Al-Zahraa University Hospital Research Articles

Pattern of antibiotic use among children caregivers: a cross-sectional study

BackgroundAntibiotic resistance, a major global health concern, is primarily caused by the irrational use of antibiotics. Parents play a crucial role in antibiotic use by children, directly impacting their clinical outcomes. This study aimed to assess the pattern of antibiotic use among parents and its related factors.MethodsA cross-sectional study was conducted among 400 parents randomly selected from the pediatric outpatient clinics of Al-Zahraa University Hospital, Cairo. Data were collected using a structured interview questionnaire about sociodemographic data, antibiotic use patterns, parental knowledge and attitudes, common sources of information, and reasons for self-prescribing antibiotics.ResultsOut of the 400 parents surveyed, 87.7% were mothers with a mean age of 31.9 ± 7 years, 76% were highly educated, almost half were not working, 63% came from urban areas, and 95.2% had sufficient income. As for their children, 57.5% had male children; their average age was 5.5 ± 3.7 years. The misuse of antibiotics was prevalent among 37.2% (95% CI = 32.5–42.2%) of parents. When assessing parents’ knowledge and attitude towards antibiotic use, 30.2% (95% CI = 25.8–35.0%) had good knowledge which was significantly more common among highly educated, working, and high-income parents, while the majority (72%, 95% CI = 67.3–76.3%) had a positive attitude. Having more and older children significantly increased the probability of antibiotic misuse, while a higher level of parental education and a positive attitude decreased the likelihood of such misuse (odds ratio (OR) was 1.31, 1.09, 0.52, and 0.11, respectively). Most parents obtained their information about antibiotics from physicians (92%) followed by experience from previous prescription (58.5%). Moreover, among inappropriate users, previous prescriptions and the parent’s perception of the child’s illness as a nonurgent condition were the most frequently cited reasons for the parents’ self-prescription of antibiotics (76.5% and 69.1%, respectively).ConclusionApproximately, one-third of surveyed parents demonstrated an inappropriate use of antibiotics. Despite possessing a highly positive attitude and a reasonable level of knowledge about antibiotics, parents often underestimate the potential adverse effects. Tailored measures to promote appropriate antibiotic use are therefore needed to combat the problem of antibiotic resistance.

Tibial scoring as a predictor for amputation-free survival in critical limb ischemic patients

Background/aim Evaluating the risk of amputation in patients with peripheral arterial disease (PAD) is essential. A critical Limb Ischemic patient (CLI) is known as end stage of PAD. Creating novel approaches to pinpoint high-risk patients would allow for targeted treatments and support specialized clinical trials focused on limb preservation. This study’s objective is to evaluate tibial adversity and scoring for risk of lower extremity amputation in critical limb ischemic patients (CLI). Patients and methods This study is a prospective study carried out on 30 patients with symptomatic lower extremity PAD in Al-Zahraa University Hospital from February 2023 to January 2024 interval. All patients were assessed by hemodynamics study and multislice noncontrast CT and tibial angioplasty according to inclusion and exclusion criteria. The patients followed up at day 1 and 3 and 6 months. Results Patients with CLI exhibited significant high (p < 0.05) tibial artery calcification scores, which were linked to increased limb ischemia levels, with high risk for amputation compared to traditional risk factors. 26 patients were amputation free rate and only 4 patients were done major amputation. Nonmodifiable risk factors correlated with elevated tibial artery calcification scores. Conclusions The present study indicated that tibial scoring independently predicts the risk of lower extremity amputation, even when considering other risk factors in patient with CLI. Increasing calcium scores are associated with greater PAD severity.

Inclusive Leadership and Emotional Intelligence among Nurses at Alzahraa University Hospital

Inclusive Leadership and Emotional Intelligence among Nurses at Alzahraa University Hospital

Improving human sperm motility via red and near-infrared laser irradiation: in-vitro study

Improved sperm motility is necessary for successful sperm passage through the female genital system, efficacious fertilization, and a greater probability of pregnancy. By stimulating the mitochondrial respiratory chain, low-level laser photobiomodulation has been shown to increase sperm motility and velocity. The respiratory chain in mitochondria is the primary site of action for cytochrome c oxidase because it can absorb light in the visible and infrared ranges. The present study aimed to investigate the effects of red laser 650 nm, near infrared laser (NIR) 980 nm, and combination of both on human spermatozoa motility and DNA integrity at different doses. An in-vitro controlled trial was performed in Al Zahraa university hospital laboratory using thirty fresh human semen specimens. Samples were exposed to red laser 650 nm, near infrared laser (NIR) 980 nm, and combination of both for various irradiation times. Sperm motility for the test and control aliquots was assessed as recommended in the manual of WHO-2021. Sperm chromatin integrity was evaluated using the Sperm Chromatin Structure Assay. Results revealed almost 70%, 80% and 100% increase in the total motility after 3 min of the 650-nm, 980-nm and the combined laser irradiation, respectively. Additionally, the Sperm Chromatin Dispersion assay was carried out on sperm heads utilizing human sperm DNA fragmentation, demonstrating that none of the three laser types had any discernible effects.Graphical abstract

Clinical aspects of human Bocavirus 1 in a sample of Egyptian infants with acute lower respiratory tract infection: A pilot study

Background/aim The recent advance in molecular technology permitted a comprehensive range of novel viral etiological causes to be detected in respiratory tract specimens. The human Bocavirus 1 (HBoV1) as a virus of the Parvoviridae family recently was defined as a human pathogen mainly linked to acute respiratory infection in children. Our aim was to identify the rate and seasonal variation of Bocavirus 1 infection and their correlation with the different clinical presentations in Egyptian infants less than 2 years old with acute lower respiratory tract infection. Patients and methods This study enrolled 100 infants aged from 4 weeks to 2 years presenting with symptoms of acute respiratory infection from Materia Hospital and Alzahraa University Hospital. Full medical history, general and local examination of the chest focusing on respiratory rate and plain chest radiograph were collected from each infant. In addition, pharyngeal swabs were collected from participated infants and were subjected to DNA extraction followed by PCR using different viral protein-targeted primer sets. Results Bronchopneumonia was the prominent diagnosis in the enrolled infants (38%) followed by bronchiolitis (34%) and bronchitis (28%) subsequently. The presence of HBoV1 among studied patients was 8% and the peak of the infection was in January (37.5%) followed by April (25%) and July (25%). Most of patients with HBoV1 positive were presented with respiratory distress and refusal of feeding. Seven percent of all patients were presented with diarrhea. Conclusions HBoV1 infection may be considered as a risk factor for lower respiratory tract infections in Egyptian children less than 2 years old.

Calcitonin gene-related peptide and its correlation with prognosis in severe pneumonia among children below 6 years at PICU of Al Zahraa university hospital

Pneumonia is known to be the biggest cause of death in children younger than five years old. In pulmonary diseases such as pulmonary arterial hypertension, asthma, acute lung injury, and pulmonary fibrosis, calcitonin gene related peptide (CGRP) has been linked to the regulation of inflammation, proliferation, and fibrosis. However, its ability to foretell the emergence of severe pneumonia is questionable. We aimed to determine whether blood levels of CGRP correlate with the outcome of critically ill children. This case-control study included 45 children with severe pneumonia admitted to the pediatric intensive care unit and 45 children with matched age and sex as controls. We investigated the serum level of CGRP as well as routine laboratory investigations of both groups. The CGRP level was lower in the patient group with median of 77 ng/L ranged from 55 to 183 as compared to control group with median of 230 ng/L ranged from 133 to 664 (p≤0.001). Also, CGRP level was significantly higher in the survived group with median of 96.1 ng/L ranged from 55 to 183 than the non-survived group with median of 63.4 ng/L ranged from 55.5 to 120.9 (p=0.022). In conclusion, we found that serum level of CGRP was extremely low in critical and extremely critically ill patients, and thus can be used as a predictor of mortality in children with severe pneumonia.

Diagnostic efficacy of systemic immune-inflammation biomarkers in benign prostatic hyperplasia using receiver operating characteristic and artificial neural network

Benign prostatic hyperplasia (BPH) is a chronic, progressive disease characterized by mesenchymal cell-predominance and stromal and glandular cell-hyperproliferation. Although, the precise cause of BPH is unknown, it is believed to be associated with hormonal changes in aging men. Despite androgens and ageing are likely to play a role in the development of BPH, the pathophysiology of BPH remains uncertain. This paper aims to evaluate the diagnostic efficacy of platelet-to-lymphocyte ratio (PLR), neutrophil–lymphocyte ratio (NLR) and systemic immune-inflammation index in in diagnosing BPH. A single-center-randomized-retrospective study was carried out at Alzahraa university hospital between January 2022 and November 2022 on 80 participants (40 non-BPH subjects and 40 patients with symptomatic enlarged prostate) who visited the outpatient clinic or admitted to the urology department. The BPH cases were evaluated by digital rectal examination (DRE), International Prostate Symptom Score (IPSS), prostate size, prostate specific antigen (PSA), TRUS biopsy in elevated PSA > 4 ng/ml, PLR, NLR and systemic immune inflammatory (SII). The diagnosing efficiency of the selected parameters was evaluated using Receiver Operating Characteristic (ROC) and Artificial Neural Network (ANN) showing excellent discrimination with 100% accuracy and AUC = 1 in the ROC curves. Moreover, the accuracy rate of the ANN exceeds 99%. Conclusion: PLR, NLR and SII can be significantly employed for diagnosing BPH.

Prevalence of refractive errors and visual impairment due to refractive errors among school children in Cairo, Egypt

Aim The aim of this research was to study the distribution and patterns of refractive errors (REs) among school children and the incidence of amblyopia in each type. Patients and methods This is an observational nonrandomized population-based cross-sectional study that included children aged 6-18 years attending the Outpatient Clinic of Al-Zahraa University Hospital, Al-Azhar University, Cairo, Egypt. All children were subjected to comprehensive eye examination including best corrected visual acuity (BCVA), expressed in LogMAR, cycloplegic REs that was documented using a NIDEK auto-refractometer-keratometer, cover-uncover testing, and fundus examination. The prevalence of REs, amblyopia, and anisometropia was estimated. Results The study included 960 children (1920 eyes), with a mean age of 13.08±3.41 years. Emmetropia was found in 834 (43.4%) eyes, while myopia was reported in 587 (30.6%) eyes, hypermetropia in 114 (5.9%) eyes, and myopic astigmatism in 385 (20%) eyes. Anisometropia was reported in 65 (6.77%) children, while amblyopia was found in 49 (5.1%) eyes. The amblyopia prevalence was statistically significantly higher among the hypermetropic group (3.9%) than the myopic astigmatism group (1.2%), (P = 0.031). Conclusion The overall prevalence of REs among the examined children was 56.6% mainly myopia followed by myopic astigmatism and lastly hypermetropia. This draws the attention to the increased incidence of myopia which needs further social studies.

Skin-to-skin contact and its effect on mothers’ postpartum psychological distress and their full-term neonate in Egypt

A randomized controlled study was conducted on 400 mothers, who were divided into two groups: 200 mothers who applied skin-to-skin infant care (SSC) for at least 1 h daily for 12 weeks and 200 mothers who performed the usual mother-infant care. The mothers were recruited from the Obstetric Department of Al-Zahraa University Hospital in Cairo, Egypt. The enrolled mothers' infants were assessed for body weight. Sleep hours and frequency of breast milk feeding were evaluated by the mother during the day. All of the mothers who took part in the study were assessed for postoperative pain, wound healing, postpartum depression, anxiety, sleep quality and newborn maternal bonding. There was a significant increase in frequencies of breastfeeding and the body weight at 12 weeks' postnatal age and also an increase in sleep hours in the infants who had SSC. The mothers who performed SSC had good sleep quality in comparison with those who performed the usual infant care; in addition, they had less postoperative pain intensity and proper wound healing apart from better maternal-infant bond, decreased anxiety and decreased depression frequency. SSC was associated with better infant breastfeeding, increased sleep hours in infants and less postpartum psychological burden in mothers.

The Effect of Surgical Salpingectomy versus Single-Dose Methotrexate on Ovarian Reserve in Ectopic Pregnancy at Alzahraa University Hospital

The Effect of Surgical Salpingectomy versus Single-Dose Methotrexate on Ovarian Reserve in Ectopic Pregnancy at Alzahraa University Hospital

Evaluation of Fetuin-A level in diabetic retinopathy

BackgroundDiabetic retinopathy (DR) is a micro-vascular consequence of diabetes mellitus (DM) that manifests clinically as retinal ischemia, neovascularization, altered retinal permeability, and macular edema. In the adult population, DR is now considered a leading cause of blindness. Fetuin-A is a multifunctional glycoprotein that, because of its dual role in insulin resistance and angiogenesis, could be an early trigger of DR pathogenesis.ObjectiveThis study aimed to evaluate the level of Fetuin-A in diabetic patients with and without retinopathy and demonstrate if it could be used as an early indicator of DR.Patients and methodsA case–control study enrolled 45 participants selected from Al-Zahraa University Hospital, between March 2021 and October 2021, they were divided into three groups: Group 1: healthy control group (n=15); Group 2: type 2 diabetic patients without DR (n=15); and Group 3: type 2 diabetic patients with DR (n=15). All groups were age- and sex-matched and were investigated by enzyme-linked immunosorbent assay (ELISA) to evaluate serum level of Fetuin-A.ResultsThere was a highly significant difference of FBG, 2HPP, and HbA1c between the studied groups (p< 0.001), while there was no significant difference between the three studied groups regarding Fetuin-A. There were no significant correlation between Fetuin-A, glycemic parameters, and diabetic duration in Groups 2 and 3.ConclusionFetuin-A has no significant role in the pathogenesis of diabetic retinopathy.

Assessment of Utero-Cervical Angle as an ultrasound screening tool to predict spontaneous preterm birth in singleton pregnancy

Introduction: Several attempts have been made from healthcare professionals around the world to determine the effective methods for early prediction and prevention of preterm birth. Aim of Work: The aim of this study was to determine the predictive value for spontaneous preterm birth by using transvaginal ultrasonography of the uterocervical angle (UCA) in pregnant women with singleton pregnancy. Subjects and methods: This study was a prospective Case-control study that was conducted at Obstetrics and Gynecology Department at Al-Zahraa University Hospital and Kafr Elshiekh General Hospital. Results:Utero Cervical angle (UCA) was significantly increased in preterm group&gt;95 degree compared to control group (p&lt; 0.001). Also, CL was significantly decreased in preterm group less than 27mm compared to control group .By using ROC-curve analysis, UC can predict preterm birth with accuracy (75.4%). The sensitivity, specificity, PPV and NPV was 70%, 76%, 74.47% and 71.7% respectively (p&lt; 0.001). CL can predict preterm birth with accuracy (66%). The sensitivity, specificity, PPV and NPV was 74%, 62%, 66.07% and 70.45% respectively (p= 0.003). Conclusion: Ultrasonographic measurement of uterocervical angle performed in routine vaginal ultrasound during second trimester is a useful strategy in the prediction of preterm birth in pregnancies and better than cervical length alone.

A Case control study on ischemic heart disease and serum zinc at Al-Zahraa university hospital

A Case control study on ischemic heart disease and serum zinc at Al-Zahraa university hospital

Role of duplex-guided infragenicular angioplasty in saving limbs

Background/aim Critical limb ischemia (CLI) is known as ischemic rest pain at rest or tissue loss with peripheral arterial disease. Endovascular intervention has many advantages than surgical bypasses and it is used frequently with fragile patients, at the same time, it has many adverse effects for both surgeon and patient such as radiation effect for both and renal-induced nephropathy for the patient. Worldwide duplex-guided infragenicular angioplasty is a new method that has been started to emerge and to be a common technique in such patients, That is why the present study aims to assess the feasibility and efficacy of duplex-guided infragenicular angioplasty to save limbs and to detect if it is applicable or not. Patients and methods Twenty CLI patients were admitted to the vascular unit from 2015 to 2017 in Al-Zahraa University Hospital, Al-Azhar University, Cairo, Egypt. We included patients with good femoral pulse and significant infragenicular lesions. We excluded those with proximal outflow lesions and with acute embolic or thrombotic insults. Percutanous transluminal angioplasty was done to all the patients through ipsilateral femoral access by using 0.014 and 0.018 wires 4 F catheters and low-profile balloons, then we followed them clinically and with duplex ultrasound at 1, 3, 6, and 12 months with calculating the hemodynamic studies. Results The present study enrolled 20 patients, six (30%) of them are females and 14 (70%) males, with mean age of 59.2. The clinical history of smokers, cardiac, diabetics, renal, and hypertensive were 65, 60, 50, 85, and 80%, respectively. Technical success was 90%. Groin hematoma, distal thrombosis, and vessel perforation were technical complications, with 5% for each. Optimal procedural success was achieved in 70%, of suboptimal in 20%, and then we failed in 10%. Rest paint completely disappeared from 75% of patients. Sixteen limbs were saved postintervention, Kaplan–Meier curve showed 70% survival rate at 6 months, while at 9 months, the drop occurred to be 28%, which was still to be the percent at 12 months. Conclusion Modern duplex ultrasound can be used to map the arterial disease and to show guide wires, sheaths, balloons, and stents for the treatment of infragenicular arterial lesions. Also, it seems to be safe, easy and effective technique, a bedside procedure, and cost-effective as well. It has a crucial role in saving limbs for CLI patients.

Audit on gynecological surgeries in AL-Zahraa University Hospital in year 2017

Audit on gynecological surgeries in AL-Zahraa University Hospital in year 2017

Desarda repair versus Lichtenstein repair for treatment of inguinal hernia

Background: Inguinal hernias remain an important medical problem. The definitive treatment of all hernias is surgical repair. Desarda’s technique is a tension-free, mesh-free repair method that pays attention to the physiology of the inguinal region.Methods: This prospective comparative study was conducted in general surgery department at Al-Zahraa University Hospital and Damanhour Medical National Institute in the period between March 2019 and March 2021. It included 50 patients who were randomly divided into two equal groups: A (Desarda technique) and B (Lichtenstien technique).Results: The mean operative time in group A was 70.36 minutes and in group B was 64.88 minutes. Seroma formation occurred in 1 patient in group A (4%) while it occurred in 2 patients in group B (8%). The other postoperative complications were comparable in both groups during 1 year of follow-up, hernia recurrence occurred in 1 patient in group B (4%).Conclusions: Desarda repair of inguinal hernia is a good alternative to Lichtenstein repair.

Serum midkine level as a diagnostic biomarker of hepatocellular carcinoma in Egyptian patients with chronic hepatitis C

Background Early diagnosis and treatment are the keys for effective treatment of patients with hepatocellular carcinoma (HCC). The use of serological markers in patients at the highest risk of developing HCC may thus decrease HCC mortality and reduce medical costs. Midkine (MK) has an essential role in activities related to carcinogenesis such as proliferation, anti-apoptosis, transformation, migration, and angiogenesis, in many types of tumors, including HCC. Aim To evaluate serum levels of MK as a diagnostic biomarker for early detection of HCC in relation to conventional markers, such as alpha-fetoprotein (AFP). Patients and methods This study was conducted on 90 individuals who attended the Hepatogastroenterology and Infectious Diseases Department, Al-Zahraa University Hospital, Al Azhar University. The patients were divided into three groups: group I comprised 30 patients with HCC on top of hepatitis C virus and group II comprised 30 patients with cirrhotic liver post-hepatitis C virus. Control group The control group comprised 30 healthy adult participants. Results Highly statistically significant increase in serum MK in groups I and II in comparison to the control group and statistically significant increase in group I in comparison to group II. Serum MK can be used to discriminate between groups I and II at a cutoff level of more than 97.7,with 80% sensitivity, 90% specificity, 88.9% positive predictive value and 81.8% negative predictive value and area under curve=0.94. Also, it used to discriminate between groups I and III at a cutoff level of more than 76.5, with 100% sensitivity, specificity, positive predictive value, and negative predictive value with area under the curve=1.0. Conclusion MK is more accurate than AFP in diagnosing HCC, especially in detecting early stage HCC and AFP-negative HCC.

Correlation of serum apelin level with carotid intima–media thickness and insulin resistance in a sample of Egyptian patients with type 2 diabetes mellitus

Background:Type 2 diabetes mellitus (T2DM) is a growing health problem in Egypt, with a significant impact on morbidity and mortality. Measurement of the carotid Intima-media thickness (CIMT) allows early detection of atherosclerotic blood vessel diseases. Apelin is an adipose tissue-derived hormone that may be associated with insulin resistance (IR). This study aimed to assess the level of serum apelin in patients with T2DM and its relation to IR and CIMT.Materials and Methods:A case-control study was conducted on 60 patients with T2DM and 30 healthy controls. T2DM was diagnosed based on American Diabetes Association criteria. The study was carried out at Al-Zahraa University Hospital, Cairo, Egypt, through the period from June to December 2019. The laboratory investigations included serum apelin and blood glucose hemostasis markers. CIMT was assessed using B-mode ultrasonography.Results:Patients’ group had a statistically significant higher apelin level than healthy controls (407.96 ± 291.07 versus 83.32 ± 10.55 ng/dL, P < 0.001). The correlation analysis showed that the serum apelin level correlated positively with glycemic indices, body weight, and waist circumference (P < 0.05). At cutoff value of >96 ng/dL, the serum apelin exhibited a sensitivity of 98.3% and specificity of 96.7%, positive predictive value of 98.1%, and negative predictive value of 96.5%, with a diagnostic accuracy of 95.1%. Serum apelin correlated positively with CIMT (r = 0.296, P = 0.022). Logistic regression analysis showed that systolic and diastolic blood pressures, Homeostasis Model Assessment of IR, and CIMT were independent predictors of serum apelin.Conclusion:Serum apelin may be correlated with the degree of carotid atherosclerosis and hence can be used as a prognostic biomarker.

Galectin-3 as a prognostic biomarker for diabetic nephropathy

Background Diabetes mellitus (DM) type 2 is a major health condition that has shown an increased incidence globally. The most common complication in type 2 DM is diabetic nephropathy (DN). Aim To determine serum galectin-3 as a prognostic biomarker in type 2 DN. Patients and methods A case–control prospective study was done in the Internal Medicine Department of AL-Zahraa University Hospital, Cairo, Egypt. The study was conducted on 90 patients, including 60 patients with type 2 DM and 30 age-matched and sex-matched healthy volunteers as a control group. The 90 patients were classified into four groups: group I included 20 diabetic patients (type 2) with an albumin/creatinine ratio (ACR) of less than 30 mg/g (normoalbuminuria), group II included 20 DM (type 2) with an ACR of 30–300 mg/g (microalbuminuria), group III included 20 DM (type 2) with an ACR of more than 300 mg/g (macroalbuminuria), and control group included 30 age-matched and sex-matched healthy individuals. History, examination, fasting blood sugar, glycated hemoglobin, urea, creatinine, estimated glomerular filtration rate, ACR, lipid profile, and serum galectin-3 were done for all participants. The study was approved by the Al Azhar University Ethics Board. Results Galectin-3 was significantly higher in patients with macroalbuminuria than in those with microalbuminuria and normoalbuminuria. Galectin-3 level has a significant positive correlation with parameters of DN progression (age, DM duration, fasting blood sugar, glycated hemoglobin, cholesterol, low-density lipoprotein, triglyceride, urea, creatinine, and ACR) and a significant negative correlation with estimated glomerular filtration rate and high-density lipoprotein levels. Conclusion Galectin-3 was significantly higher in type 2 diabetic patients with macroalbuminuria than in those with microalbuminuria and normoalbuminuria.

Corticosteroid treatment versus surgical treatment of chronic rhinosinusitis with nasal polyposis

Background and Aim The definition of chronic rhinosinusitis is inflammation of the nose and paranasal sinuses characterized by two or more symptoms like nasal obstruction, congestion of nasal mucosa, reduction or loss of smell, facial pain, and either endoscopic signs of polyps edema or mucosal obstruction primarily in middle meatus, maybe computed tomography changes showing mucosal changes within the ostiomeatal complex and sinuses. The aim of this study was to assess the outcome of medical treatment in comparison with functional endoscopic sinus surgery as a treatment of allergic nasal polyposis. Patients and methods A prospective study was carried out at Al-Zahraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, which included 40 patients (30 males and10 females) divided into two groups, mean age of group A (36.9±10.2) and mean age of group B (39.8±9). Results There is no statistically significant difference between both groups as regards runny nose, nasal obstruction, postnasal drip, smell sensation, taste sensation, sneezing, fascial pain, or headache before intervention. There is a statistically significant difference between both groups after intervention (by medication or surgery) as regards runny nose (P=0.034), nasal obstruction was highly significant (P=0.001), and smell sensation was highly significant (P=0.005), while there was no significant difference between both groups as regards other symptoms like postnasal drip, fascial pain, headache, sneezing, and taste sensation (P&gt;0.05). Conclusion We conclude from our data that medical treatment was cost-effective and time-saving. Many patients who received medical treatment responded well to the point of refusing any surgical procedure, functional endoscopic sinus surgery is essential when medical treatment was not sufficient in improving manifestations.