ORIGINAL_ARTICLE
Have Guidelines Affected Ear, Nose, and Throat Specialists’ Diagnoses and the Prescription of Antibiotics for Acute Otitis Media?
Introduction:The Ministry of Health and Medical Education of Iran, and similar institutions in many other countries, advises physicians to use current guidelines for the diagnosis and treatment of acute otitis media (AOM). However, there has been no evaluation of the effectiveness of such guidelines or whether physicians in Iran adhere to them. Thus, as laryngologists are the most important group of people who interact with patients with AOM, the aim of this study was to evaluate the attitude of laryngologists to the established guidelines. Materials and Methods:A total of 120 anonymous surveys were mailed to 120 otolaryngologists in Tehran, Iran, to evaluate the patterns of diagnosis and treatment of AOM used by these physicians. The survey included questions regarding the otolaryngologists’ age, gender, place of work, and attitude towards diagnosis and treatment of AOM. Results:Sixty-two completed surveys were received, for a response rate of 51%. There was no significant difference between respondents to these surveys according to sex, age, practice setting, graduation year, or the number of patients with AOM seen each month. Conclusion: Our study adds new insights to the previous literature on the use of guidelines in the management of AOM. We can now assess the impact of guidelines on the usual practice of physicians in evidenced-based management of AOM.
https://ijorl.mums.ac.ir/article_204_b774469b28f17a2241259759d5269df7.pdf
2012-04-01
55
62
10.22038/ijorl.2011.204
Acute otitis media
Attitude
Knowledge
Otolaryngologist
Kamran
Kamrava
skkamrava@yahoo.com
1
Assistant professor of otolaryngology, ENT, Head & Neck Department and Research Center, Hazrat Rasoul Akram Hospital, Tehran University of medical sciences
AUTHOR
Maryam
Jalessi
drmaryamjalesi@gmail.com
2
Assistant professor of otolaryngology, ENT, Head & Neck Department and Research Center, Hazrat Rasoul Akram Hospital, Tehran University of medical sciences
AUTHOR
Alimohamad
Asghari
sbresearchcenter@gmail.com
3
Assistant professor of otolaryngology, ENT, Head & Neck Department and Research Center, Hazrat Rasoul Akram Hospital, Tehran University of medical sciences
AUTHOR
Mohammad
Farhadi
4
Professor of otolaryngology, ENT, Head & Neck Department and Research Center, Hazrat Rasoul Akram Hospital, Tehran University of medical sciences
AUTHOR
Alireza
Ahmadvand
5
Assistant professor in community medicine, Department of community medicine, Faculty of medicine, Tehran University of Medical Sciences
AUTHOR
Babak
Ghalehbaghi
ghalehbaghi@gmail.com
6
Fellow of Allergy and Clinical Immunology, Hazrat Rasoul Akram Hospital, Tehran University of medical sciences
AUTHOR
Mehdi
Saffari jourshari
7
Student of medical sciences, faculty of medicine, Tehran University of medical sciences
AUTHOR
Mir Abolfazl
Motiei jouibari
8
Student of medical sciences, faculty of medicine, Tehran University of medical sciences
AUTHOR
Jeppesen J, Faber CE. Surgical complications following cochlear implantation in adults based on a proposed reporting consensus. Acta Otolaryngol. 2013 Oct;133(10):1012-21. doi: 10.3109/ 00016489. 2013. 797604. PMID: 23768013; PMCID: PMC3793264.
1
Loundon N, Blanchard M, Roger G, Denoyelle F, Garabedian EN. Medical and Surgical Complications in Pediatric Cochlear Implantation. Arch Otolaryngol Head Neck Surg.2010; 136(1):12–15. doi:10.1001/archoto. 2009.187
2
Mehanna AM, Gamaleldin OA, Fathalla MF. The misplaced cochlear implant electrode array. Int J Pediatr Otorhinolaryngol. 2019 Feb;117:96-104. doi: 10.1016/j.ijporl.2018.11.027. Epub 2018 Nov 23. PMID: 30579097.
3
Tange RA, Grolman W, Maat A. Intracochlear misdirected implantation of a cochlear implant. Acta Otolaryngol. 2006;126:650–2. doi: 10.1080/00016480500445206.
4
Gözen ED, Tevetoğlu F, Yener HM, Kara E, Ataş A, Şirolu S, Kızılkılıç O, Cansız H, Karaman E. Extra-Cochlear Insertion in Cochlear Implantation: A Potentially Disastrous Condition. J Int Adv Otol. 2019 Dec;15(3):358-363. doi: 10.5152/iao.2019.6492. PMID: 31347506; PMCID: PMC6937184.
5
Vashishth A, Fulcheri A, Prasad SC, Bassi M, Rossi G, Caruso A, Sanna M. Cochlear Implantation in Cochlear Ossification: Retrospective Review of Etiologies, Surgical Considerations, and Auditory Outcomes. Otol Neurotol. 2018 Jan;39(1):17-28. doi: 10.1097/MAO.0000000000001613. PMID: 29065093.
6
Weinreich HM, Francis HW, Niparko JK, Chien WW. Techniques in cochlear implantation. Oper Tech Otolaryngol-Head Neck Surg.2014;25:312–20. doi: 10.1016/j.otot.2014.09.002
7
Mangus B, Rivas A, Tsai BS, Haynes DS, Roland JT Jr. Surgical techniques in cochlear implants. Otolaryngol Clin North Am. 2012 Feb;45(1):69-80. doi: 10.1016/j.otc.2011.08.017. PMID: 22115682.
8
Kaya S, Paparella MM, Cureoglu S (2016) Pathologic Findings of the Cochlea in Labyrinthitis Ossifcans Associated with the Round Window Membrane. Otolaryngol Head Neck Surg 155(4):635–640
9
Singla A, Sahni D, Gupta AK, Loukas M, Aggarwal A (2014) Surgical anatomy of round window and its implications for cochlear implantation. Clin Anat 27:331–336
10
Wysocki J, Skarzynski H (1998) Distance between the cochlea andadjacent structures related to cochlear implant surgery. Surg Radiol Anat 20:267–271
11
Yilmazer R, Karatay E, Akbulut S, Alkan Z, Sarikaya B. Anatomical landmarks for cochlear implantatıon in ossifıed cochleas. Eur Arch Otorhinolaryngol. 2020 Dec;277(12):3301-3306. doi: 10.1007/s00405-020-06044-1. Epub 2020 May 21. PMID: 32440899.
12
Jain S, Gaurkar S, Deshmukh PT, Khatri M, Kalambe S, Lakhotia P, Chandravanshi D, Disawal A. Applied anatomy of round window and adjacent structures of tympanum related to cochlear implantation. Braz J Otorhinolaryngol. 2019 Jul-Aug; 85(4):435-446. doi: 10.1016/j.bjorl.2018.03. 009. Epub 2018 Apr 19. PMID: 29759935.
13
Singla A, Sahni D, Gupta AK, Aggarwal A, Gupta T. Surgical anatomy of the basal turn of the human cochlea as pertaining to cochlear implantation. Otol Neurotol. 2015 Feb;36(2):323-8. doi: 10.1097/MAO.0000000000000371. PMID: 24770412.
14
Kavitha Y, Sabarigirish K, Joish UK, Saxena S, Dutta A. A Study of Effect of Consanguinity on Cochlear Morphology in Patients with Congenital Bilateral Profound Sensorineural Hearing Loss. Indian J Otolaryngol Head Neck Surg. 2017 Dec; 69(4):483-487. doi: 10.1007/s12070-017-1230-2.
15
Kumar JU, Kavitha Y. Application of Curved MPR Algorithm to High Resolution 3 Dimensional T2 Weighted CISS Images for Virtual Uncoiling of Membranous Cochlea as an Aid for Cochlear Morphometry. J Clin Diagn Res. 2017 Feb;11(2):TC12-TC14. doi: 10.7860/JCDR/ 2017 /23206.9456.
16
Laurikainen E, Kanninen P, Aho H, Saukko P. The anatomy of the human promontory for laser Doppler flowmetry. European Archives of Oto-rhino-laryngology. 1997 ;254(6):264-268. DOI: 10.1007/bf02905984. PMID: 9248732.
17
ORIGINAL_ARTICLE
A Comparative Study of Two Different Uncinectomy Techniques: Swing-Door and Classical
Introduction:The aim of this study was to determine which technique of uncinectomy, classical or swing door technique. Materials and Methods:Four hundred eighty Cases of sinusitis were selected and operated for Functional Endoscopic Sinus Surgery (FESS). Out of these, in 240 uncinectomies classical uncinectomy was done whereas in another 240 uncinectomies swing door technique was used. Initially patients were medically managed treated according to their symptoms and prior management. Patients who had received previous adequate medical management were evaluated with CT scan of the sinuses. If disease still persists than they were operated for FESS.Results:The authors' experience indicates that Functional endoscopic sinus surgery can be performed under local or general anesthesia, as permitted or tolerated. In this review classical technique was used in 240 uncinectomies. Out of this, ethmoidal complex injury was noted in 4 cases, missed maxillary ostium syndrome (incomplete removal) was reported in 12 patients and orbital fat exposure was encountered in 5 patients. As compared to 240 uncinectomies done with swing door technique, incomplete removal was evident in 2 cases and lacrimal duct injury was reported in 3 cases. 'Evidence that underscores how this 'swing door technique' successfully combines 'the conservation goals of the anterior-to-posterior approach and anatomic virtues of the posterior-to-anterior approach to ethmoidectomy of the total 480 uncinectomies operated. Out of which 240 uncinectomies have been performed using the 'swing-door' technique. The 240 uncinectomies performed using classical technique were used as controls. The incidence of orbital penetration, incomplete removal, ethmoidal complex injury and ostium non-identification was significantly less with the new technique. Three lacrimal injuries occurred with the 'swing-door' technique compared to no injuries with classical technique.Conclusion:The authors recommend swing door technique as it is easy to learn, allows complete removal of the uncinate flush with the lateral nasal wall and allows easy identification of the natural ostium of the maxillary sinus without injuring the ethmoidal complex
https://ijorl.mums.ac.ir/article_205_1153e05f99afd0153057de17a9ffa4a9.pdf
2012-04-01
63
67
10.22038/ijorl.2011.205
Classical
Endoscopic surgery
Functional
Sinus
Swing-door technique
Uncinectomy
Ankit A
Singhania
1
Department of otorhinolaryngology, SBKS Medical College, Sumandeep University, Waghodia, Vadodara, Gujarat, India.
AUTHOR
Chetan
Bansal
2
Department of otorhinolaryngology, SBKS Medical College, Sumandeep University, Waghodia, Vadodara, Gujarat, India.
AUTHOR
Nirali
Chauhan
3
Department of otorhinolaryngology, SBKS Medical College, Sumandeep University, Waghodia, Vadodara, Gujarat, India.
AUTHOR
Saurav
Soni
4
Department of otorhinolaryngology, SBKS Medical College, Sumandeep University, Waghodia, Vadodara, Gujarat, India.
AUTHOR
Abdel-Hak B, Gunkel A, Kanonier G, Schrott-Fischer A, Ulmer H, Thumfart W. Ciliary beat frequency, olfaction and endoscopic sinus surgery. ORL J Otorhinolaryngol Relat Spec 1998; 60(4): 202-5.
1
Erminy M, Bonfils P. Acute and chronic sphenoid sinusitis. Review of the literature. Ann Otolaryngol Chir Cervicofac 1998; 115(3): 106-16.
2
Buehring I, Friedrich B, Schaaf J, Schmidt H, Ahrens P, Zielen S. Chronic sinusitis refractory to standard management in patients with humoral immunodeficiencies. Clin Exp Immunol 1997; 109(3): 468-72.
3
Park AH, Lau J, Stankiewicz J, Chow J. The role of functional endoscopic sinus surgery in asthmatic patients. J Otolaryngol 1998; 27(5): 275-80.
4
Moses RL, Cornetta A, Atkins JP Jr, Roth M, Rosen MR, Keane WM. Revision endoscopic sinus surgery: The Thomas Jefferson University experience. Ear Nose Throat J 1998; 77(3): 190-202.
5
Senior BA, Kennedy DW, Tanabodee J, Kroger H, Hassab M, Lanza D. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998; 108(2): 151-7.
6
Vanclooster C, Jorissen M. Endoscopic septal spur resection in combination with endoscopic sinus surgery. Acta Otorhinolaryngol Belg 1998; 52(4): 335-9.
7
Coste A, Idrissi F, Beautru R, Lenoir G, Reinert P, Manach Y, et al. Endoscopic endonasalethmoidectomy in severe sinusitis of cystic fibrosis. Mid-term results in 12 patients. Ann Otolaryngol Chir Cervicofac 1997; 114(4): 99-104.
8
Sabini P, Josephson GD, Reisacher WR, Pincus R. The role of endoscopic sinus surgery in patients with acquired immune deficiency syndrome. Am J Otolaryngol 1998; 19(6): 351-6.
9
Halvorson DJ, Dupree JR, Porubsky ES. Management of chronic sinusitis in the adult cystic fibrosis patient. Ann Otol Rhinol Laryngol 1998; 107(11 Pt 1): 946-52.
10
Parsons DS, Stivers FE, Talbot AR. The missed ostium sequence and the surgical approach to revision functional endoscopic sinus surgery. Otolaryngol Clin North Am 1996; 29:169-83.
11
ORIGINAL_ARTICLE
Evaluation of Children with Chronic Rhinosinusitis after Adenotonsillectomy
Introduction:
Chronic rhinosinusitis (CRS), defined as an inflammatory process involving the paranasal sinuses that continues for at least three months, is a major cause of morbidity in the pediatric population and a difficult entity to treat with a poorly defined pathophysiology. The cornerstone of treatment for children with CRS remains aggressive antibiotic therapy, but many patients fail to improve even after extended courses of broad-spectrum oral antibiotics. However, good treatment results with adenoidectomy alone have been reported in pediatric patients with CRS. The purpose of this study was to evaluate the effect of adenotonsillectomy on chronic rhinosinusitis in children.
Materials and Methods:
In this clinical trial the study population was 40 children under 14 years old who had been selected for adenotonsillectomy. Prior to the procedure, a Waters’ view radiograph was performed on individuals that suffered from CRS and displayed symptoms such as rhinorrhea, halitosis, and chronic cough. Only patients with bilateral clouding of the maxillary sinuses were enrolled in study. A further radiograph was performed on the 28th day following the procedure and the outcome of the treatment evaluated.
Results:
Of the 40 patients under 14 years old who were evaluated, 22 (55%) were female and 18 (45%) were male. The mean age of the patients was 7.22 years while the oldest was 14 and the youngest was 4 years old. Nasal congestion, rhinorrhea, post nasal drip, and chronic cough were present in all of the patients. Following the adenotonsillectomy, these symptoms were significantly reduced and were present in only 15.5%, 0%, 20%, and 20% of the patients, respectively. Multivariate analyses were performed using McNemar’s test.
Conclusion:
According to the results of this study, where 72.5% of patients showed a complete recovery following treatment, an adenotonsillectomy can be considered as a treatment modality for CRS.
https://ijorl.mums.ac.ir/article_206_5db350a048f17e2eb61d62fe70487b12.pdf
2012-04-01
69
74
10.22038/ijorl.2011.206
Adenoid
Adenoidectomy
Palatine tonsil
Tonsillectomy
Fatholah
Behnoud
1
Associate Professor Hamedan university of medical sciences ENT department Besat Hospital
AUTHOR
ORIGINAL_ARTICLE
The Epidemiological and Clinical Aspects of Nasal Polyps that Require Surgery
Introduction:
The objective of this retrospective cross-sectional study was to obtain epidemiological data from the charts of 297 patients with nasal polyposis who were operated on in a referral hospital in Mashhad and to determine the frequency of the presenting symptoms of nasal polyps.
Materials and Methods:
The variables recorded included age, gender, the presence of asthma or allergic rhinitis, family history, and previous treatments. We studied the main symptoms of nasal polyposis (nasal obstruction, rhinorrhea, anosmia, headache, epistaxis, snoring, and so on), as well as ear problems and facial deformity.
Results:
Nasal polyposis affects men (60.3%) more frequently, at a mean age of 39.5 years. The most frequent symptom was nasal blockage (81.1 %) followed by rhinorrhea (37.7%). A total of 11.1% of the patients had a history of epistaxis. Asthma was found in 10.4% of patients with nasal polyposis and the ears were affected in 5.1% of patients. In all, 7.4% of patients had first-degree relatives who suffered from asthma or allergic rhinitis.
Conclusion:
This study highlights the need for large-scale epidemiologic research exploring the prevalence and incidence of nasal polyposis in Iran.
https://ijorl.mums.ac.ir/article_207_415fa1f4f200fa543625d3a65409f0f6.pdf
2012-04-01
75
78
10.22038/ijorl.2011.207
Clinical Features
Epidemiology
Nasal polyposis
Ahmad
Meymane Jahromi
1
Assistant Professor of Otolaryngology. Department of Otorhinolaryngology, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
Ayeh
Shahabi Pour
2
Otolaryngology Resident. Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
ORIGINAL_ARTICLE
Prophylactic Antibiotics in Otolaryngologic Surgeries:
From Knowledge to Practice
Introduction:
The management and use of antimicrobial drugs has clinical, economic, and environmental implications. In many countries, antimicrobial drugs are the most frequently prescribed therapeutic agents. Therefore, health-care policy should focus on how to establish a rational attitude toward antibiotics. This study was performed to investigate antibiotic usage as a prophylactic regimen in head and neck surgeries.
Materials and Methods:
This study was a retrospective case series. Patients undergoing otolaryngology surgeries in a tertiary referral otolaryngology center were included. Members of operating room staff that were unaware of the study objectives collected patients’ data using a questionnaire that contained information regarding general medical condition, disease, surgical procedure, and prophylaxis regimen and duration.
Results:
Excluding infected patients, we studied 1349 patients during a four-month period who needed prophylactic antibiotics. A total of 34 different types of surgical procedures were performed. Out of the total number of patients, 503 (37.0%) received a parenteral antibiotic directly before surgery. The main antibiotics used before surgery were cephalosporins (94.9%). All of the 1349 patients were administered antibiotics after the procedure. These antibiotics where given with a mean number of doses of 4.81 (range: 1–68), and also consisted of mostly cephalosporins.
Conclusion:
Our results indicate that prophylactic antibiotics were being significantly misused in a tertiary referral center of a university hospital. Although teaching the principles of prophylaxis to physicians is important, we think that finding a way to bring this knowledge to practice is more important.
https://ijorl.mums.ac.ir/article_208_6f8f0ab88bcbb777dda0b142bf0cdd58.pdf
2012-04-01
79
84
10.22038/ijorl.2011.208
Minoo
Khatami-Moghadam
1
Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Amir-Alam University Hospital
AUTHOR
Mohammad-Taghi
Khorsandi-Ashtiani
2
Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Amir-Alam University Hospital
AUTHOR
Mohammad-Ali
Mohagheghi
3
Cancer Institute, Cancer Research Center, Tehran University of Medical Sciences
AUTHOR
Mehrdad
Hasibi
4
3Department of Infectious Diseases Tehran University of Medical Sciences, Tehran, Iran
AUTHOR
Ali
Kouhi
a-kouhi@tums.ac.ir
5
Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Amir-Alam University Hospital
AUTHOR
ORIGINAL_ARTICLE
Incidence of Etiologic Factors in Squamous Cell Carcinoma of Head and Neck in Ahvaz
Introduction:
Squamous cell carcinoma (SCC) is the most common head and neck malignancy. Smoking, alcohol consumption, viral infections, exposure, oral hygiene, and dietary, genetic, and occupational factors are the most important etiologic factors. The aim of this study was determining the incidence of etiologic factors in head and neck SCC.
Materials and Methods:
This is a cross-sectional survey study for the determination of the etiologic factors of head and neck squamous cell carcinoma over a five-year period in the Otolaryngology Department of the Imam Khomeini & Golestan hospitals in Ahwaz.
Results:
176 patients, comprising 151(85.8%) men and 25(14.2%) women, were studied. Overall mean age was 67.2 years. 148 (84.1%) patients were smokers. prolong exposure to chemical fertilizer in 101 (57.4%) patients, Sun exposure in 21 (11.9%) patients, Low socioeconomic status in 124 (70.5%) patients, poor oral hygiene in 128 (72.7%) patients, high intake of hot tea drinking in 84 (47.7%) patients and malignancies in family in 12 (6.8%) patients were the most frequent risk factors. 17 (9.6%) patients have had opioid addiction and HPV was positive in 7 (3.9%) patients by PCR.
Conclusion:
According to this study, tobacco smoking was the most important etiologic factor and had a strong effect on risk of head and neck squamous cell carcinoma. Other factors are also important and need more research study.
https://ijorl.mums.ac.ir/article_209_bdac0d75c958c7bba08385d2ffd99cbe.pdf
2012-04-01
85
90
10.22038/ijorl.2011.209
Etiologic factors
Head
Neck
Smoking
Squamous cell carcinoma
Soheila
Nikakhlagh
nikakhlagh.s@gmail.com
1
Associated Prof. of Otorhinolaryngology of imam Khomeini hospital
AUTHOR
Nader
Saki
ahvaz.ent@gmail.com
2
Associated Prof. of Otorhinolaryngology of imam Khomeini hospital
AUTHOR
Mahmood
Hekmat shoar
3
Resident of Otorhinolaryngology of imam Khomeini hospital
AUTHOR
Amin
Sartipipor
4
General Physician of Ahvaz health care
AUTHOR
Sara
Saki
5
Medical Student of shiraz university
AUTHOR
ORIGINAL_ARTICLE
Foreign Bodies: Aspirated or Ingested? A Report of Two
Unusual Cases
Introduction:
The diagnosis of foreign bodies in the upper aerodigestive tract is usually straightforward but sometimes it can be delayed or the location of esophageal and upper airway foreign bodies can be mistakenly interchanged.
Case Report:
We present two interesting cases that caused diagnostic challenges which could have led to serious complications if a greater delay in diagnosis had occurred.
Conclusion:
In order to diagnose upper aerodigestive tract foreign bodies without delay, a careful history and physical examination with proper X-rays are helpful.
https://ijorl.mums.ac.ir/article_210_018721a8b7ddca4e80d422b82065a031.pdf
2012-04-01
91
94
10.22038/ijorl.2011.210
Aspiration
Bronchus
Esophagus
Foreign body
Aliasghar
Arabi Mianroodi
mrarabi@yahoo.com
1
Department of Otolaryngology, Head and Neck Surgery, Shafa Hospital, Kerman, Iran
AUTHOR
Yeganeh
Teimouri
2
Department of Otolaryngology, Head and Neck Surgery, Shafa Hospital, Kerman, Iran
AUTHOR
Neil
A.Vallance
3
Department of Otolaryngology, Head and Neck Surgery, Monash Medical Center, Melbourne, Australia
AUTHOR
ORIGINAL_ARTICLE
A Schwannoma of the Soft Palate in a Child: Histological and Immunohistochemical Features and Surgical Method
Introduction:
Schwannoma, or neurilemmoma, is a benign neoplasm of Schwann cells that is extremely rare in the soft palate. Herein we present a case of a soft palate schwannoma presenting with an ulcerated surface and purplish colour in a 12 year-old girl. This report also introduces a successful surgical technique for coverage of the defect left by surgery.
https://ijorl.mums.ac.ir/article_211_f6deb9c37d6b9888bf10da5baab99b41.pdf
2012-04-01
95
99
10.22038/ijorl.2011.211
immunohistochemistry
Schwannoma
Soft palate
Surgical procedures
Amin
Rahpeyma
rahpeymaa@mums.ac.ir
1
Assistant Professor of oral and maxillofacial surgery, Oral and Maxillofacial Diseases Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
Amir Hosein
Jafarian
2
Assistant Professor of pathology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
Saeedeh
Khajehahmadi
3
Assistant Professor of oral and maxillofacial pathology, Dental Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran.
AUTHOR
Javad
Sarabadani
4
Assistant Professor of Oral and Maxillofacial Diseases, Oral and Maxillofacial Disease Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
AUTHOR