Otorhinolaryngologic Diseases Commons^™

Combatting Bacterial Infections: The Efficacy Of Poly-Gamma-Glutamic Acid On The Prevention Of Nasopharyngeal Infections Among Individuals With Cleft Lip And Palate, Florence Pun

Scripps Senior Theses

Cleft lip and palate (CLP) is a medical condition where children are born with an unfused lip and palate. While surgery is required to fuse the lip and palate, there are other conditions that children with CLP face after surgeries, such as otitis media (OM), speech impediments, and difficulty breathing. Particularly, OM occurs frequently in individuals with CLP because the tensor veli palatini muscles cannot open the Eustachian tube frequently and ventilate the middle ear properly, even after surgery. This thesis is a research proposal to evaluate whether γ-PGA can be used in nasal washes to safely prevent nasopharyngeal infections …

Editorial Letter, Reda Kamel, Ahmed Elfarouk

Pan Arab Journal of Rhinology

No abstract provided.

Editorial Letter, Reda Kamel, Ahmed Elfarouk

Pan Arab Journal of Rhinology

No abstract provided.

Radiographic Changes Of The Nasal Septal Swell Body In Patients With Sinonasal Polyposis, Yasser Mohammed Hassan Mandour, Ahmed Soliman El Kady, Hamada Mohamed Khater, Mohamed Afify Mohamed Afify, Samer Badie Kamel, Abdelrahman Ahmed Abdelal

Pan Arab Journal of Rhinology

Background: The nasal septal body is a dilated section of the anterior nasal septum that is situated anterior to the middle turbinate and around 0.7–1.5 cm above the nasal floor.

Aim: This study analyses the measures taken from patients without sinonasal polyposis in order to identify the structural alterations in the nasal septal body (NSB) among patients with sinonasal polyposis.

Patients and methods: This retrospective study was conducted between April 2021 and February 2022 involving a review of paranasal sinus computed tomography (PNS CT) scan among patients with sinonasal polyposis and without sinonasal disease. The anterior part (A) was measured …

Olfactory Function As A Postoperative Parameter For Success Of Functional Endoscopic Sinus Surgery In Chronic Rhinosinusitis With Nasal Polyps, Wael S. Mohamed, Mohamed T. El-Ghonemy

Pan Arab Journal of Rhinology

Introduction : allergic nasal polyps associated with chronic rhinosinusitis always leads to disturbed sense of smell and impaired life quality. After failure of medical treatment in the form of anti-histaminic and local steroids, we usually proceed to functional endoscopic sinus surgery (FESS) to improve life quality.

Materials and methods : Total 48 patients were comprised in this work. All patients were subjected to routine nasal examination, nasal endoscopy and CT scans paranasal sinuses axial and coronal cuts before surgery and 3 months after operation. We used Sniffin’ sticks to assess psychophysical olfactory function.

Results : Disturbance of sense of smell …

Transnasal Endoscopic Piezoelectric Surgery For Repair Of Choanal Atresia, Ramez Sabry Fahim, Mohammed Sayed Abd El Azeem Fawaz, Ashraf Mahmoud Khaled, Maie Mohammed Hossam El-Den, Rabie Sayed Youssef

Pan Arab Journal of Rhinology

Background: Restenosis and reclosure of the choana are challenging complications after repair of choanal atresia (CA). Modifications to bone drilling with no injury to surrounding nasal soft tissues may reduce postoperative reclosure. Objectives: Our study aims to assess the effectiveness of piezoelectric device in preservation of muco-periosteal flaps and its outcome in reducing postoperative granulation tissue formation and restenosis. Methods: 20 patients with unilateral boney or boney membranous choanal atresia underwent removal of the atretic plate using the piezoelectric device with preservation of the muco-periosteal flap to cover the borders of the neo-choana. Checkup of the cases ranged from 6 …

Endoscopic Dacryocystorhinostomy With Nasal Mucosal Flaps: A Comparative Study, Heba Mohamed Mahmoud Hamdy, Mohammad Abdelaziem Mohammad, Ismail Seddik Elnashar, Wael Fayez Nasr, Waleed Mohamed Basha Amin Mohamed Khamis, Ahmed Ibrahim Elsayed

Pan Arab Journal of Rhinology

Introduction:

Endoscopic dacryocystorhinostomy is a procedure employed to treat epiphora caused by anatomical obstruction of the nasolacrimal pathway. Its principle is to create a connection between the lacrimal sac and the nasal cavity to bypass the obstruction and restore the tear flow. Diverse modifications to conventional endoscopic dacryocystorhinostomy have been developed to improve its success rate. The present study aims to compare the results and assess the outcome of endoscopic dacryocystorhinostomy using a novel flap technique, inferiorly-based nasal mucosal flap, versus the posteriorly-based flap in cases of epiphora due to primary acquired nasolacrimal duct obstruction.

Patients and Methods:

Under general …

Piezosurgery Versus Conventional Osteotomies And Rasping In Open Rhinoplasty, Amr Gouda Shafik, Mohamed Sherif Abdelmonem, Ashraf Mahmoud Khaled, Tamer Abdelmonem Azzam, Khaled Abd El Moaty Hafez

Pan Arab Journal of Rhinology

Background: Piezosurgery is appropriate for all bony surgeries, but it is predominantly helpful when access is limited and/or the bones are close subtle soft tissue, Aim and objectives; this work aimed for comparing conventional osteotomies and rasping with the Piezosurgery medical device, as regard operative time, post-operative edema, ecchymosis, and pains in open rhinoplasty patients. Subjects and methods: It is a prospective study done at our university hospital from June 2019 to December 2020. This study included 40 patients, 20 done with Piezosurgery technique in osteotomy and rasping, other 20 with conventional technique in osteotomy and rasping. This study involves …

Myofunctional Therapy For Treatment Of Obstructive Sleep Apnea: A Narrative Review, María Teresa García Iriarte, Laura Rodriguez Alcala, Peter Baptista, Guillermo Plaza, Carlos O’Connor-Garcia, Carlos O’Connor-Reina

Pan Arab Journal of Rhinology

Obstructive sleep apnea (OSA) is a serious and prevalent public health disorder that can have long-term detrimental effects on the cardiovascular, nervous, and metabolic systems, and increase the risk of accidents and mortality. Newly identified pathophysiological traits of OSA include decreased upper airway pharyngeal dilator muscle responsiveness. Myofunctional therapy (MT) has been proposed as a treatment to improve dilator tone by performing isotonic and isometric exercises of the tongue and other upper airway muscles. This article reviews the beginnings of this therapy and describes systematic reviews and meta-analysis published until February in 2023 focusing in our experience using MT as …

Comparative Study Between The Efficacy Of Azelastine-Fluticasone Nasal Spray Combination And Fluticasone Nasal Spray Combined With Oral Cetrizine In Allergic Rhinitis, Irinie Georges Makarious Soliman, Ahmed Ashraf Salah Elhamshary, Mostafa Gomaa Sobhy El Shahat

Pan Arab Journal of Rhinology

Aim: Comparison between administering intranasal AZE/FLU combination, and the conventionally used oral Cetrizine, with intranasal Fluticasone for Allergic Rhinitis. Methods: A prospective randomized controlled study, where 100 patients were enrolled to two groups; Group A patients received AZE/FLU twice daily, while Group B patients received Fluticasone propionate once daily in the morning PLUS oral Cetrizine at night. Patients recorded nasal and ocular symptoms scores daily in a diary using a clear Arabic printout of VAS score. Pre- and post-treatment scores were collected at regular visits. Results: Regarding progression of symptoms through checkpoints over trial time; on days seven, 14 and …

Impact Of Nasal Septum Surgery On Sinonasal Symptoms In Patients With Nasal Septum Deviation, Mahmood A. Hamed, Noha M. Elsherif, Mostafa A. Eltaher

Pan Arab Journal of Rhinology

Objectives: The nasal septum is an important physiological and support structure of the nose. Nasal septal deviation is common in population and reported to be between 18.8-57.6%. In this study we aimed to evaluate the impact of nasal septal surgery on sinonasal symptoms using pre and post-operative sinonasal outcome test (SNOT-22) questionnaire as a subjective measure for the disease and improvement. Methods: We had 40 patients presented with nasal complaints due to deviation of the nasal septum to whom septal correction was performed. Pre and 3 months post-operative SNOT 22 were compared. Results: A highly significant difference was found between …

Egyptian Clinical Pathway For Post Covid-19 Acute Invasive Fungal Rhinosinusitis, Ashraf Khaled, Ismail Elnashar, Ahmed Hassan Sweed, Ahmaed Elfarouk, Hossam Elsherif, Ahmed Ragab, Zakareya Elraei, Mohamed Elsharnouby, Baleegh Hamdy, Alaa Ghita, Omar Elbanhawy, Reda Kamel

Pan Arab Journal of Rhinology

Acute invasive fungal rhinosinusitis (AIFRS) is a rare but fatal disease, particularly in immune-compromised patients, including those with hematological malignancies, poorly controlled diabetes mellitus (DM), and those who received immunosuppressive treatment following organ transplantation or chemotherapy for solid organ malignancies. Mortality rates remain high, around 50-80%, though some recent studies have shown higher survival rates with early diagnosis and complete surgical resection. Surgical debridement, systemic antifungal therapy, and prompt correction of the underlying systemic disease are necessary for treatment of AIFRS. During the COVID- 19 pandemic, an increased rate of AIFRS was reported in the course of; or following COVID-19 …

Clinical Outcomes After Septoplasty Using Cartilaginous Batten Graft In The Management Of The Caudal Septal Deviation, Abdelrahman Ahmed Abdelalim, Ashraf Alhamshary, Ibrahim Said Reyad, Ayman Abdelaal Mohamady

Pan Arab Journal of Rhinology

Background: Caudal septal deviation is a major cause of nasal obstruction. This problem greatly inhibits normal nasal breathing by narrowing of the nostril and external nasal valve area. It also represents a clear aesthetic problem due to the asymmetry of the nostrils Objectives: To evaluate the clinical outcomes of septoplasty using cartilaginous batten graft in cases with caudal septal deviation regarding the relief of nasal obstruction and aesthetic results. Materials and methods: This prospective single armed study was conducted on twenty patients suffering nasal septal caudal deviation. Septoplasty was performed using a caudal septal batten graft with different technique in …

Piezo Assisted Turbinoplasty: A Nopel Rapid And Safe Technique

Pan Arab Journal of Rhinology

No abstract provided.

Endoscopic Dacryocystorhinostomy For Recurrent Epiphora After Previous Nasolacrimal Duct Surgery, Mostafa Talaat, Balegh H. Abdelhak, Ayman Samir Megahed, Mohamed Esmail Khalil, Raafat Abdelrahman Abdallah, Ahmed Abdel Rahman Abdelaziz

Pan Arab Journal of Rhinology

Background: Revision of external DCR may be required due to various factors, including complications of the initial surgery or unaddressed concurrent nasal pathologies. This study focuses on endonasal revision DCR for patients with persistent epiphora symptoms after failed external DCR. Methods: We included 67 patients (19 male and 48 female), aged 19–45, who had previously undergone primary external DCR and presented with persistent epiphora symptoms after at least 12 months of the primary procedure. All patients were clinically examined for concurrent nasal pathology by exploratory endoscopy and computerized tomography (CT) of the nose and paranasal sinuses. Revision endonasal DCR was …

Nasal Surgery Versus Pharyngeal Surgery In The Treatment Of Obstructive Sleep Apnea, Ruxandra Oana Alius, Viorel Zainea, Catalina Voiosu, Irina Gabriela Ionita, Andreea Rusescu, Oana Denisa Balalau, Catalin Alius, Raluca Oana Pulpa, Razvan Hainarosie

Journal of Mind and Medical Sciences

The endemic spread of obesity and unhealthy behaviors of modern society led to revisiting the real prevalence related to obstructive sleep apnea. Recent data support a paradigm shift towards individually tailored treatments which include functional surgery of the upper airways. This paper presents the results of a randomized interventional, prospective study on 68 patients referred by the general practitioner for obstructive sleep apnea. The eligible cohort consisted of 28 patients who were offered functional surgery for definitive relief of obstructive symptoms. After topographic diagnosis of the obstruction site and grading of the severity of the obstructive sleep apnea, the eligible …

Investigating The Correlation Between Lpr & Obesity, Andrew S. Franklin Bs, Chad A. Nieri Bs, M. Boyd Gillespie Md

Longitudinal Scholar's Project

Objectives: To determine whether Drug-Induced Sleep Endoscopy (DISE) findings of Laryngopharyngeal Reflux (LPR) correlate with obesity, gender, Epworth Sleepiness scale, and OSA severity.

Study design: Single center retrospective cohort study.

Methods: Patients greater than 18 years of age who underwent DISE by one surgeon at a tertiary care center from July 2016 to July 2022 were included. DISE findings, patient characteristics, demographics, polysomnogram(s), and Epworth Sleepiness Scale(s) were extracted. Fisher’s exact test was used to compare categorical variables, and independent sample t-test was used to compare continuous variables. All statistical analyses were performed using IBM SPSS Statistics 28.

Results: …

Complications Of Pediatric Cochlear Implant Surgery, Andrew Stefan, Sabrina Bernardo, William Azkoul Ii, Bianca Siegel

Medical Student Research Symposium

Background:

Cochlear implantation (CI) surgery is the standard of care treatment for pediatric patients diagnosed with severe to profound sensorineural hearing loss. While considered a relatively safe operation, any invasive procedure involving the cranium has risks. However, there are few recent studies in the United States that have analyzed complication rates among children who have received CI. Furthermore, existing studies fail to discuss specific risk factors that led to post-operative complications, nor offer solutions to reduce their incidence. This study aims to 1) determine the incidence of specific complications in pediatric CI patients and 2) identify evidence-based risk factors for …

Diagnosis, Management, And Treatment Of Lymphadenitis And Deep Neck Space Infections At A Children’S Hospital, Aaron Shaw

Research Days

Background: Although cervical lymphadenitis and deep neck space abscesses (DNSA) are relatively common pediatric diagnoses, no standardized approach exists for management of these infections.

Objectives/Goal: To assess variability in diagnosis and treatment of cervical lymphadenitis and DNSA in a children’s hospital.

Methods/Design: Charts were obtained using ICD9/10 codes for diagnoses of retropharyngeal and parapharyngeal abscess, and lymphadenitis between 1/1/10-12/31/20. 1,237 charts were identified. Patients with a retropharyngeal and/or parapharyngeal abscess were defined as DNSA. Charts were excluded if the diagnosis was not a bacterial infection (e.g. Kawasaki disease), if the lymphadenitis was not in the neck, or if caused by …

Identification Of Risk Factors Associated With Nasopharyngeal Carcinoma (Npc) In The Pahang State Of Malaysia Hospitals, Azmir Ahmad, Muzaitul Akma Mustapa Kamal Basha, Wardah Mohd. Yassin, Nor Azlina A. Rahman, Wan Ishlah Leman, Luqman Rosla, Sharifah Nor Ezura Syed Yussof, Mark Paul, Kamariah Mohamed Awang, Kahari Abdullah, Mohd. Arifin Kaderi

Makara Journal of Health Research

Background: Nasopharyngeal carcinoma (NPC) is the fifth most common cancer reported in Malaysia. Although several studies on NPC have been carried out, the risk factors associated with NPC in Malaysia are unknown. Therefore, this study was designed to investigate the risk factors associated with NPC cases in Pahang state.

Methods: NPC cases that were diagnosed between 2012 and 2017 were recruited from two referral hospitals in Pahang. An interview was conducted using adapted questionnaires, which included demographic data, family history of cancer, and lifestyle. The data were analyzed statistically to identify the associations between the selected variables and …

The Egyptian Clinical Practice Guidelines Of Otorhinolaryngology, Audio-Vestibular & Phoniatrics (Ecpg-Orlap)

Pan Arab Journal of Rhinology

1. Acute Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines
Ahmed Ragab, Reda Kamel, Ashraf Khaled, Baliegh Hamdy, Ahmed Elfarouk, Mohamed Elsharnouby, Hossam Elsherif

2. Chronic Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines
Ahmed Elfarouk, Magdy Eisa, Mohamed Osama Tomoum

3. Allergic Rhinitis: Adapted Egyptian Clinical Practice Guidelines
Ahmed Ragab, Reda Kamel, Mohamed Gamea, Ayman Medani, Zeyad Mandour

4. Epistaxis: Adapted Egyptian Clinical Practice Guidelines
Ibrahim Rezk Mohammed, Diaa Elhennawi, Mohamed Rifaat Ahmed

5. Cerebrospinal Fluid Rhinorrhea (CSF): Adapted Egyptian Clinical Practice Guidelines
Ismail Elnashar, Mostafa A. El Taher, Ashraf Elhosini, Tamer Orabi

6. List of Contributors

7. Acknowledgement

Retropharyngeal Abscess And Pott’S Disease Due To Tuberculosis: A Case Report, Bailey N. Hassman, Steven D. Curry, Jonathan H. Ryder, Angela L. Hewlett, Jayme R. Dowdall

Graduate Medical Education Research Journal

Introduction: Extrapulmonary mycobacterial infection can lead to vertebral spondylitis and osteomyelitis (Pott’s disease). Retropharyngeal abscess with concurrent spinal osteomyelitis is a rare presentation of tuberculosis in the US. Chart review on a patient was completed, and the relevant published literature was reviewed.

Case Presentation: A previously healthy 34-year-old male originally from Sudan presented to an outside hospital with a 2-month history of neck pain, sore throat, odynophagia, fevers, and chills. MRI showed a retropharyngeal abscess and suspected cervical spine osteomyelitis. Acid-fast bacillus (AFB) smear was positive from a neck drain specimen, but sputum was negative. Chest imaging did not show …

Generating Cisplatin Resistant Hpv-Positive Hnscc Cell Lines, Temitope Akintola

Undergraduate Student Research Internships Conference

Acquired or innate resistance to chemotherapy poses a significant challenge in the treatment of head and neck squamous cell carcinomas (HNSCC). HNSCCs are often treated with a combination of surgery, radiation and chemotherapy, with cisplatin being a standard-of-care chemotherapy drug. Human Papillomavirus (HPV) associated HNSCCs have better treatment outcomes and prognosis when compared to HPV- HNSCCs. However, a subset (15-20%) of HPV+ patients develop treatment resistant diseases. The purpose of this study is to generate in-vitro models of cisplatin resistance in five HNSCC cell lines. We aim to characterize the generated cells in order to identify target genes that may …

Resilience And Its Associated Factors In Head And Neck Cancer Patients In Pakistan: An Analytical Cross-Sectional Study, Nida Zahid, Wajeeha Zahid, Wardah Khalid, Syed Iqbal Azam, Mubasher Ikram, Aneesa Hassan, Haissan Iftikhar, Shireen Shehzad Bhamani, Adnan Jabbar, Shabbir Akhtar, Moghira Siddiqui, Mohammad Sohail Awan, Nargis Asad, Khabir Ahmad

Department of Surgery

Introduction: The study aimed to assess resilience and its associated factors in head and neck cancer patients, post-treatment in a low middle income country (LMIC) such as Pakistan.
Methods: An analytical cross-sectional study was conducted from November 2019 to May 2020 among head and neck cancer patients aged at least 18 years at the largest private tertiary care hospital, in Karachi, Pakistan. Information regarding their resilience scores was collected through Wagnild and Young's Resilience scale that comprises of 14 items (RS-14). Moreover, depression and anxiety were also assessed via Hospital Anxiety and Depression Scale (HADS) and social support was assessed …

Synchronous Primary Diffuse Large B-Cell Lymphoma And Papillary Thyroid Carcinoma: A Case Report Highlighting "Lymphoma First Approach", Rahim Dhanani, Ambreen Abdullah Unar, Muhammad Hassan Danish, Hamdan Ahmed Pasha, Ummiya Tahir, Mubasher Ikram

Section of Otolaryngology, Head & Neck Surgery

Papillary thyroid carcinoma (PTC) is the most common type of all thyroid carcinomas and accounts for up to 90% of all thyroid malignancies. It is the most indolent form of the disease and has an excellent prognosis. On the other hand, Primary thyroid lymphoma (PTL) is a rare entity accounting for only about 1% to 5% of all thyroid malignancies and only 2% of extranodal lymphomas. Synchronous PTC and PTL is a very rare condition and only a few cases have been reported in the literature up till now. We report one such case in a 52-year-old lady who was …

Adenoid Cystic Carcinoma Of External Auditory Canal: A Rare Disease, Abdul Basit Shah Vardag, Muhammad Hassan Danish, Mohammad Sohail Awan, Muhammad Usman Tariq, Omaima Anis Bhatti, Muhammad Hammad Deewani

Section of Otolaryngology, Head & Neck Surgery

External auditory canal, like other epithelialized surfaces is predisposed to malignancies such as Squamous cell carcinomas (SCC), melanomas and adenocarcinomas. In this background, malignancies like adenoid cystic carcinoma (ACC) are a rare occurrence and need to be thoroughly evaluated both locally and for distant extension. The malignancy needs to be addressed with an aggressive approach surgically with adequate marginal clearance. The role of radiation is debatable considering the outcomes in the limited data. Here we present the case of a 35-year-old female who came in with otalgia and otorrhea associated with a mass in the external auditory canal. After biopsy …

Streptococcal Pharyngitis: Delving Deeper Than The Throat, Sadaf Sheikh, Umair Javed, Muhammad Akbar Baig

Department of Emergency Medicine

Acute rhabdomyolysis and elevated transaminases during streptococcal pharyngitis are rare presentations. The proposed pathophysiological mechanisms include direct bacterial invasion and toxin generation. Physicians should be aware of the association between these infections and the above-mentioned complications to facilitate optimal treatment of these patients. We present the case of a 18-years-old gentleman with β-haemolytic streptococcal pharyngitis complicated by rhabdomyolysis and elevated liver function tests. Such high levels of creatine phosphokinase of 111856 IU/L and elevated liver function tests with aspartate aminotransferase (AST) of 1862 U/L and alanine aminotransferase (ALT) of 1003 U/L in streptococcal pharyngitis is rare to find in the …

Prevalence Of Allergic Fungal Sinusitis Among Patients With Nasal Polyposis, Rahim Dhanani, Shayan Khalid, Basit Salam, Hamdan Ahmed Pasha, Farah Hafiz Yousuf, Mubasher Ikram

Section of Otolaryngology, Head & Neck Surgery

Objective: To determine the frequency of allergic fungal sinusitis among patients with nasal polyps, and to compare Lund-Mackay scores of patients with and without allergic fungal sinusitis.
Methods: The cross-sectional longitudinal study was conducted at a tertiary healthcare centre in Karachi, Pakistan, from December 2016 to November 2018, and comprised patients with sinonasal polyposis undergoing surgery. The patients were categorised as having allergic fungal sinusitis when histopathology showed allergic mucin with fungal hyphae and culture was positive for fungal growth. Lund-Mackay scoring of each patient was noted and mean scores of allergic fungal sinusitis and non-allergic fungal sinusitis patients were …

Level I Nodal Positivity As A Factor For Involvement Of The Submandibular Gland In Oral Cavity Carcinoma: A Case Series Report, Hamdan Ahmed Pasha, Rahim Dhanani, Shayan Khalid, Kulsoom Ghias, Mumtaz Jamshed Khan

Section of Otolaryngology, Head & Neck Surgery

Introduction: The routine practice of neck dissection in the surgical management of oral carcinoma has evolved into a more functionally conservative approach. Over time, the rationale for removal of the submandibular gland has been questioned. Routine extirpation of the submandibular gland can aggravate the xerostomia experienced by many patients, significantly affecting their quality of life.
Objective: The objective of the present study was to determine the incidence of submandibular gland metastases in oral cavity carcinoma and to identify possible factors that may affect their involvement.
Methods: A total of 149 cases of oral carcinoma presenting at a private tertiary care …

Role Of Contrast Enhanced Computed Tomography In Assessing Cervical Lymph Node Metastases In Oral Cavity Squamous Cell Carcinoma, Talha Ahmed Qureshi, Muhammad Wasif, Mohammad Sohail Awan, Adnan Yar Muhammad, Ainulakbar Mughal, Abdullah Ameen

Section of Otolaryngology, Head & Neck Surgery

Objective: To evaluate the diagnostic accuracy of contrast-enhanced computed tomography scan in detecting cervical nodal metastasis in oral cavity squamous cell carcinoma.
Methods: The retrospective cross-sectional study was conducted at Aga Khan University Hospital, Karachi, Pakistan. and comprised records from January 1, 2015, to October 31, 2016, of patients diagnosed with oral cavity squamous cell carcinoma and who underwent surgical resection of primary tumour along with neck dissection after having a contrast-enhanced computed tomography scan of head and neck. Diagnostic accuracy of the scans was calculated using final histopathology as the gold standard. All scans were reviewed by a consultant …