speech sound disorder

(i.e., in children with no observable neurological
abnormalities or neurobehavioral disorders or
conditions). +++ ++
Causes GPP Strong
Moderate Low
3.As primary or secondary signs within complex
neurobehavioral disorders (e.g., autism, epilepsy,
and syndromes, such as fragile X, Rett syndrome,
and Prader–Willi syndrome; or in association with
known neurological events (e.g., intrauterine or
early childhood stroke, infection, trauma, brain
cancer/tumor resection.
Comprehen- To date, there are no available CAS-specific Level A,B Strong +++ +++
sive Assess- standardized screening tools. In addition, CAS Moderate Moderate
ment may not be identified during screening because
the diagnosis sometimes results from observations
made over the course of treatment
1-Language assessment Level A Strong ++++ ++++

High High
• Expressive language skills are delayed.
• Receptive language skills are greater than

expressive language skills.
• Syntax errors and omissions. ++++ ++++

Level A, B Strong High High
• Word sequencing errors.
• Word-finding difficulties.
• Difficulty reading a word. Able to produce each

sound in the word but unable to blend the
sounds together to make a word.

Average
reviewers
2-Perceptual speech characteristics:
Other characteristics that have been reported in
children diagnosed with CAS articulatory groping—
articulatory searching prior to phonating;
consonant distortions
• difficulty with smooth, accurate movement

transitions from one sound to the next;
• increasing difficulty with longer or more

complex syllable and word shapes;
• schwa additions/insertions—insertion of schwa

between consonants or at the end of words;
• slower than typical rate of speech
• syllable segregation—pauses between

sounds, syllables, or words that affect smooth
transitions;
• voicing errors—voiceless sounds produced as

their voiced cognates; and
• Vowel errors—vowel distortions or

substitutions.
3-Motor speech assessment
• nonspeech articulatory postures (e.g., smile)

and sequences (e.g., kiss–smile) versus speech
sounds and words;
• well-practiced/automatic versus volitional

speech;
• speaking tasks that require single postures

versus sequences of postures (e.g., single
sounds such as [a] vs. words, such as [mama]);
++++
• speech production at the single syllable, Level A,B Strong ++++
High
bisyllable, multisyllable, phrase, and sentence High
levels; and
• sequential and alternating movement

repetitions (e.g., [papapa] and [pataka];
• Sequencing errors may consist of inaccuracies,

inconsistency, or mis-ordering sounds.
• In preschool children, consistency and

accuracy of repetitions are likely to be more
useful performance indicators than repetition
rate.

Average
reviewers
4-Dynamic assessment
• Using dynamic assessment procedures, the

cliniian can provide cues (e.g., gestural or
tactileues).
• CAS may manifest as metathesis, coalescence,

syllable deletion, and other word-level errors
due to the longer motor plan required to
+++ +++
produce these words. In languages with a Level A,B Strong
Moderate Moderate
higher frequency of single-syllable words.
• CAS may be more likely to manifest in vowel

errors and inconsistent consonant production
in the early stages of speech development.
• CAS may have an increased impact

on intelligibility and error frequency.
5- Diagnosis Under 3 Years of Age: Differences

include less vocalizations overall, fewer consonants, +++ +++
Level A Strong
a less diverse phonetic repertoire, and later Moderate Moderate
consonant acquisition
6- CAS Versus Speech Delay or Other Speech Sound
Disorders
• Differentiating CAS from some types of

dysarthria
+++ +++
• Less commonly, but on occasion, there is a GPP Strong
Moderate Moderate
need to differentiate between apraxia and
dysfluency (stuttering, cluttering),
• In rare cases, CAS can co-occur with dysarthria

or fluency disorders; therefore, it may not be
an “either-or” diagnosis.
7- The following may be observed in children with

CAS who speak more than one language
• They may rely on earlier mastered sounds +++ ++

GPP Strong
across all languages spoken. Moderate Low
* They may appear to favor or use one language

over another.
Treatment Motor speech disorders require repetitive planning,

Approaches programming, and production practice; therefore,
intensive and individualized treatment of childhood
apraxia is often necessary. To the extent possible,
treatment takes place in naturalistic environments,
is provided in a culturally appropriate manner. ++++ ++++
Level B Strong
High High
Many children with CAS also have phonological
impairment and language impairment. The relative
contribution of motoric and linguistic deficits is
considered when planning treatment.

Average
reviewers
1- Motor programming approaches
• Use motor learning principles, including

the need for many repetitions of speech
movements to help the child acquire skills
accurately.
• Consistently, and automatically make sounds

and sequences of sounds.
• Provide frequent and intensive practice of

speech targets.
++++ ++++
• Focus on accurate speech movement; Level B Strong
High High
• Include external sensory input for speech
production (e.g., auditory, visual, tactile, and
cognitive cues).
• Carefully consider the conditions of practice

(e.g., random vs. blocked practice of targets);
and
• Provide appropriate types and schedules of

feedback regarding performance.
2- Linguistic approaches
• Focus on CAS as a language learning

++++ ++++
disorder; these approaches teach children how Level B Strong
High High
to make speech sounds and the rules for when
speech sounds and sound sequences are used
in a language.
3-Combination approaches—use both motor ++++ ++++

GPP Strong
programming and linguistic approaches. High High
4-Rhythmic (prosodic) approaches
• Such as melodic intonation therapy.

++++ +++
Level A Strong
• Use intonation patterns (melody, rhythm, High Moderate
and stress) to improve functional speech
production.
5-Treatment approaches: using movement patterns
versus sound patterns
+++ +++
• Shaping the best/most accurate productions
Moderate Moderate
possible. Level A Strong
• Sensory cueing approaches that involve using

the child’s senses (e.g., visual, auditory, pro-
prioceptive, and/or tactile cues).
6-Augmentative and Alternative Communication
(AAC)for children with persisting speech difficulties
who had difficulties in the normal development of ++++ +++
Level B Strong
speech that do not resolve as the child matures or High Moderate
even after they receive specific help for these prob-
lems.

Average
reviewers
7-Considerations For Bilingual and Multilingual
Populations
• Targeting errors that are present in only one

language is unlikely to improve intelligibility in
the other language.
• Beginning treatment by targeting phonemes

shared by both languages may yield the great-
++++ +++
est improvement in intelligibility across lan- Level A Strong
High Moderate
guages in the shortest amount of time.
• Selecting stimulus targets that affect both lan-

guages can result in cross-linguistic transfer of
skills.
• Goals and targets in each language are chosen

based on the properties and word shapes of
each language.
Flow chart for childhood apraxia of speech based on the summary of CPG1
Created by the committee members

References https://www.asha.org/Practice-Portal/Clinical-Topics/
Childhood-Apraxia-of-Speech.
1. Elizabeth Murray, Patricia McCabe, Kirrie J Ballard.
A comparison of two treatments for childhood 4. Angela T Morgan, Elizabeth Murray, Frederique J
apraxia of speech: Methods and treatment protocol Liégeois (2019). In Morgan AT, Murray E, Liégeois FJ,
for a parallel group randomized control trial BMC Cochran library Interventions for childhood apraxia
Pediatrics. 2012;12:112. of speech. Cochrane Database of Systematic Reviews
2018, Issue 5. Art. No.: CD006278.Copyright ©
2. E. Maas & C. E. Gildersleeve-Neumann & K. J. 2019.Published by John Wiley & Sons, Ltd.
Motor-Based Intervention Protocols in Treatment
of Childhood Apraxia of Speech (CAS). (2014) 5. Gregg P. Allen, M.D. (2019). Asuris Musculoskeletal
CurrDevDisord Rep 1:197–206.DOI 10.1007/s40474- Benefit Management Program: Speech Therapy
014-0016-4. Services V1.0.2019. Clinical guidelines for medical
necessity review of speech therapy services. © 2019
3. American Speech-Language and Hearing Association eviCore healthcare.
Childhood-Apraxia-of-Speech (Practice Portal) (2019)

Articulation Disorders (Speech Sound Disorders): Adapted Egyptian

Clinical Practice Guidelines
Assembly Board: Nirvana Hafiz,8 Rasha Shoeib,8 Yossra Sallam10
Ahlam Abdel Salam,11 Omayma Afsa,12 Ahmad Ali,13 Essam Eldin Aref,14 Asmaa El-Dessouky,15 Iman ElRouby,16 Safaa ElSady,8
Aisha Fawzy,9 Dalia Mostafa,9 Aya Sheikhany9
Reviewing Board: Hasnaa Othman,17 Yomna Hassan,8 Hedia Serry8
1
Department, Faculty of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/ Tanta University,
6
Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 7Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/Ain
Shams University, 9Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 10Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Al-Azhar University, 11Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Sohag University, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Mansoura
University, 13Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Beni-Suef University, 14Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Assuit University, 15Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Menoufia University, 16Phoniatrics Unit, Otorhinolaryngology Department/ Hearing and Speech Institute,
17
Phoniatrics Unit, Medical Studies for Children Center at the Faculty of Postgraduate Childhood Studies.
Introduction and background highest scores as regards the currency, contents and
quality. It was graded GRADE by 10 expert phoniatricians
Speech sound disorders is the preferred term for and reviewed by 3 expert reviewers.
describing difficulties that young children have with
speech production. Grade Definition
Speech sound disorders include sound substitutions, High ++++

omissions, distortions and additions.
We are very confident that the true effect lies close to that
Scope and purpose of the estimate of the effect.
The purpose of this guideline is to provide a stepwise Moderate +++

procedure for delineating the assessment and
management of speech sound disorders after excluding We are moderately confident in the effect estimate: the
other articulation disorders. true effect is likely to be close to the estimate of the effect,
but there is a possibility that it is substantially different
Methods
Low ++
The adaptation cycle passed over: set up phase,
adaptation phase (Search and screen, assessment: Our confidence in the effect estimate is limited: the true
Currency, Content and Quality and Decisions/selection) effect may be substantially different from the estimate of
and finalization phase that include revision. the effect.
Results Very Low +
Ten guidelines were assessed by 3 expert phoniatricians We have very little confidence in the effect estimate: the
and the Regence speech service guideline4 had the true effect is likely to be substantially different from the
estimate of effect.
Accepted specific recommendations
Modified specific recommendations
Added recommendations
Articulation Disorders 2021 (Volume 1) Pages: 179-187 179

Strength of Strength Average

Statement Level of recommendation after grading
Action of recommendation
topic evidence according to the adaptation/ for
selected CPG adoption reviewers
Speech sound disorders (SSD) include sound
substitutions, omissions, distortions and
additions. In addition, there can be errors
that affect the word level and/or the rhythm
and intonation characteristics of running
speech.
Speech sound disorders result from

difficulties with speech, motor production Not ++++ ++++
Definition Not Reported
and coordination of speech movements, as Present High High
well as the lack of phonological knowledge
or misapplication of the phonological rules
associated with the child’s native language.
All languages are governed by phonological
rules which determine the appropriate
speech sounds (or phonemes) and phoneme
sequences that characterize a particular
language.
The cause of speech sound disorders in most

children is unknown.
The cause of some speech sound problems is

Not +++ ++++
Presentation known and can be the result of motor speech Not Reported
Present Moderate High
disorders (e.g., Apraxia and Dysarthria),
structural differences (e.g., cleft-palate),
syndromes (e.g., Down Syndrome) or
sensory deficiencies (e.g., hearing loss).
Apart from short term memory disorders,

the exact cause of speech sound disorders in
most children is unknown.
The cause of other articulation disorders is

known and can be the result of motor speech
disorders (e.g., Apraxia and Dysarthria),
structural differences (e.g., cleft-palate), Not ++++ ++++
Presentation Not Reported
syndromes (e.g., Down Syndrome) or present High High
sensory deficiencies (e.g., hearing loss).
SSD have to be clearly differentiated from

other organic articulation disorders as early
as possible during preliminary diagnosis in
order to direct the patient to the suitable
diagnostic procedure
180 2021 (Volume 1) Pages: 179-187 Articulation Disorders

Average
Statement topic Action of recommendation grading for
reviewers
Risk factors. • Gender-males being higher risk. Not Present Not Reported ++++ +++
High Moderate
• Ear, nose and throat problems.
• Family history of speech and

language problems.
• Limited parental education/

learning support at home.
• Omissions/deletions: Specific
sounds are omitted or deleted
(e.g., boo for book and geen for
green).
• Substitutions: One or more ++++ ++++

Symptomatology Not Present Not Reported High High
sounds are substituted (e.g., wed
for red and dut for duck, widuh for
rider).
• Additions: One or more extra

sounds are added into a word
(e.g., bulack for black).
• Distortions: Sounds are modified

or altered (e.g., a slushy
/s/).
• Whole-word/syllable-level errors:
Weak syllables are deleted (e.g.,
boon for balloon); a syllable is
repeated or deleted (e.g., nana for
candy).
• Prosody errors: Errors that

occur in stress, rhythm and
intonation.
Case history
• Family history of speech/language

difficulties.
• Recurrent middle ear infections.

++++ ++++
Assessment • Child’s primary language used in Not present Not Reported
High High
the home.
• Family and teacher concerns.
• Age developmental milestones

were met.
• Medical history.

Strength of Average
Strength after
Statement Level of recommendation grading
Action of recommendation adaptation/
topic evidence according to the for
adoption
selected CPG reviewers
Oral mechanism examination includes:
• Assessment of dentition and

alignment of teeth
• Muscle movement as well as

development of the jaw, lips
and tongue and the integrity
of the oral structures (hard
and soft palate, jaw, maxilla,
lips and tongue)
Not ++++ +++
Assessment • Oral motor reflexes as well Not Reported
Present High Moderate
as purposeful movement
through imitation of non-
speech actions
• Diadokokinetic rate: muscle

movement for coordination
and sequencing
• Assessment of tongue and

mouth resting posture to
determine existence of
tongue thrust

Statement Level of recommendation after grading
Action recommendations
topic evidence according to the adaptation/ for
selected CPG adoption reviewers
Assessment Will be provided to children during the initial Not Present Not Reported ++++ ++++
Hearing Speech and Language Evaluation unless results High High
screening of a comprehensive audiological assessment
has already been completed. Follow up hearing
screening is indicated when progress in speech
development has not been achieved or is mini-
mal and evidence suggests risk for hearing im-
pairment.
Not Present Not Reported ++++ ++++
The evaluation process may include the selec-
High High
tion of administration of standardized tests, lan-
Speech guage/speech samples, or a descriptive analysis
Sound of informal findings.
Assessment
Assess articulation at the word, phrase and con-
versational levels.
Establish a phonetic inventory for the child (i.e.,

what sounds can the child produce?).
Identify the error patterns the child uses and

look for phonological process use in children who
are less intelligible.
Identify speech sound production inconsisten-

cies. The child does not always misarticulate the
error sound the same way in all words.
Evaluate stimulability of error sounds.
Evaluate intelligibility.
Assessment Child’s ability to produce target sounds with cues Not Present Not Reported ++++ ++++
Stimulability High High
• Used to select treatment targets based
on the child’s ability to utilize these cues
• Assists in determining prognosis.


recommendation after grading
according to the adaptation for
selected CPG /adoption reviewers
Intelligibility Intelligibility refers to the listener’s Not Present Not Reported ++++ ++++
ability to understand the child’s speech. High High
A guideline for expected

conversational intelligibility levels of
typically developing children talking
to unfamiliar listeners is summarized
below
• 1 year- 25% intelligible
Intelligibility can be impacted by

several factors including:
• Length of utterance
• Familiarity with child’s

speech.
• Child’s speech rate,

intonation, loudness level,
vocal quality and fluency
• Contextual cues
• Presence of ambient noise

during conversation.
Onset of If SSD is not attributed to any other Not Present Not Reported +++ +++
intervention communication disorder, intervention Moderate Moderate
should be started at the age of 5-6
years.
Therapy should be postponed to give

chance for completing the phonemic
inventory and disappearance of all
phonological processes including
devoicing
Intervention Treatment starts with practicing Not Present Not Reported +++ ++++
syllable based contexts in which the Moderate High
Contextual sound is produced correctly. That
utilization syllable is used to train more difficult
productions. For example, a /s/ may
be more easily produced in the syllable
with a high front vowel.
Targets focus on a specific phoneme

Not Present Not Reported ++++ ++++
feature using contrasting word pairs.
High High
Minimal pairs are different by one
Contrast therapy feature or phoneme that changes the
word meaning (tip vs. ship). Maximal
pairs use a sound target differing by
several distinctive features which affect
phoneme placement and manner to
introduce sounds that the child cannot
produce ( beat vs. cheat)

Average
Statement Level of recommendation after
topic evidence according to the adaptation /
reviewers
Core Used with children who are highly Not Present Not Reported +++ +++
vocabulary unintelligible due to inconsistent Moderate Moderate
approach misarticulations and may not respond
well to traditional therapy. This is a
word-based approach as opposed to a
phoneme-based technique. Words the
child commonly uses are selected for
practice and feedback is provided to
reinforce the most accurate production
of each word.
Focuses on improving phonological

patterns with a strategy similar to
Cycles normal sound acquisition. It is used with
approach children who have poor intelligibility, +++ +++
characterized by numerous omissions Not Present Not Reported Moderate Moderate
and limited phonemic inventories. Each
cycle targets all phonological patterns in
error until they emerge in spontaneous
speech.
Focuses on sound features the child

cannot produce (nasals, fricative,
voicing, placement) and is usually used
with children who substitute. Not Present Not Reported ++++ ++++
Distinctive High High
sounds. Error patterns are targeted
features
using tasks such as minimal pair
approach
contrasts; usually once a contrast
pattern emerges, it can be generalized.
to other sounds that share the same

feature.

Strength of
Statement Strength after Average
Action of recommendation adaptation/ grading for
topic evidence according to the
adoption reviewers
selected CPG
Metaphone Used with children who appear to
therapy have not mastered phonological
system rules. Examples are +++ ++++
descriptive and provide information Not Present Not Reported Moderate High
about how a sound is produced, e.g.,
voiced (noisy) vs. voiceless (quiet).
Sounds most impacting intelligibility
are selected first.
Uses everyday activities to elicit

the target sound frequently during
++++ ++++
Naturalistic the session. For example, the child
Not Present Not Reported High High
Speech is asked about a toy that involves
Intelligibility responses using the targeted sound.
Intervention (i.e., “What color is the car?” “Red.”)
Appropriate productions are recast
(i.e., casually modeled by the clinician
or parent).
Speech perception tasks are used

to help the child gain a consistent
Speech ound perception of the target sound. Tasks
Perception may include auditory bombardment Not Present Not Reported ++++ ++++
Training and sound identification tasks. High High
Usually used prior to or at the
same time as speech production
intervention.

Flowchart for Articulation Disorders, based on the summary of CPG4 and created by the committee members.

References handbook/handbook.html.
1. Baker E, McLeod S. Evidence-based management of 3. Child Speech Disorder Research Network October
phonological impairment in children. Journal of child (2017): Good practice guideline for the analysis of
language teaching and therapy. 2004;261-285. child’s speech.
2. Schünemann H, Brożek J, Guyatt G, et al. GRADE 4. Clinical guideline Speech therapy version 10 (2019):
handbook (2013). https://gdt.gradepro.org/app/ Regence speech service guideline.

Cochlear Implantation: Adapted Egyptian Clinical Practice Guidelines

Assembly Board: Samia Bassiouny,8 Tamer Abou-Elsaad,10 Ayman Shawky,11 Ahlam El-Adaawy,12 Youssra Sallam,13 Effat Zaky,14
Ahmed Ali15
Safaa El Sady,8 Aisha Fawzy,9 Nervana Hafez,8 Dalia Mostafa9
Reviewing Board: Marwa Saleh,8 Reham El Maghraby16
1
6
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Mansoura University, 11Phoniatrics Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Military Armed Forces, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/
Sohag University, 13Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Al-Azhar University, 14Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Minia University, 15Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Beni-Suef University, 16Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/Alexandria
University.
Introduction and background Results
Systematic advancements in cochlear implant technology The authors searched four of the best evidence based
and practices have resulted in improvements in guidelines. And selection of the most appropriate
communication outcomes. Outcomes are characterized Guideline was based on having the highest score
by wide variability that are attributed to many factors. regarding the currency, contents and quality. The selected
Which include, age at onset of the hearing loss, stimulation one was: The American Academy of Audiology, Clinical
of the auditory pathway prior to implantation, pre/post- Practice Guidelines: Cochlear Implants 2019. It was then
lingual deafness, age at implantation, cochlear implant graded by 2 expert phoniatricians & reviewed by 2 expert
experience and auditory training, residual hearing, spiral reviewers.
ganglion cell survival in auditory pathways, cognitive
abilities, patient/family personality and motivation, Explanation of Levels of Evidence and Grades of
parental involvement and commitment, quality of device Recommendation
programming, and consistency of follow-up appointments.
Levels of Evidence
Scope and purpose
1. Systematic reviews and meta-analyses of randomized
The aim of these clinical guidelines is to provide controlled trials
phoniatricians and clinicians with a set of statements,
2. Randomized controlled trials
recommendations, and strategies for best practices,
directed to the evaluation and management of patients 3. Non-randomized intervention studies
undergoing cochlear implantation.
4. Descriptive studies (cross-sectional surveys, cohort
These guidelines are meant to provide the evidence studies, case-control designs)
base from which the clinician can make individualized
decisions for each patient. 5. Case studies
The process of developing these guidelines was Evidence- 6. Expert opinion

based which integrates clinical expertise with the best
available clinical evidence derived from systematic Grades of Recommendation
research, related to candidacy criteria and communicative
A. Consistent Level 1 or 2 studies.
rehabilitation of cochlear implanted patients.
B. Consistent Level 3 or 4 studies or extrapolations from
Methods
Level 1 or 2 studies.
The adaptation cycle passed over: The set-up phase,
C. Level 5 studies or extrapolations from Level 3 and 4
adaptation phase (Search and screen, assessment:
studies.
Currency, content and Quality and Decisions/selection)
and finalization phase that included revision. D. Level 6 evidence or troubling inconsistencies or
inconclusive studies at any level.
188 2021 (Volume 1) Pages: 188-192 Cochlear implantation

The Grading of Recommendations, Assessment, Development and Evaluation using the (GRADE) approach to Decision
frameworks (GRADE Working Group, 2013)
Grade Definition
High We are very confident that the true effect lies close to that of the estimate of the effect
++++
Moderate We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the
+++ effect, but there is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate
++ of the effect.
Very Low We have very little confidence in the effect estimate: the true effect is likely to be substantially different from
+ the estimate of effect
Accepted statements
Modified statements
Added statements
CI Guidelines Statements
Strength of
Strength
Statement Level of recommendation Average
after
Action recommendations according to grading for
topics Evidence adaptation/
the selected reviewers
adoption
guidelines
may affect candidacy and predict post-
1. Age at Systematic ++++ ++++
operative outcomes. Information should A
implantation Reviews High High
be documented clearly in the case history.
Perinatal problems, such as meningitis,

hyperbilirubinemia, and other etiologies
associated with sensorineural hearing loss Systematic ++++ ++++
2. Etiology A
may affect candidacy and predict post- Reviews High High
operative outcomes. Information should
3. Duration of Duration of deafness may affect candidacy

deafness and predict post-operative outcomes. Non-randomized ++++ ++++
B
Information should be documented clearly control study (3) High High
in the case history.
4. Hearing aid Hearing aid use prior to implantation
use may affect candidacy and predict post- Descriptive ++++ ++++
B
operative outcomes. Information should Studies (4) High High
Prelingually deafened adolescents
5. Prelingually and adults may benefit from cochlear Non Randomized
deafened adults ++++ ++++
implantation and should not be excluded Intervention B
High High
from candidacy. Families should be Studies (3)
counseled regarding realistic expectations.
Children with disabilities in addition to
deafness may benefit from cochlear
6. Other implantation in quality-of-life outcomes
disabilities Systematic ++++ ++++
and environmental awareness. These A
Reviews (1) High High
groups should not be excluded from
candidacy. Families should be counseled
regarding realistic expectations.
Audiometric threshold testing is used to
determine candidacy; better pre-operative
Systematic ++++ ++++
7. Assessment hearing thresholds are associated with A
Reviews (1) High High
better post-operative outcomes in children
and prelingually deafened adults.
Cochlear implantation 2021 (Volume 1) Pages: 188-192 189

Strength of
Strength
Statement Level of recommendation Average
after
Action recommendations according to grading for
topics Evidence adaptation/
adoption
guidelines
8. Assessment Cognitive evaluation or cognitive screener Non Randomized

++++ ++++
should be considered when evaluating Intervention B
High High
children and older adults. Studies (3)
A speech and language evaluation may
be recommended in adult candidacy Systematic ++++ ++++
9. Assessment A
evaluations and could be considered Reviews (1) High High
critical in pediatric candidacy evaluations.
No Published
10. Expectations Counseling toward appropriate
Evidence ++++ ++++
expectations should be done by the Not Reported
(Current Clinical High High
audiologist. (Current clinical practice).
Practice)
For children, evaluation of audibility
and auditory, speech, and language
development should be conducted
11. Follow up routinely throughout development. Descriptive ++++ ++++
B
assessment More frequent monitoring of progress is Studies High High
warranted in those children who are in
the period of developing language and
auditory skills.
12. Follow up Informational and adjustment counseling ++++
assessment should be provided to support consistent Descriptive ++++ High
B
device use, implementation of intervention Studies High
strategies, and psychosocial well-being.
Non Randomized
High performance in children who use a ++++
Intervention
13. Consistent cochlear implant has been linked to full- ++++ High
Studies (3) B
use of CI time use of the cochlear implant in home High
and school environments.
14. Bilingualism Individuals who use cochlear implants Non Randomized

++++ ++++
can experience success in using multiple Intervention B
High High
languages. Studies (3)
All individuals who use a cochlear implant
should be considered as a potential ++++
15. Assisstive candidate for hearing assistive technology; Systematic ++++ High
hearing A
technology particularly those who experience complex Reviews High
listening environments and school-aged
children.
Intervention for adults may focus on ++++
auditory training. The specific intervention Systematic ++++ High
16. Intervention A
needs may vary based upon factors known Reviews High
to affect outcomes.
The amount and quality of language used ++++
Non Randomized
by parents/caregivers of children who use ++++ High
17. Intervention Intervention B
cochlear implants has a strong influence High
Studies (3)
on these children’s linguistic development.
Engaging family members in therapy and
coordinating efforts among therapists and Systematic ++++ ++++
18. Intervention B
educators is believed to result in the best Review High High
outcomes for children and families.
The likelihood of a child gaining high
benefit in the areas of speech perception,
speech production, and spoken language Systematic ++++ ++++
19. Intervention A
increases when more emphasis is placed Reviews High High
on listening and spoken language in the
child’s home and educational setting.
The progress of children with other
20. Intervention comorbidities should be measured by Systematic ++++ ++++
with other A
disabilities criteria that are unique to them and that Reviews High High
reflect the goals of the family.
Bilateral stimulation should be considered

Systematic ++++ ++++
21. Intervention for all individuals who use a cochlear A
Reviews High High
implant, if not otherwise contraindicated.

Cochlear implantation 2021 (Volume 1) Pages: 188-192 191

References 3. American Academy of Audiology; Clinical Practice

Guidelines: Cochlear Implants. 2019.
1. Clinical Guidelines for Pediatric Cochlear Implantation,
Department of Health, State of Western Australia. 4. Cochlear implants for children and adults with
2011. severe to profound deafness, Technology appraisal
guidance, National Institute for health and care
2. Implant Centre Teachers of the Deaf (ICTOD), excellence NICE. 2019.
Guidelines for Good Practice Working with Children
and Young People with Cochlear Implants. 2014.

Learning Disability: Adapted Egyptian Clinical Practice Guidelines

Assembly Board: Safaa Refaat El-Sady,8 Azza Abdel-Aziz Azzam,10 Omayma Elsayed Afsah,11 Aisha Fawzy Abdel Hady9
Ahmed Ali,12 Ahlam El-Adawy,13 Iman El Rouby,10 Dalia Mostafa Osman,9 Rasha Farouk Safwat,9 Yossra Sallam,14 Aya Sheikhany9
Reviewing Board: Sahar Saad Shohdi,9 Sabah Hassan,8 Fatema Kaddah8
1
6
Unit, Otorhinolaryngology Department/ Hearing and Speech Institute, 11Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Mansoura University, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Beni-
Suef University, 13Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 14Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/Al-Azhar University.
Introduction and background Currency, Content and Quality and Decisions/selection)

Specific Learning Disability (SLD) means a disorder in
one or more basic psychological processes involved in Results
understanding or in using language; spoken or written;
that may manifest itself in an imperfect ability to listen, Four guidelines were assessed by 4 expert Phoniatricians
think, speak, read, write, spell or do mathematical and the Ontario Psychological Association Guidelines for
calculations in spite of normal sensory channels, intact Diagnosis and Assessment of Children, Adolescents, and
psyche, normal cognitive abilities and given opportunity. Adults with Learning Disabilities (June 2018) and Virginia’s
Guidelines for Educating Students with Specific Learning
Scope and purpose Disabilities (2017) had the highest scores as regards to
the currency, contents and quality. It was graded GRADE
The purpose of this guideline is to identify the causes by 11 expert phoniatricians and reviewed by 3 expert
and types of SLD and to determine the appropriate reviewers.
assessment tools and management strategies needed
for each case. The goals are to improve the diagnostic Good Practice Points
accuracy for SLD cases and to promote appropriate use
of rehabilitation methods. These are recommendations that can be made when it
is deemed they will be helpful to the clinician, such as
Methods recommendations to perform something that is standard
of care, but there is no direct evidence to support the
The adaptation cycle passed over: set up phase, recommendation and that is unlikely to ever be formally
adaptation phase (Search and screen, assessment: studied. These should be sparingly in guidelines.
Explanation of Levels of Evidence and Grades of Recommendation
Grade of recommendation Level of evidence Interventions
1a Systematic review of randomized controlled trials

A
1b Individual randomized controlled trial
2a Systematic review of cohort studies
2b Individual cohort study
B
3a Systematic review of case-control studies
3b Individual case-control study
C 4 Case series
Expert opinion without explicit critical appraisal or based on physiology
D 5
or bench research
Learning Disability 2021 (Volume 1) Pages: 193-206 193

Grade Definition
++++
Moderate We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the
+++ effect, but there is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: the true effect may be substantially different from the esti-
++ mate of the effect.
Very Low We have very little confidence in the effect estimate: the true effect is likely to be substantially different from
+ the estimate of effect
Accepted statements
Modified statements
Added statements
Learning Disability Guideline Statements Guided by Ontario Guidelines
Average
reviewers
Specific Learning Disability means a
disorder in one or more basic psychological
processes involved in understanding or
Professional
in using language, spoken or written
1.Criteria for a consensus
that may manifest itself in an imperfect +++ ++++
Diagnosis of Learning (Ontario) Good practice point
ability to listen, think, speak, read, write, Moderate High
Disability
spell, or do mathematical calculations in Level D
spite of normal sensory channels, intact
psyche, normal cognitive abilities and
given opportunity”.
History of academic functioning below
the level typically expected for individuals
of the same chronological age, and it is
based on the difference between a child’s Professional
cognitive ability and his/her present Consensus
2.History of academic ++++ ++++
academic achievement score or the need (Ontario) Good Practice Point
impairment High High
for excessive time or support to develop
or maintain typical levels of academic Level D
functioning, as judged by the parents and
educators.
Other conditions or disorders (e.g.,
intellectual disabilities, uncorrected
visual or auditory acuity, physical
or chronic health disabilities, other
neurodevelopmental disorders,
3.Evidence that or disruptive behavior disorders
the difficulties in (internalizing or externalizing disorders)- Professional
reading, writing, or Environmental factors (e.g., psychosocial consensus ++++ ++++
mathematics cannot adversity, inadequate or inappropriate Good Practice Point
(Ontario) High High
be accounted for educational instruction) through history Level D
primarily by other taking:
factors
-Insufficient motivation or effort through
history taking or observation through his
performance in the applied tests;
- Cultural or linguistic diversity through
history taking.
194 2021 (Volume 1) Pages: 193-206 Learning Disability

Average
reviewers
These tests include the Wechsler tests,

Stanford Binnet (The Arabic versions of
Wechsler and Stanford Binnet 5th edition).
4.Assess abilities
Strong ++++ ++++
essential for thinking **Standard scores that are between 85 Not Present
Recommendation High High
and reasoning. and 115 (i.e. within one standard deviation
of the mean) should be considered to be
average and is an essential criterion for
diagnosis of specific learning disability.
5.Assess and rule

out other factors
that could better Subjective impression is mandatory by
explain the pattern parents, teachers and even clinicians for Strong ++++ +++
Not Present
of results, including effort done by the child, motivation and Recommendation High Moderate
effort, motivation and compliance.
non-compliance with
instructions
Risk factors for LD identified within
international research include:
• heritability of reading disabilities

• prenatal, Newborn or postnatal risk
6.Evidence of risk factors
factors for LD and ++++ ++++
• Available Arabic test battery for LD) Not Present Good Practice Point
other learning High High
can pose a light on the child different
difficulties
psychological processing aptitude
responsible for LD.
• slow development of reading decoding
skills in culturally and linguistically diverse
individuals.
A core aspect of the definition of LD is that
the individual’s academic achievement is
below average (i.e., at least one standard
deviation below the mean) in at least one
of:
Reading- indicated by any of :

-PA (phonologic awareness test)
-MADST(Modified Arabic Dyslexia
Screening Test)
-ARST (Arabic Reading Screening Test)
7.Assess academic
achievement Writing – MADST- Dysphagia Severity Strong ++++ ++++
scale Level D
Mathematics- indicated by any of
Calculation, including but not limited
to: numeracy, algebra, geometry and
calculation fluency; applications such
as the understanding of time, money,
measurement, data analysis; and word
problem-solving including geometry and
data interpretation.
And this can be followed up with the

child’s grades at school depending on the
school academic testing.

Average
reviewers
- Individuals with LD are at increased
risk for social, emotional and behavioral
8.Assess comorbid difficulties.
emotional and behav-
In some cases, these difficulties are Good Practice ++++ ++++
ioral problems doc- Not Present
associated with ADHD which is frequently Points High High
umented by clinical
comorbid with LD).
judgment and testing
(Conners test can be recommended for
diagnosis)
From the Phoniatric point of view, Supple
(2000) categorized language-based
learning disabilities into:
(1) Lower order process disorders:

Phonological awareness- Phoneme-
grapheme correspondence
(2) Higher order process disorders:

Vocabulary including word finding
difficulty
Semantic deficit
Syntactic deficit
9.Develop a
formulation and (3) Attention & Memory deficits
diagnostic statement Strong ++++ ++++
The development of a clear diagnostic Level B
in accordance with Recommendation High High
statement requires the results
the above criteria for
of many clinical tests including:
a diagnosis of LD
Language testing
• Psycholinguistic
ability test
• Phonological
awareness test
• Dyslexia test
• Reading test
• Dysgraphia
severity scale.

Average
reviewers
Recommendations for intervention are
most likely to be comprehended and
implemented when the recommendations
are “SMARTS”: Specific and clear,
10.Identify the types
according to the profile of strengths and
of evidence-based
weaknesses of the child, Measurable, Professional
and realistic supports
Applicable to the individual’s needs, Consensus Good Practice ++++ ++++
and interventions that
Realistic to implement in the context, (Ontario) Points High High
are required
Timely, and Supported by research. Level D
Put objectives and reassess after 3-6

months for child’s achievement in the
specifically designed program of therapy
in areas of weakness.
Results of the assessment must be
discussed with parents, teachers and
11.Communicate
even with the older children. Professional
the results of the
Consensus Good Practice ++++ +++
assessment, the By grade 3 if the child is not able to read (Ontario) Points High Moderate
diagnosis and it is a challenge to close the gap and Level D
recommendatio-ns great efforts has to be done by the child,
his family, therapist and teachers.
-Age of psychometric, language
assessment and psycholinguistic ability
tests is by kindergarten entry (4 years).
IQ involve effective screening of all

children in kindergarten and grade one for
early identification and to optimize access
to early intervention. Those determined
to be at risk, based on low early
literacy (e.g., phonemic processing) and
numeracy skills, and are then provided
with evidence-based intervention in
kindergarten and the early grades. Age of
phonologic awareness assessment is by
(5.5 years).
Age of dyslexia screening is by 6.5 years.

12.The optimal age to
first screens for and Interventions are delivered in the regular
Strong ++++ ++++
diagnoses LD? classroom or in small groups. Level B
recommendation High High
However, if a child is struggling
academically and has gone unidentified
or unsupported during grade one,
assessment to indicate the nature
of difficulties to guide intervention is
essential.
Waiting until the end of grade two

may reduce the effectiveness of future
interventions (By the end of second
primary (8 years) the gap would be very
wide with poorer prognosis so our chance
is in the early years).
So by kindergarten entry, if suspect SLD,

tests could be applied and proceed in
therapy either in main stream or in small
groups or even one-to-one.

Average
reviewers
Such as children with early symptoms or
diagnosis of
- ADHD.
-DLD, ASD.
13.Children at -Children with complex medical

disproportionate conditions: (e.g. extreme prematurity, Professional
risk for learning congenital heart disease). consensus ++++ ++++
Good practice point
challenges (Ontario) High High
-Early brain injury (e.g. Newborn stroke, Level D
brain tumor, traumatic brain injury).
- Epilepsy.
Children with learning co-morbidities will

also benefit from early assessment with
a focus on contributing to school-based
support.
For the First (L1) and Second (L2)
learners
• Consider a diagnosis of LD in L2
individuals who have had two or more
years of English or French reading
instruction and have below average
word-level reading and spelling skills.
• Examine the types of errors that

individuals make on language Consider
positive transfer (e.g., they may use
words that are similar in their L1 to
understand the L2), and negative transfer
14-What adaptations (they may apply grammatical structures
are required for that are correct in their L1 to their L2
assessments of when that is not appropriate).
Culturally and
• Compare the functioning of the
Linguistically Diverse Strong ++++ +++
individual with siblings from the same Level B
(CLD) individuals Recommendation High Moderate
context.
experiencing learning
difficulties as regard • Assess in the individual’s first language
language and literacy
when appropriate.
skills
• Assess cognitive processes (phonological
processing, rapid automatized naming
“RAN”, and non-word repetition).
• Consider that if phonological processing

scores are below average that this may
represent a Learning Disability, rather
than being due to English language
learning “ELL” status alone.
• Supplement standardized cognitive and

achievement tests including non verbal
test with few instructions and use clinical
judgment when interpreting test scores.

Average
reviewers
• The following strategies are
recommended to decrease cultural and
linguistic loading for CLD.
• Use multiple sources (self- family

and teacher reports) and methods
(observations, interviewing, formal
objective rating scales, and informal
projective tests such as drawings and
sentence completions).
15.Social, Emotional • Use standardized rating scales written Professional

and Behavioral in the individual’s or parent’s L1. consensus ++++ ++++
Good Practice Point
Assessment in CLD (Ontario) High High
Individuals -Consider acculturation effects (i.e. effects Level D
of cultural modification of CLD individuals
caused by merging of cultures).
• Analyze narratives provided by the

individual and family members.
-Be sensitive to signs of post-traumatic

stress disorder “PTSD”, and other
disorders that are associated with
loneliness, trauma, and immigration
struggles.
Above average intelligence does not
negate the possibility of having areas of
16.Issues should be
strengths and weaknesses in major areas
considered when
of academic functioning and psychological
diagnosing LD in Professional
processing.
individuals with very consensus ++++ +++
Good Practice Point
superior intellectual (Ontario) High Moderate
Maddocks (2018) found that children
ability Level D
with high IQ could be diagnosed as LD
when taking into consideration both intra-
individual ability-achievement discrepancy
criteria and academic impairment.

Learning Disability Guidelines Statements Guided by Virginia Guidelines
Strength of
Average
Level of grading
Statement topic Action of recommendation tion according adaptation/
evidence for re-
to the selected adoption
viewers
CPG
Early identification and intervention can lead to Good Practice ++++ ++++
Early identification Level D
better prognosis. Point High High
Effective reading
instruction should include elements that teach five

critical areas of literacy:
(a) Phonemic awareness.
(b) Phoneme grapheme correspondence.
(c) Decoding (Alphabetic reading).
(d) Fluency (Automatic decoding=orthographic

reading). Strong ++++ ++++
Reading strategies Level A
(e) Text comprehension, with care for vocabulary
store, semantics, syntax.
* This program is applicable to SLD children (IQ=

85-115) and slow learners (IQ= 70-84).
*Slow learners can benefit from the same read-

ing strategies, except that phonological awareness
training would be difficult owing to their impaired
cognitive abilities, so direct instruction in pho-
neme-grapheme correspondence would be recom-
mended.=3.6.
The followings are evidence-based
fluency interventions:
• Repeated readings of the same passage.
• Vocabulary instruction (Words that are useful

to know and are likely to appear in a variety
Reading fluency Strong ++++ ++++
of settings may have the widest impact.). Level A
strategies Recommendation High High
• Choral reading.
• Partner reading.
• Tape-assisted reading.
• Training for rapid automatized naming.

Strength of
Average
Level of grading
evidence for re-
viewers
CPG
• Improving listening and reading

comprehension (through
vocabulary “WFD training”,
semantics, and syntax).
• Direct instruction on Background Knowledge.
• Graphic Organizers.
• Explicit instruction of Text Structure.
• Finding the Main Idea.
• Summarization.
• Question-Answer Relationships Strategy.

Reading
Strong ++++ ++++
Comprehensi-on • Self-Questioning Strategies. Level A
recommendation High High
strategies
• Reciprocal Teaching.
• Collaborative Strategic Reading.
*Attention (auditory and visual) and short term/

working memory training helps maintenance and
retrieval of knowledge.
*Regarding hearing impaired children, improving

comprehension through training higher order
processes (including vocabulary, semantics and
syntax) should be emphasized. Provision of
phonological awareness training should be limited
to cases with good auditory abilities (i.e. cochlear
implanted cases).
Three written language skills:
(1) Handwriting.
(2) Spelling.
(3)Written expression. Although one skill influences

the other, students may have problems in one area
but not in the others.
For handwriting
Written language direct, explicit instruction of letter formation and Strong ++++ ++++
guided practice with the use of a multisensory Level A
approach is recommended.
For spelling, multisensory approach (using

visual, auditory, tactile, and kinesthetic modalities)
and reading remediation is recommended.
Written expression through sentence writing

strategy and sentence-combining strategy.
It is important to differentiate whether dysgraphia

is dyslexic, motor, or spatial. Occupational therapy
may help motor and spatial types.
Explicit instruction should be provided using
manipulatives, cognitive strategies, using visual
Mathematics Strong ++++ ++++
representations while solving mathematical Level A
problems, using graphic organizers to solve
systems of linear equations, etc.

Strength of
Average
Level of grading
evidence for re-
viewers
CPG
Effective strategies include:
-Pre teaching vocabulary before introducing a unit.

Social studies and -Mnemonic (memory enhancing) instruction. Level A
science Strong ++++ ++++
-Giving students outlines, semantic webs or a Recommendation High High
Level C
strategies graphic organizer of key information.
-Getting acquainted with Tier III words (which are

low-frequency, subject-specific words).
Accommodations are considered to be “changes
to the delivery of instruction, method of student
performance, or method of assessment that do
not significantly change the content or conceptual
difficulty level of the curriculum”.
Examples of accommodations
Include:
a) Use of mnemonics strategy.
b) Cooperative learning groups. Level A Strong ++++ ++++

Accommodations
c) Modeling procedures. Level C
d) Word processors.
e) Providing preferential seating.
f) Pproviding special lighting or acoustics.
g) Oral versus written response.
h) Administering a test in several timed sessions.

i) Use of assistive technology.
Modifications are changes to the curricular
content, changes to the conceptual difficulty level Level A Strong ++++ ++++
Modifications of the curriculum, or changes to the objectives
and methodology. These involve more significant Level C
changes than accommodations.
Establishing routines can reduce students’ working
memory overload. The use of visual clues, modeling
and rehearsal of desired behaviors, breaking tasks
Classroom into subtasks can also address working memory Good Practice ++++ ++++
Level D
management problems. Points High High
Classroom management may be somehow difficult

in Egypt.

Strength of
Average
Level of grading
evidence for re-
viewers
CPG
* Motivation
* A student with SLD should be involved in

transition planning and have an individualized
transition plan no later than age 14.
* Promoting self-determination which includes

Adolescents with characteristics such as assertiveness, self- Level A
SLD Good Practice ++++ +++
advocacy, and independence.
Points High Moderate
Level B
* Preparing adolescents with SLD for transition

from high school to adulthood is one of the goals
of instruction, to enable them to advocate for their
rights and prerogatives.
Dealing with adolescents with SLD is questionable

in Egypt.
Use of visuals and graphics, repetition and
paraphrase, pre-teach vocabulary, audiotape the
Students
text, having a word bank for assignments that
from diverse
require short answers. Good Practice ++++ ++++
backgrounds with Level D
SLD Points High High
Providing written directions along with oral
directions, use more pauses within a lesson.
Brainstorming, “think-pair-share”, peer tutoring.

*Twice-exceptional students are those learners
who meet criteria for being identified as both
gifted and having a specific learning disability.
The Twice-
Exceptional * Teachers must consider the students’ strengths Level A Strong ++++ ++++
Students (e.g., problem solving, metacognition) and recommendation High High
Level C
problem areas (e.g., basic skills, organization).
Twice-exceptional students need teachers
who will provide them with emotional support,
effective instruction, accommodations.
(e.g., calculators, spell-checkers), and skills for
self-advocacy.

Modified learning disability flow chart for assessment.

Modified learning disability flow chart for therapy
Modified learning disability flow chart for therapy.

References 3. Watson S, et al. Virginia’s Guidelines for Educating

Students with Specific Learning Disabilities. Virginia
1. John A, et al. Practice Guidelines: Learning Disability. Department of Education Division of Special
Indian Journal of Clinical Psychology. 2013;40(1):65- Education and Student Services. 2017.
83.
4. Beal L, et al. Consensus Statement on Diagnosis and
2. Andrus M, et al. California Dyslexia Guidelines. Assessment of Children, Adolescents, and Adults
California Department of Education Sacramento. with Learning Disabilities. Ontario Psychological
2017. Association. 2018.

Aphasia: Adapted Egyptian Clinical Practice Guidelines

Assembly Board: Nirvana Gamal El Din Hafiz,8 Iman El-Rouby10
Aisha Fawzy Abdel Hady,9 Reham Abdelwakil,11 Essam Eldin Aref,11 Azza Abdel Aziz Azzam,10 Dalia Mostafa Osman,9 Asmaa
El Dessouky Rashad,12 Yossra Salam13
Reviewing Board: Nahla Refai,8 Alia El-Shobary,8 Azza Samy10
1
6
Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain
Otorhinolaryngology Department/ Hearing and Speech Institute, 11Phoniatrics Unit, Otorhinolaryngology Department, Faculty
of Medicine/ Assuit University, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Menoufia University,
13
Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/Al-Azhar University.
Introduction and background on highest scores which was Guideline 3: The top ten: Best
practice recommendations for aphasia (Linda W. et al., 2016).
Dysphasia (Aphasia) is a long-term and life-changing
condition. It is an acquired communication disability most The adaptation cycle passed through the following steps: set
commonly in adults, resulting from damage to the language up phase, adaptation phase (search and screen, assessment,
areas of the brain most often due to cerebrovascular currency, content, quality and decisions/selection and
stroke. Other causes include: Traumatic Brain Injury (TBI) finalization phase that included revision.
, Brain Tumor, Brain Infection, and Progressive Neurological
Diseases . Results
Scope & purpose The chosen guideline based on the highest scores regarding
currency, content and quality. The guidelines were assessed
The aim of the clinical practice guidelines (CPG) is to by 8 phoniatricians and reviewed by 3 Expert reviewers
provide Phoniatricians and Clinicians with explicit statements (Phoniatricians).
and recommendations regarding clinical assessment &
management of dysphasia that are based on the current Explanation of levels of Recommendation /Evidence
evidence. They can assist in the clinical decision-making
• Level A: Body of research evidence can be trusted to
process by providing information on what is considered to be
guide practice
the minimum best practice.
• Level B: Body of research evidence can be trusted to
Methods
guide practice in most situations
The members in the subcommittee searched for the best
• Level C: Body of research evidence provides some
evidence based guidelines. Five Guidelines were selected.
support for recommendation
The guidelines selected were then scored by the members of
• Level D: Body of research evidence is weak
the sub-committee regarding credibility, observability, relative
advantage, easy to install & understand, compatibility and • Good Practice Point (GPP): Recommendation is based
testability. on expert opinion or consensus.
Selection of the best & most appropriate guideline was based
Aphasia 2021 (Volume 1) Pages: 207-212 207

Grade Definition
We are moderately confident in the effect estimate: the true effect is likely to be close
Moderate
to the estimate of the effect, but there is a possibility that it is substantially differ-
+++
ent
Our confidence in the effect estimate is limited: the true effect may be substantially
Low ++
different from the estimate of the effect.
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the esti-
Very Low +
mate of effect
Strength of
Strength
recommendation Average
Level of after
Statement topics Action recommendations according to grading for
Evidence adaptation/
adoption
guidelines
1-All adult patients with brain damage

or progressive brain disease should be ++++ ++++
Screening Level C Strong
screened for communication deficits and High High
presence of aphasia.
2-People with suspected language
++++ ++++
Assessment deficits should be assessed by a qualified Level B,C Strong
High High
professional Phoniatrician.
3-A comprehensive assessment should

extend beyond the use of screening
++++ ++++
Assessment measures to determine the nature, Level B,C Strong
High High
severity and personal consequences of the
suspected communication deficit.
4-The assessment process may incorporate

a range of approaches, including interview,
conversation, observation and selective use
of different Aphasia assessment Batteries ++++ +++
Assessment Level C Strong
and tools .During spontaneous recovery High Moderate
(periods of rapid changes), formal
standardized assessments may be done
and then repeated again after 1-2 months.
5-Assessment of the individual’s language

strengths and weaknesses should be
carried out. However, bilingual individuals
++++ +++
Assessment may exhibit aphasia in diverse ways for Level C strong
High Moderate
each language spoken, depending on
proficiency, when language was learned,
and how often each language is used.
6-The process of assessment should

encompass the perception of the individual
++++ +++
and relevant others with regard to the Level C Strong
High Moderate
impact of the language disability on their
lives.
Assessment
7-Obtain a baseline from which to measure Level C ++++ ++++
Strong
improvement High High
8-Design an individualized program of
++++ ++++
therapy, specific to the needs of the GPP
High High
individual.
208 2021 (Volume 1) Pages: 207-212 Aphasia

Strength of
Strength
Level of after
adoption
guidelines
9-The outcome of aphasia is determined

by the initial severity lesion, patient age,
lesion site and size, gender, education level,
+++ ++++
Assessment patient motivation in treatment, family GPP
Moderate High
support, onset of therapy, comorbidities,
and the amount of spontaneous recovery
that occurs over time.
10- All assessment results should be
documented and reported in an accessible ++++ ++++
Assessment GPP
format to people with aphasia and their High High
families.
11-People with aphasia should receive
information regarding aphasia, aetiologies
Information for of aphasia (e.g., stroke) and options for ++++ +++
Level A-C Strong
patients treatment. This applies throughout all High Moderate
stages of healthcare from acute to chronic
stages.
12- No one with aphasia should be
discharged from services without some
means of communicating his or her
needs and wishes (e.g., supports, trained
Means of commu- partners) or a documented plan for +++ ++++
GPP GPP
nication how and when this will be achieved. Moderate High
Compensatory strategies as augmentative
& alternative communication (AAC) are
used for aphasics with nonverbal abilities
and failed traditional therapy.
13- People with aphasia should be offered

intensive and individualized aphasia therapy
designed to have a meaningful impact on
communication and life. This intervention
++++ ++++
Therapy should be designed and delivered under Level A Strong
High High
the supervision of a qualified professional
Phoniatrician. Outcomes are superior for
people receiving treatment that is intensive
(more than two hours per week).
14- Intervention might consist of

impairment-oriented therapy (impaired
comprehension skills, impaired verbal
language skills, impaired reading,
impaired writing), Sentence processing
++++ ++++
Therapy impairments, conversation therapy, GPP strong
High High
functional/participation oriented therapy,
environmental intervention and/or
training in communication supports , and
compensatory training as augmentative
and alternative communication (AAC).

Strength of
Strength
Level of after
adoption
guidelines
15-Modes of delivery might include

individual therapy, group therapy,
telerehabilitation and/ or computer assisted ++++ ++++
GPP Strong
treatment. Computer -based therapy offers High High
the potential to provide intensive home-
based therapy with minimal clinician input.
16-Individuals with aphasia due to stable
(e.g., stroke) as well as progressive
forms of brain damage benefit from
Therapy intervention. Treatment frequency
and duration must be based on:
Severity of objective clinical
++++ ++++
findings. Presence of and number of GPP Strong
High High
complicating factors and comorbidities.
Natural history and chronicity of
condition. Expectation for functional
improvement with skilled intervention.
Response to treatment provided.
Patient’s level of independence.
17-Individuals with aphasia due to stroke
and other static forms of brain damage can
benefit from intervention in both acute and
chronic recovery phases. The difference in ++++ ++++
Therapy GPP Strong
outcomes is greatest in the acute stage of High High
recovery (less than 3 months post onset
(MPO) but continues to be appreciable
even in the long term (more than 12 MPO).
18-Communication partner training should
Communication ++++ ++++
be provided to improve communication of Level A,B Strong
partner High High
the person with aphasia.
Communication 19-Train the communication partner on
partner verbal and non-verbal strategies (e.g. Total
communication as gestures, drawing, using ++++ ++++
Level A,B Strong
a communication book, pointing, writing High High
key words) to improve communication
interactions and conversations.
Families 20-Families or caregivers of people
with aphasia should be included
in the rehabilitation process.
a. Families and caregivers should receive
++++ ++++
education and support regarding the Level A-C Strong
High High
causes and consequences of aphasia.
b. Families and caregivers should learn to
communicate with the person with aphasia
using verbal and nonverbal strategies.
21-Services for people with aphasia should
+++ ++++
Services be culturally appropriate and personally GPP GPP
Moderate High
relevant.
22-All health and social care providers
working with people with aphasia across the
continuum of care (i.e., acute care to end- +++ ++++
Healthcare Level C Strong
of-life) should be educated about aphasia Moderate High
and trained to support communication in
aphasia.
23-Information intended for use by
people with aphasia should be available ++++ ++++
Information Level C Strong
in aphasia-friendly/communicatively High High
accessible formats.


References (NHMRC) Centre for Clinical Research Excellence

(CCRE) in Aphasia Rehabilitation. (2014): Australian
1. Royal college of speech & language therapists Aphasia Rehabilitation Pathway (AARP).Retrieved
(RCSLT) (2005): RCSLT Clinical Guidelines: Aphasia. June 7, 2015, from http://www.aphasiapathway.com.
London: RCSLT. au National Quality Forum. (2003). Safe practices for
better health care: A consensus report. Washington,
2. American Speech Language Hearing Association
DC: National Quality Forum.
(ASHA) (2011), Evidence maps: Aphasia. Retrieved
January 15, 2013, from www.http://ncepmaps.org/ 5. Linda W, et al. (2016): The top ten: best practice
aphasia. recommendations for aphasia. (behalf of the
Aphasia United Best Practices Working Group
3. Katharina Dworzynski, Gill Ritchie, Elisabetta Fenu,
and Advisory Committee) . Aphasiology. DOI:
Keith MacDermott, E Diane (2013): Rehabilitation
10.1080/02687038.2016.1180662.
after stroke: summary of NICE guidance. Playford,
on behalf of the Guideline Development Group. 6. Clinical Guidelines (2019): Speech therapy. Regence
© eviCore healthcare.
4. National Health and Medical Research Council

Dysarthria: Adapted Egyptian Clinical Practice Guidelines

Assembly Board: Nirvana Gamal El Din Hafez Helmy,8 Ayman Shawky10
Azza Abdelaziz,11 Essam Aref,12 Ahlam El Adawy,13 Safaa El Sady,8 Dalia Mostafa,9 Asmaa El-Dessouky Rashad,14 Youssra Sallam15
Reviewing Board: Nahla Refaie,8 Ahlam Eladawy,13 Sabah Hassan8
1
6
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Military Armed Forced, 11Phoniatrics Unit, Otorhinolaryngology
Department/ Hearing and Speech Institute, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Assuit
University, 13Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Sohag University, 14Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Menoufia University, 15Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Al-Azhar University.
Introduction & background research, related to candidacy criteria and communicative

rehabilitation.
Dysarthria is a heterogeneous group of neurological
speech disorders whose characteristics reflect Methods
abnormalities in the strength, speed, range, timing,
or accuracy of speech movements as a result of The adaptation cycle passed over: the set up phase,
pathophysiologic conditions such as weakness, spasticity, adaptation phase (Search and screen, assessment:
ataxia, rigidity and a variety of involuntary movements Currency, Content and Quality and Decisions/selection)
(e.g., dystonia and choreoasthetosis). Dysarthrias can and finalization phase that included revision.
affect the respirators, laryngeal, velopharyngeal, and oral
Results
articulatory subsystems, singly or in combination. The
impact of dysarthria ranges from a barely appreciable The authors searched five of the best evidence-based
speech disorder to a reduction in the intelligibility of guidelines. And selection of the most appropriate Guideline
speech to an inability to speak. This group of disorders was based on having the highest score regarding the
varies along a number of dimensions, including age currency, contents and quality.
of onset (Congenital or acquired at any age), cause
(vascular, traumatic, neoplastic, and so on), natural • Guideline1: Evidence based practice guidelines for
course (Developmental, recovering, stable, degenerative, dysarthria, management of velopharyngeal function.
and so on), site of lesion (Many sites in the central or Yorkston, KM etal., 2001. Journal of medical speech
peripheral nervous system or both), neurologic diagnosis and language pathology. 9:4:257-274.
Parkinson’s disease, traumatic. In addition, dysarthria is a
speech disorder due to disturbed muscular control of the • Guideline 2: Royal college of speech and language
speech mechanism resulting from impaired motor control therapists. Clinical guidelines. Speechmark publishing
involved in the execution of speech. It has a neurogenic 2005
origin.
• Guideline 3: ANCDS Bulletin Board ANCDS,
Scope and purpose evidence for effectiveness of treatment of loudness,
rate or prosody in dysarthria. A systematic review.
The aim of these clinical guidelines is to provide all Yorkston KM etal. 2007.
Phoniatricians with a set of statements, recommendations,
and strategies for best practices, directed to the evaluation • Guideline 4: ASHA Summary of the clinical practice
and management of patients have dysarthria. These guideline. 2017.
guidelines are meant to provide the evidence base from
• Guideline 5: Clinical guidelines speech therapy e vi
which the clinician can make individualized decisions for
core healthcare. 2019.
each patient.
The one selected was Evidence based practice guidelines
The process of developing these guidelines was Evidence-
for dysarthria, management of velopharyngeal function.
based which integrates
Yorkston,KM etal., 2001. Journal of medical speech and
clinical expertise with the best available clinical evidence language pathology. 9;4:257-274.
derived from systematic
Dysarthria 2021 (Volume 1) Pages: 213-225 213

Explanation of Levels of Evidence and Grades of Grade Definition

Recommendation
High ++++
According to Royal College of Speech & Language
Therapists (RCSLT), the evidence was graded according We are very confident that the true effect lies close to that
to the methodological design, and after the title of each of the estimate of the effect.
recommendation this grading is indicated by the letter A,
Moderate +++
B or C. There are four levels of evidence which correspond
to the methodological design of the study. The levels used We are moderately confident in the effect estimate: the
are I–IV, in descending order, corresponding to the degree true effect is likely to be close to the estimate of the effect,
of bias or chance which is perceived to have possibly but there is a possibility that it is substantially different
occurred. Therefore, a randomized controlled trial which
is statistically good at minimizing chance is awarded level Low ++
I. However, a nonexperimental design, e.g., case study, is
awarded III as the outcomes are more prone to chance, Our confidence in the effect estimate is limited: the true
and generalization of results can be problematic. Expert effect may be substantially different from the estimate of
opinion is level IV. the effect.
The Grading of Recommendations Assessment, Very Low +

Development and Evaluation (GRADE) approach to
We have very little confidence in the effect estimate: the
Decision frameworks (GRADE Working Group 2013)
true effect is likely to be substantially different from the
estimate of effect.
Dysarthria Guidelines Statements
Strength of
recommendation Strength after Average
Level of
Statement topics Action recommendations according to adaptation/ grading for
Evidence
the selected adoption reviewers
guidelines
History Taking
This phase of the assessment involves

gathering pertinent information from
the patient, the medical records and the
referral source. Information should be
gathered on areas such as the following:
• The onset of symptoms and medical/

dental history.
Assessment of VP ++++ ++++
Level III Not Reported
Function • the nature, duration, and natural High High
course of velopharyngeal (VP)
impairment.
• Reports of previous treatment.
• The level of concern about the

problem.
• The patient’s motivation relative to

treatment.
Assessment of VP Not Professional ++++ ++++

Search for etiological factors
Function Present Consensus High High
Determining the severity of the

velopharyngeal impairment and the
The perceptual degree to which the velopharyngeal
+++ ++++
assessment of impairment disrupts speech production Level III Not Reported
High High
speech is critical to establishing the need for
intervention and for accurate therapeutic
intervention.
214 2021 (Volume 1) Pages: 213-225 Dysarthria

Strength of
Level of
Evidence
guidelines
Physical Examination
This involves an assessment of the Not ++++ ++++

Examination Not Reported
structure and function of the oral Present High High
mechanism, including the velopharynx at
rest and during movement.
It is necessary to directly observe and
measure velopharyngeal activity.
Instrumentation may include

videoflouroscopy, nasoendoscopy,
aerodynamic (pressure-flow).
assessments, and acoustic assessment.

This instrumentation allows for the
evaluation of
Instrumental • Intraoral air pressure and nasal

examination of the airflow during production of pressure Professional +++ ++++
Not Reported
velopharyngeal consonants. Consensus Moderate High
mechanism
• Palatal movement.
• Lateral pharyngeal wall movement.
• Sphincteric activity during speech.
• Nasal airflow and intraoral air

pressure.
• The timing of velopharygeal

movements.
*Audio recording of speech sample
to compare between before and after
Documentation by
therapy.
audiorecording and Not Professional +++ +++
nasofibroscopic Present Consensus Moderate Moderate
*Nasofibroscopic examination to
examination determine degree of palatal mobility and
lateral pharyngeal wall mobility.
Enhancement of speech and

Resonance Not ++++ ++++
communication function is a fundamental Not Reported
Intervention goal Present High High
target of intervention.

Strength of
Strength Average
recommendation
Level of after grading
Statement topics Action recommendations according to
Evidence adaptation/ for
the selected
adoption reviewers
guidelines
Palatal lift fitting has a long history associated
Prosthetic ++++ ++++
with improved speech function in selected Not Present Not Reported
intervention High High
cases of dysarthria.
Surgical It is not considered unless all other interventions ++++ +++
Not Present Not Reported
intervention have failed. High High
It is increasingly important to document the
Measurement of outcomes of intervention. A variety of outcome ++++ ++++
Outcomes measures may be obtained and can be High High
categorized.
Respiratory/phonatory impairment is a
common manifestation of dysarthria and
Respiratory can have a major impact on the adequacy
and phonatory of speech production. Treatment of the ++++ ++++
Level IV Not Reported
disorders in respiratory and phonatory subsystems. High High
dysarthria It is often given priority because improvements
at this level generate improvements in other
aspects of speech as well.
History of the problem
1. Onset and medical history.
2. Nature, duration and course of

dysfunction.
Assessment of 3. Report of previous treatment.

++++ ++++
respiration and Level IV Not Reported
4. Level of patient’s concern about the High High
phonation
impairment and social limitations.
5. Patient’s motivation relative to treatment.

Specific attention should be paid to
the patient’s presenting complaints as
they may provide the initial evidence of
respiratory or phonatory involvement.
Speech characteristics can provide a window
into the nature and existence of respiratory
and/or phonatory subsystem involvement.
Assessment of perceptual evaluation of loudness and breath
++++ +++
phonation and patterning. Inadequate loudness and improper Not Present Not Reported
High Moderate
respiration control of loudness, as well as abnormal
patterning of inhalation and exhalation during
speech, may serve as indicators of impaired
respiratory and function.

Strength of
Strength Average
recommendation
Statement topics Action recommendations according to
the selected
adoption reviewers
guidelines
Loudness
• Overall loudness level.
• Inconsistent loudness level.
• Sudden, uncontrolled alterations in

loudness.
• The patient is unable to increase loudness.
• The patient is unable to speak quietly.
• The patient is unable to emphasize words

in a sentence by increasing loudness.
Assessment of Breath Patterning

++++ ++++
respiration and Not Present Not Reported
• The patient does not demonstrate High High
phonation
the normal pattern of quick inhalation
followed by prolonged exhalation and
• Does not inhale to appropriate lung

volume levels (Chenery, 1998)
• Speech is interrupted by sudden, forced

inspiratory/expiratory
• The patient runs out of air before inhaling
• The patient produces few words/syllables

on one breath.
• Breaths occur at syntactically

inappropriate locations in the utterance.
Determination of Overall grade of dysphonia
Assessment of
(Breathy, rough, asthenic or strained) ++++ ++++
respiration and Not Present Not Reported
Determination of pitch and associated vocal High High
phonation
fry.

Strength of
Strength Average
recommendation
Level of after ad- grading
Statement topics Action recommendations according to the
Evidence aptation/ for re-
selected guide-
adoption viewers
lines
Physical Examination
A physical examination of the structure and

function of the speech mechanism should be
conducted, particularly if there are concerns
of respiratory involvement.
* The body position of the patient during

evaluation (and treatment) should be con-
Physical sidered.
++++ +++
Not present Not Reported
Audible breathy inspiration, inhalatory stri- High Moderate
Examination
dor, or an audible grunt at the end of ex-
piration.
* Observation of these symptoms may pro-

vide insight into the presence of respirato-
ry/phonatory impairment, and whether the
dysfunction stems from weakness, incoordi-
nation, involuntary movements, and/or mal-
adaptive strategies.
Clinical Screening
• A simple water glass manometer.
• A hand-held respirometer is an
economical device for gathering data
on vital capacity.
• Contrasting the sharpness of the +++ ++

Clinical screening Not Present Not Reported
patient’s cough with the glottal coup. Moderate Low
• Sustained phonation time is also used as

a very general estimate of respiratory/
phonatory capacity.
• Sustained phonation with changes in

loudness may also be implemented to
estimate respiratory drive.
A number of valuable respiratory/airflow
measures (e.g., vital capacity, forced
expiratory volume, functional residual
capacity, inspiratory capacity, and
expiratory/inspiratory reserve volumes) and ++++ +++
Instrumental Measures subsequently compare them to predicted Not Present Not Reported
High Moderate
values based on the patient’s age, height
and sex.
Additionally, kinematic assessment allows

the SLP to infer the airflow volume.
*Maximum phonation time is often used as
a global assessment of phonatory capacity.
++++ +++
Instrumental Measures Not Present Not Reported
*laryngeal adduction can be inferred from High Moderate
the sharpness of a patient’s cough and
glottal coup.
Phonatory Function/ laryngeal assessment.
A formal laryngeal assessment should be

++++ ++++
Phonatory assessment conducted when structural lesions or lesions Not Present Not Reported
High High
of the vagus nerve are a possibility or prior
to intensive voice therapy, such as the Lee
Silverman Voice Treatment program.

Strength of
Strength
Level of after
adoption
guidelines
• Endoscopy.
• Videostroboscoopy.
• High-speech photography.
• Optically precise rigid laryngoscopes.
• Flexible fiberoptic laryngoscopy.
• Aerodynamic measures have

Instrumental
demonstrated utility in documenting
assessment Professional ++++ ++++
perceptual voice characteristics Not Reported
of phonatory Consensus High High
and differentiating speakers with
dysfunction
hypokinetic dysarthria.
• Photoglottography.
• Electroglottography.
• Spectrographic/acoustic analyses.
• Laryngeal aerodynamics.
• Indirect mirror laryngoscopy.

Interventions vary as a type of dysarthria,
Individual severity of dysarthria, and co-existing ++++ ++++
Intervention factors. Therefore, individual intervention High High
plans must be developed.
Staging of Intervention. Dysarthria often
is not a stable condition. For example,
children with developmental dysarthria may
experience physiologic changes affecting
Individual speech production as they mature. Adults ++++ ++++
Intervention with acquired dysarthria may experience High High
phases of recovery; as in dysarthria
associated with traumatic brain injury; or
phases of degeneration. (i.e., the timing of
treatment) is critical for successful outcomes.

Strength of
Strength Average
recommendation
Statement topicss Action recommendations according to
the selected
adoption reviewers
guidelines
The symptoms of respiratory/phonatory
impairment may be categorized as
reductions in:
Management of 1. Respiratory support. +++ +++

Reduced Function Moderate Moderate
2. Respiratory/phonatory coordination
and control.
3. Phonatory functioning.
The following techniques have
demonstrated clinical utility for improving
respiratory support:
• Controlled exhalation tasks.
• Maximum inhalation and exhalation

tasks.
Improving the • Pushing and pulling techniques. ++++ ++++

respiratory support High High
• Breathing against resistance.
• Using an air pressure transducer

with feedback from an oscilloscope
or computer screen.
• Sustaining phonation with feedback

from Visipitch or the VU meter on a
tape recorder.
Expiratory boards or paddles provide a
stationary object for the patient to lean +++ ++++
Prosthetic Assistance Not Present Not Reported
into while speaking, thus increasing Moderate High
expiratory force.
Manipulations of breathing patterns
+++ ++
Speech Tasks during speech production can provide a Not Present Not Reported
Moderate Low
means of improving respiratory support
Nonspeech Tasks
Rehearsing a speech-like breathing

pattern (i.e., quick inspirations and slow,
controlled expirations)
• Implementing “inspiratory
checking” without accompanying
speech (if it is problematic for
the patient to speak on controlled
Improving ++++ ++++
exhalations). Not Present Not Reported
Coordination/Control High High
• Facilitating inspiratory coordination
and speed through sniffing, or
exhalatory coordination through
blowing.
• Practicing switching between

inspiration and expiration; the
speed of the task can eventually be
increased.

Strength of
Strength
Level of after
adoption
guidelines
Speech Tasks
Initiate speech at variable points in the

respiratory cycle and need more consistent
inspiratory control.
• Initiate speech at inappropriate lung

volume levels and need to vary the
depth of consecutive inhalations.
• Terminate speech late in the expiratory

cycle with resultant diminished loud-
ness.
• Exhibit abnormal or maladaptive respi-

ratory patterns, such as speaking on
inhalation and forced expiration, often
seen in patients with hyperkinetic dys-
arthria or patients with a concomitant
cognitive impairment. ++++ ++++
High High
• Adopt a fatiguing pattern of breathing,
such as excessive shoulder elevation.
The speaker can then practice read

ing paragraphs in which the respira
tory patterns or breath group bound
aries have been marked.
• Cued conversational scripts. Conver-

sational scripts for two speakers are
prepared. The patient can practice
modifying inhalations according to
the marked respiratory patterns while
speaking with another person.
• Un cued reading/conversation. The

patient reads aloud or speaks conver-
sationally without the aid of respiratory
pattern markings.

Strength of
Strength
Level of after
adoption
guidelines
Physical Strategies to Enhance
Adduction: Clasping hands together
and squeezing palms together as hard
as possible
• Interlacing hands and pulling outward.
• Pushing down on the speaker’s raised

arms in a rapid, uninterrupted motion.
• Sitting in a chair, grasping the bottom

with both hands, and pulling upward.
• Sitting in a chair and pushing down on

the seat bottom with both hands.
• Pushing against a lap board, the arms

of a wheelchair, or against any other
firm surface.
• Pushing the head forward against

Improving resistance provided by the examiner’s
Phonatory Function ++++ ++++
hands placed on the forehead of the Not Present Not Reported
High High
speaker.
• Grunting and controlled coughing (To

elicit phonatory behavior).
Trigger Better Speech with Increased

Loudness
• High phonatory and physical effort
• Intensive treatment: Daily practice

opportunities are requisite; treatment
is administered four times a week for
16 sessions in one month.
• Sensory calibration/perception:
Speaker learns to identify the
appropriate amount of effort.
• Quantification: Quantified feedback

by the clinician is key to motivating
speakers.
Perceptual measures.
Measurement of ++++ ++++
Measure of activity. Not Present Not Reported
Outcomes High High
Measures of impairment.
Alternative and
If a speaker remains unable to communicate
augmentative ++++ ++++
satisfactorily following intervention, AAC Level III Not Reported
communication High High
modes should be pursued.
tools
The most common explanation for selecting
a particular intervention for a speaker
with dysarthria was based on physiologic
features. Because the respiratory ++++ ++++
Candidacy Not present Not Reported
subsystem provides the energy source High High
and the phonatory system provides the
sound source, both are critical to speech
production.
Articulation Working with articulatory deficits as an +++ ++
Level IV Not Reported
therapy isolated error of articulation. Moderate Low

Strength of
Strength
Level of after
adoption
guidelines
Prognostic indicators were provided for
intervention.
* In speakers with flaccid dysarthria,

improved phonation with pushing exercises
was used as a rationale for a complete Professional ++++ ++++
Not Reported
program to enhance respiratory drive. Consensus High High
* In persons with Parkinson disease,

improved phonation with instructions to
speak loudly was cited as a positive indicator
of candidacy for treatment.

Strength of
Strength Average
recommendation
Statement Level of after grading
Action recommendations according to
topics Evidence adaptation/ for
the selected
adoption reviewers
guidelines
Smith accent voice therapy technique will
improve function of respiration and phonation in
the form of:
Improving • Increase loudness. ++++ ++++

phonatory Not Present Not Reported
High High
Function • Better respiratory support.
• Slowing the rate of speech.
• Adjust onset of phonation and respiration.

Treatment of articulatory errors using:
Consonant exaggeration.
Syllable by syllable attack.
Articulation Slowing the rate of speech. +++ ++++

Not Present
therapy Moderate High
Oral muscular exercises are not mandatory
for weak musculature as muscle tone needed for
speech is different from muscle tone needed for
the swallowing process.
Restrict oral muscle exercises in drooling.

Therapeutic intervention for:
Prosodic ++++ ++++
Not Present
correction High High
Pitch inflections, stress and tone units.
Augmentative and alternative communication in
case of:
++++ ++++
AAC Not Present
*Failed traditional therapy. High High
*Anarthria.
Good prognosis with:
Young age. +++ ++++

Prognosis Not Present
Moderate High
Early intervention.
Intensive therapeutic strategies.

Flow chart of Dysarthria.
References 3. Yorkston KM, et al. Evidence for effectiveness of

treatment of loudness, rate, or prosody in Dysarthria:
1. Yorkston KM, Spencer K, Duffy J, Beukelman, et al. A systematic review. Journal of Medical speech and
Evidence –Based Practice guidelines for dysarthria: language pathology. ANCDS Bulletin Board. Carl
Management of velopharyngeal function. Academy Coehlo. 2007;15(2).
of Neurologic Communication Disorders and Science:
Bulletin Board ANCDS, Journal of Medical Speech 4. ASHA Summary of the clinical practice guideline 2017,
language pathology. 2001;9(4):257-274. https://www.asha.org/articlesummary.dysarthria.
2. Royal college of speech and language therapists. 5. Clinical guidelines speech therapy e vi core
Clinical guidelines. Speech mark publishing. 2005. healthcare. 2019.

Upper Airway Assessment in Adults with Snoring and Obstructive Sleep

Apnea Hypopnea Syndrome (OSAHS): Adapted Egyptian Clinical Practice
Guidelines
Assembly Board: Reham Abdelwakil Ibrahim,10 Amal Saeed,11 Hemmat El Baz,12 Aya Sheikhany9
Aisha Fawzy Abdel Hady,9 Ahmed Ali AbdelMonem,13 Omayma Afsah,12 Salwa Ahmed,14 Azza Abdel Aziz Azzam,15 Iman
El-Rouby,15 Mohamed Darweesh,16 Dalia Mostafa Osman,9 Yossra Salam17
Reviewers team: Rasha Shoeib,8 Sabah Hassan,8 Hassan Ghandour,8 Ahmed Elsayed Gelaney18
1
6
Otorhinolaryngology Department, Faculty of Medicine/Mansoura University, 7Audiovestibular Unit, Otorhinolaryngology
Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain
Otorhinolaryngology Department, Faculty of Medicine/ Assuit University, 11Phoniatrics Unit, Otorhinolaryngology Department,
Faculty of Medicine/ Zagazig University, 12Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/Mansoura
University, 13Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Beni Suef University, 14Phoniatrics
Unit, Otorhinolaryngology Department, Faculty of Medicine/ Banha University, 15Phoniatrics Unit, Otorhinolaryngology
Department/ Hearing and Speech Institute, 16Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Tanta
University, 17Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Al-Azhar University, 18Phoniatrics Unit,
Otorhinolaryngology Department, Faculty of Medicine/ Sohag University.
Obstructive sleep apnea hyoponea syndrome (OSAHS) is The members of the subcommittee reviewed the best
characterized by recurrent periodic episodes of cessation evidence-based guidelines and four guidelines were
of breathing during sleep due to recurrent upper airway selected which were then scored regarding the credibility,
obstruction. Upper airway evaluation includes the observability, relative advantage, easy to install and
assessment of the structure and function of the upper understand, compatibility, and testability.
airway in such cases. Despite of the availability of various
tools of upper airway assessment, there is currently no The adaptation cycle passed over: Set up phase,
available national benchmark to determine the suitable adaptation phase (Search and screen, assessment:
tool for each case. Currency, Content and Quality and Decisions/selection)
and finalization phase that included revision.
Scope and purpose
Results
The purpose of this guideline is to provide national
standards for the upper airway assessment in adult Four guidelines were assessed by 4 expert phoniatricians
cases with snoring and OSAS that can be implemented and the clinical practice guideline recommendations on
in clinical practice. These standards will improve our examination of the upper airway for adults with suspected
understanding of the pathophysiology of snoring and obstructive sleep apnoea-hypopnoea syndrome
OSAS which will help in the selection of the appropriate (The Spanish Society of Otolaryngology & the Spanish
treatment option for different patients and monitor the Sleep Society and the Spanish Society of Maxillofacial
treatment outcomes. Surgery ) 4 had the highest scores as regards to the
currency, contents and quality. It was graded by 9 expert
phoniatricians and reviewed by 4 expert reviewers.
Grade Definition
High We are very confident that the true effect lies close to that of the estimate of the effect
++++
++ effect
+ of effect
226 2021 (Volume 1) Pages: 226-231 Obstructive Sleep Apnea Hypopnea Syndrome
Explanation of the types of Recommendations

Types of Recommendations Judgment
Interventions that have shown more benefit than risk in the majority of
Strong Recommendation to Favor
the target population
Interventions that may have a benefit but must be individualized in the
Potentially Strong Recommendation
context of patient’s preference
Interventions that have shown more risk than benefit for the majority of
Strong Recommendation against
the target population
Potentially strong Recommendation against Interventions that may have a risk more than a benefit
Explanation of the level of Evidence
Level Level of Scientific Evidence
Evidence from meta-analysis, systemic reviews of randomized clinical trials (RCT) or RCTs with a very low risk of
1++
having biases
1+ Evidence from meta-analysis, systemic reviews of RCTs or RCTs with a low risk of bias and well conducted
Evidence from systemic reviews of cohort studies, high quality case control or case studies with a very low risk of
2++
factor bias
2+ Evidence from either cohort or case-control studies performed with a low risk of confounding or chance bias
3 Evidence from non-analytical studies (well-deigned non-experimental descriptive, and case series studies
4 Evidence from expert opinion
Final Recommendations statements (CPG recommendations)

Accepted statements
Modified statements
Added statements
Obstructive Sleep Apnea Hypopnea Syndrome 2021 (Volume 1) Pages: 226-231 227
OSAHS Guidelines Statements
Strength of
Level of
Evidence
guidelines
A. Assess the presence of

chronic rhinitis or chronic nasal +++ +++
2++ Potentially Strong
obstruction through validated Moderate Moderate
questionnaires or interview.
1.Recommendations B. Structural nasal examination

for nasal (endoscopy or rhinoscopy) in
examination patients with suspected OSAHS
and positive nasal obstruction
Strong ++++ ++++
symptoms as there is a clear 1++
correlation between nasal
obstruction and disturbed
sleep quality, snoring level, and
excessive daytime sleepiness.
A. Systematic pharyngeal
examination by visualization of 1++
Strong ++++ +++
palate length and thickness, uvula
Recommendation High Moderate
size, jaw narrow-ness, and tonsil
size.
B. Modified Mallampati score;
2.Recommendations Friedman staging determines
for visual and the presence or severity of their Potentially strong +++ ++++
endoscopic 2++
OSAHS because, although the Recommendation Moderate High
examination of the correlation is small, it has a good
upper airway: cost-opportunity ratio.
C. Awake endoscopy with Müller’s
maneuver at velopharynx,
oropharynx, and hypopharynx
Strong ++++ ++++
level, should be considered to 2++
give an initial idea about levels
and patterns of upper airway (UA)
collapse.
A diagnosis of certainty of
3.Recommendations OSA is made by nocturnal
for using polysomnog- polysomnography for predicting Strong ++++ ++++
2++
raphy in the assess- response to continuous positive Recommendation High High
ment of OSA airway pressure (CPAP)
treatment.
A. An examination of the oral
cavity and the occlusal situation
in patients with suspected Strong ++++ ++++
2++
OSA should be considered as Recommendation High High
4.Recommendations an indirect marker of skeletal
for radiological upper disorders predisposing to OSA.
airway and dental B. Evaluate the facial profile
assessment of patients based on their
approximate equivalence Potentially Strong +++ +++
2++
with cephalometry to identify Recommendation Moderate Moderate
craniofacial patterns that may
predispose to OSA.
Strength of
Level of
Evidence
guidelines
A. Assess the possibility of alter-

native treatments to CPAP espe-
cially surgical treatments on the Strong ++++ ++++
1++
soft tissues of the upper airway, Recommendation High High
as this may condition the thera-
peutic strategy.
B. Performing DISE is not recom- Potentially Strong ++++ ++++

2++
mended before the use of CPAP. Recommendations High High
C. DISE is performed in patients

who have failed CPAP therapy or Strong ++++ ++++
2++
who encounter difficulties in toler- Recommendation High High
ating CPAP.
D. During DISE procedure; local

anesthesia may be avoided, as
loss of pharyngolaryngeal muco-
sal sensitivity would bias results.
Vasoconstrictors are contraindi-
Strong ++++ ++++
5.Recommendations cated before 15 years of age, and 2++
for upper airway thus cannot be used in children.
examination under Atropine to reduce salivation is
induced sleep (Drug not recommended, due to cardio-
Induced Sleep Endos- vascular effects liable to impact
copy DISE) examination.
E. DISE could provide further
information in patients in whom
previous surgery has failed and
may allow the clinician to recom- Strong ++++ ++++
2++
mend either further surgical inter- Recommendation High High
vention addressing the relevant
anatomical segment that may be
causing residual symptoms.
F. The DISE benefits from a
learning curve, both for the clas-
sification of collapses and for their
interpretation and treatment rec-
ommendation after it has been
performed, because not all col- Strong ++++ ++++
2++
lapses visualized in the DISE need Recommendation High High
to be treated in order to cure
patients. It is therefore recom-
mended that the DISE team have
experience in sedation and the in-
terpretation of the findings.
References gradepro.org/app/handbook/handbook.html.
1. American Society of Anesthesiologists. Practice 4. Esteller E., Carrasco M., Diaz-Herrera M., et al.,
guidelines for the perioperative management of Clinical practice recommendations on examination
patients with obstructive sleep apnea: A report by of the upper airway for adults with suspected
the American Society of Anesthesiologists Task obstructive sleep apnoea-hypopnea syndrome. Acta
Force on perioperative management of patients Otorhinolaryngol Esp. 2019;70(6):364-72.
with obstructive sleep apnea. Anesthesiology.
2006;120:268-86. 5. Leclere J.C., Marianowski R., Monteyrol
P.J., et al., Guidelines of the French Society of
2. Epstein L.J., Kristo D., Strollo P.J., et al., Clinical Otorhinolaryngology. Role of the ENT specialist
guidelines for the evaluation, management and in the diagnosis of obstructive sleep apnea-
long term care of obstructive sleep apnea in adults. hypopnea syndrome (OSAHS). Part 2: Diagnostic
Journal of Clinc. Sleep Med. 2009;5(3):263-276. investigations apart from sleep studies. Europ. Ann.of
Otorhinolaryngol. Head and Neck Dis. 2019;136:295-
3. Holger Schünemann, Jan Brożek, Gordon Guyatt, and 99.
Andrew Oxman. GRADE handbook 2013. https://gdt.
Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG List of Contributors
List of Contributors in alphabetical order (Last Name)

A
1 Hossam Abdel Ghaffar Helwan University
2 Adel Adbel Maksoud Ain Shams University
3 Ahmed Musaad Abd Elfattah Mansoura University
4 Fatthi Abdelbaki Alexandria University
5 Ahmad Abdel Fattah Al Azhar University
6 Gamal Abdel Fattah Misr University
7 Hisham Abdel Fattah Alxandria University
8 Aisha Fawzy Abdel Hady Cairo University
9 Hazem M. Abdel Tawwab Cairo University
10 Mahmoud AbdelAziz Tanta University
11 Mohamed Abdelghaffar Sohag University
12 Doaa Abd Elhalem Alazhar University
13 Rafeek Mohamed Abdelkader Minia University
14 Magda Abdellatif Al-Azhar University for Girls
15 Ahmad Salama Abdelmeguid Mansoura University
16 Ahmed Ali AbdelMonem Bani-Suef University
17 Montaser Abdelsalam Minia University
18 Ibrahim Abdel-Shafie Menoufia University
19 Heba Abdel Rahem Abo Elnaga Menoufia University
20 Alaa Abo Setta Suez Canal University
21 Ahmad Abou Elwafa Assuit University
22 Tamer Abou-Elsaad Mansoura University
23 Eslam Farid Abu Shady Banha University
24 Sherif Adly Cairo University
25 Omayma Afsah Mansoura University
26 Mohamed Rifaat Ahmed Suez Canal University
27 Salwa Ahmed Banha University
28 Magdi Abdallah Al -Ahl Zagazig University
29 Ashraf A. Alhamshary Banha University
30 Sameh Amin Fayoum University
31 Mostafa Ammar Tanta University
32 Ahmed Anany Zagazig University
33 Essam Aref Assuit University
34 Mohamed Askar Tanta University
35 Sherif Mohammad Askar Zagazig University
36 Anas Askoura Ain Shams University
37 Azza Abdel Aziz Azzam Hearing and Speech Institute
38 Tamer Azzam Police Academy
39 Mohamed Badr El-Dine Alexandria University
B
40 Samia Bassiouny Ain Shams University
41 Essam Behairy Menoufia University
42 Aziz Belal Alexandria University
43 Khaled Belasy Police Academy, The Medical Sector MOI
D
44 Abeir Dabbous Cairo University
45 Khaled Dahy Sohag University
46 Mohamed Darweesh Tanta University
232 2021 (Volume 1) Pages: 232-237

List of Contributors Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG

E
47 Magdy Eisa Tanta University
48 Mohamed Ekram Assuit University
49 Iman El Adawi Al Azhar Female
50 Ahlam El Adawy Sohag University
51 Hesham El-Adl Mansoura University
52 Sherif Elaini Armed Forces college of Medicine
53 Mona El Akkad Fayoum University
54 Lamees El-Amragy Ain Shams University
55 Mohamed El Ayadi Cairo University
56 Hossam Abd El-Azeem Banha University
57 Mohamed El Badry Minia University
58 Ahmed Mahmoud El Batawi Cairo University
59 Hemmat El Baz Mansoura University
60 Omer Elbanhawy Menoufia University
61 Mahmoud Fawzy Elbestar Cairo University
62 Iman El-Danasoury Ain Shams University
63 Ahmed Ali Eldegwi Mansoura University
64 Asmaa El Dessouky Menoufia University
65 Hossam El Dessouky Cairo University
66 Tarek El Dessouky Bani-Suef University
67 Haitham Elfarargy Kafr Elsheikh University
68 Ahmad Elfarouk Cairo University
69 Lobna ELfeky Ain Shams University
70 Aly Elgarem Cairo University
71 Hani El Garem Alexandria University
72 Mai EL Ghazaly Alexandria University
73 Mai El Gohary Hearing and Speech Institute
74 Ashraf A. Elhamshary Banha University
75 Ahmed S. Elhamshary Tanta University
76 Diaa Elhennawy Suez Canal University
77 Ashraf Elhosini Zagazig University
78 Rasha Elkabarity Ain Shams University
79 Tawfik Elkholy Al Azhar University
80 Ahmed Elkhateeb Military Medical Acadamy
81 Wafaa El Kholy Ain Shams Universty
82 Reham El Maghraby Alexandria University
83 Trandil ElMehallawi Tanta University
84 Esmail Elnashar Zagazig University
85 Ahmad El Naggar Tanta University
86 Abdellatif Elrashidy Menoufia University
87 Mostafa Elrfaie Tanta University
88 Mohamed El Rubaie Tanta University
89 Safaa El Sady Ain Shams University
90 Mohamed Elsalmawy Cairo University
91 Enas El Sayed Assiut University
92 Mohamed Mohamed Elsharnouby Ain Shams University
93 Reham Elshafie Fayoum University
94 Reham El Shennawy Cairo University
95 Amira El Shennawy Cairo University
2021 (Volume 1) Pages: 232-237 233


96 Mohamed Naser ElSheikh Tanta University
97 Magid Elshennawy Cairo University
98 Abdelaziz Elsherif Al-Azhar Assuit University
99 Hosam El-Sherif Tanta University
100 Ezz Eldine Elshikh Zagazig University
101 Alia El-Shobary Ain Shams University
102 Hossam Elsisi Mansoura University
103 Mostafa A. El Taher Sohag University
104 Mohamed Eltabbakh Suez Canal University
105 Abdel Rahman Eltahhan Suez Canal University
106 Ahmad Eltelety Cairo University
107 Iman El-Rouby Hearing and Speech Institute
108 Saad Elzayat Kafr El Sheikh University
109 Tarek Abdelzaher Emara Zagazig University
110 Fathi Erfan Tanta University
111 Eman Ezat Menoufia University
F
112 Mohamed Fawwaz Bani-Suef University
113 Ayman Fouad Tanta University
G
114 Mohamed Mostafa Gaballah Hearing & Speech Institute
115 Nahla Gad Zagazig University
116 Ahmed Galal Alexandria University
117 Amr Galal Hearing & Speech Institute
118 Ahmed Gamae Tanta University
119 Mohamed Gamea Misr University For Science And Technology
120 Ahmed Elsayed Gelaney Sohag University
121 Hassan Ghandour Ain Shams University
122 Tarek Ghannoum Cairo University
123 Hebba Ghannoum Helwan University
124 Alaa Gheita Military Medical Academy
125 Mohamed R. Ghonim Mansoura University
126 Amr Gouda Ain Shams University
127 Sherif Safwat Guindi Fayoum University
H
128 Nirvana Gamal El Din Hafiz Ain Shams University
129 Mahmoud Hagras Cairo University
130 Hisham Hamad Tanta University
131 Baliegh Hamdy Minia University
132 Mahmood A. Hamed Sohag University
133 Yasmine Hamza Ain Shams University
134 Mohamed Hassab Alexandria University
135 Haytham Hassan Alexandria University
136 Sabah Hassan Ain Shams University
137 Yomna Hassan Ain Shams University
138 Enaas Hassan Assuit University
139 Mohamed Salah Hassouna Cairo University
140 Nagwa Hazzaa Ain Shams University
141 Mohamed Hegazy Cairo University
142 Islam R. Herzallah Zagazig University
234 2021 (Volume 1) Pages: 232-237


143 Medhat Heshmat Tanta University
I
144 Ahmed Ali Ibrahim Alexandria University
145 Reham Abdelwakil Ibrahim Assuit University
146 Iman Ibrahim Al Azhar Female
147 Naema Ismail Al Azhar University
K
148 Sayed Kaddah Al Azhar University
149 Nadia Kamal Ain Shams University
150 Usama Kamal South Valley University
151 Reda Kamel Cairo University
152 Yaser khafagy Mansoura University
153 Zienab Khalaf Minia University
154 Ashraf Khaled Bani-Suef University
155 Ibrahim Ahmed Khaled Zagazig University
156 Adel Khalifa Tanta University
157 Mahmoud Khalifa Aswan University
158 Mohamed Abdel Hakeem Khalifa Menoufia University
159 Samir Halim Khalil General Organisation of Teaching Hospitals and Institutes
160 Yaser Abdel Wahab Khalil Menoufia University
161 Ahmed Khashaba Military Medical Acadamy
162 Enaas Kolkaila Tanta University
163 Rabab Koura Bani-Suef University
164 Hesham Kozou Alexandria University
L
165 Ashraf Lotfy Military Medical Acadamy
166 Sherief Lotfy Alexandria University
M
167 Elham Magdy Zagazig University
168 Mena Maher Cairo University
169 Radwa Mahmoud Banha University
170 Salwa Mahmoud Hearing and Speech Institute
171 Ali Mahrous Al Azhar University
172 Mahmoud Mandour Tanta University
173 Zeyad Mandour Alexandria University
174 Hesham Mansour Cairo University
175 Ossama Mansour Ain Shams University
176 Ayman Medany Alexandria University
177 Ahmed Mehana Alexandria University
178 Soha Mekki Zagazig University
179 Osama Metwaly Cairo University
180 Amir Gorguy Mina Alexandria University
181 Mohamed Modather Assuit University
182 Abdelwahab Mohamed Mansoura University
183 Ibrahim Rezk Mohammed Sohag university
184 Waleed Monir Mansoura University
185 Mohamed Mosleh Cairo University
186 Iman Mostafa Bani-Suef University
187 Mona Mourad Alexandria University
188 Elshaarawy Mousa Mansoura University
2021 (Volume 1) Pages: 232-237 235

N
189 Ihab Nada Misr University
190 Nashwa Nada Bani-Suef University
191 Maged B. Naguib Suez Canal University
192 Nbila Naklawy Al Azhar University
193 Yasser Nour Alexandria University
O
194 Abir Omara Benha University
195 Mohamed Omar Assiut University
196 Tamer Orabi Zagazig University
197 Dalia Mostafa Osman Cairo University
198 Hasnaa Othman Medical Studies for Children Center at the Faculty of Postgraduate
Childhood Studies
Q
199 Mohamed Qotb Fayoum University
R
200 Mohamed Rabie Assuit University
201 Amr Rabie Ain Shams University
202 Ahmed Ragab Menoufia University
203 Ayman Ragheb Nasr City Insurance Hospital
204 Abdelwahab Rakha Mansoura University
205 Mohamed Fatehy Ramadan Al Azhar Damietta University
206 Ramez Reda Beni-Suef University
207 Mohammed Refaat Suez Canal University
S
208 Mohammed Mahmoud Roushdy Assiut University
209 Amal Saeed Zagazig University
210 Rasha Safwat Cairo University
211 Abdelraof Said Zagazig University
212 Ashraf Salah ElDin Military Medical Acadamy
213 Yossra Salam Al-Azhar University
214 Mohamed Salama Assiut University
215 Ezzat Saleh Assiut University
216 Marwa Saleh Ain Shams University
217 Mohamed Abd Elbadie Salem Mansoura University
218 Mohamed Salem Assiut University
219 Magdy Samir Ain Shams University
220 Hesham Sami Minia University
221 Azza Samy Hearing and Speech Institute
222 Hosam Sanyelbhaa Menoufia University
223 Hedia Serry Ain Shams University
224 Hesham Shaalan Hearing and Speech
225 Mohamed Shabana Cairo University
226 yousef Shabana Mansoura University
227 Ayman Shawky Military Medical Academy
228 Emad Shehata Tanta University
229 Aya Sheikhany Cairo University
230 Yasser Shewel Alexandria University
231 Rasha Shoeib Ain Shams University
232 Sahar Shohdi Cairo University
236 2021 (Volume 1) Pages: 232-237


233 Sayed Siam Al-Azhar University
234 Islam Soltan Kafr Elsheikh University
235 Zakria Soliman Military Medical Academy
T
236 Hesham Taha Ain Shams University
237 Nassim Talaat Cairo University
238 Abdelzaher Tantawy Zagazig University
239 Ali Tawfik Mansoura University
240 Somia Tawfik Ain Shams University
241 Mohamed Osama Tomoum Tanta University
Y
242 Ashraf Yakoot Military Medical Academy
243 Soad Yehy Al-Azhar University for Girls
244 Mahmoud Yousef Ain Shams University
245 Ragaei Youssef Bani-Suef University
Z
246 Mohamed Zaidan Al Azhar University
247 Mohamed Zahran Alxandria University
248 Effat Zaky Minia University
249 Rehab Abd ElHafeez Zaytoun Fayoum University
250 Ismail Zohdi Cairo University
2021 (Volume 1) Pages: 232-237 237

Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG Acknowledgement
Acknowledgement
On behalf of the board of “The Egyptian Clinical Practice Guidelines

Otorhinolaryngology, Audio-vestibular & Phoniatrics - ECPG-ORLAP” and all
the contributors, we would like to thank UTOPIA Pharma Scientific team for their
enormous support and the unconditional sponsorship to help in the production of the
first Edition of the Guidelines Book.
238 2021 (Volume 1) Pages: 238

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Ministry of Higher Education and Scientific Research, Supreme Council of University Hospitals, CPG

Egyptian clinical practice

2021 (Volume 1) Pages: I I

For more information, address: info@redakamel.com

First edition October 2021

II 2021 (Volume 1) Pages: II

Professor Dr. Khaled Abdel Ghaffar

2021 (Volume 1) Pages: III III

Professor Dr. Hossam Abdel Ghaffar

IV 2021 (Volume 1) Pages: IV

Egyptian Clinical Practice Guidelines of Otorhinolaryngology, Audio-vestibular & Phoniatrics

On behalf of the board

2021 (Volume 1) Pages: V V

Ahmed Ragab MD, PhD Brussels

VI 2021 (Volume 1) Pages: VI

Module 2: Adaptation plan approval

Module 2: Search and screen

Module 3: Assess guidelines with scoring of each retrieved CPG

Module 4: Decision and selection

Module 5: Customization and adaptation

PHASE III — Finalization

Module 2: External review and acknowledgement

Module 3: After-care planning

Module 4: Final production

Module 5: Dissemination and implementation

2021 (Volume 1) Pages: VII VII

Flowchart ECPG - ORLAP

VIII 2021 (Volume 1) Pages: VIII

Chapter 3: Head and Neck

2021 (Volume 1) Pages: X X

Chapter 4: Audiovestibular Medicine

XI 2021 (Volume 1) Pages: XI

Acute Otitis Media in Children: Adapted Egyptian Clinical Practice

Acute otitis media (AOM) is an acute, suppurative infectious Methods

Acute otitis media 2021 (Volume 1) Pages: 1-6 1

Evidence Quality for Grades of Evidence

Guideline Definitions for Evidence-Based Statements

Strong recommendation means that the

2 2021 (Volume 1) Pages: 1-6 Acute otitis media

Strength according Strength after

Clinicians should diagnose acute otitis media (AOM)

Clinicians should diagnose AOM in children who

Acute otitis media 2021 (Volume 1) Pages: 1-6 3

Strength according Strength after

Clinicians may offer tympanostomy tubes for

4 2021 (Volume 1) Pages: 1-6 Acute otitis media

Recommended antimicrobial therapy

Acute otitis media 2021 (Volume 1) Pages: 1-6 5

References otitis media guidelines in selected developed and

6 2021 (Volume 1) Pages: 1-6 Acute otitis media

Otitis media with effusion in children: Adapted Egyptian Clinical Practice

Scope and purpose IIb: least one well-designed, quasi-experimental study.

Ia: Meta-analysis (with homogeneity) or randomized

Otitis media with effusion 2021 (Volume 1) Pages: 7-11 7

Recommendations statements (From 10-20 recommendations in a Table)

8 2021 (Volume 1) Pages: 7-11 Otitis media with effusion

However if there is concern about difficult follow

Tympanostomy Clinicians may perform Tympanostomy tube

Clinicians should offer bilateral tympanostomy tube

Otitis media with effusion 2021 (Volume 1) Pages: 7-11 9

10 2021 (Volume 1) Pages: 7-11 Otitis media with effusion

References 5. Blanc F, Ayache D, Calmels MN, Deguine O, François

Otitis media with effusion 2021 (Volume 1) Pages: 7-11 11