ENT October 2007

Vol. 6 Issue 1 Oct - Dec 2007

• Owned,Edited,PrintedandPublishedby Dr.VinayAggarwalforandonbehalfof

PushpanjaliMedicalPublicationsPvt.Ltd.,A-14,Pushpanjali,VikasMargExtn.,Delhi-110092

• PrintedatKumarOffsetPrinter,381,PatparganjIndustrialArea,Delhi-110092

• AlldisputestobesettledinDelhiCourtsonly.

All rights reserved. • Noresponsibilityistakenforreturning

unsolicitedmanuscriptsunlessaself-addressedstampedenvelopeisenclosed.

• ViewsexpressedinarticlesinPushpanjaliMedi-Focusdonotnecessarilyreflectthoseoftheeditorialboard.

Editor-in-Chief Dr. Vinay Aggarwal

SectionalEditors Dr. L.D. Sota

Dr. Atul Jain

EditorialBoard

Dr. Ashok Grover Dr. Hariharan Dr. Madhumita Puri Dr. Sharda Jain Dr. Parkash Gera Dr. Rajiv Gupta Dr. S. Arul Rhaj Dr. Deepak Pande Dr. Yogesh Jhamb Dr. Vineet Jain Dr. Neeraj Jain Dr. B.K. Gupta Mr. S.K. Singhal Mr. Atul Gandotra

Photographer Mr. Mukesh Kapoor

DesignandLayout Ms.Tabassum

The Eye and ENTspecialties take careof 4 out of 5 specialsenses which areneededfororientationand fulfillment ofhumanneeds.

TherewasatimewhenEyeandENTusedtobeacommonspecialty,butnowadays there issomuchadvancement thattherighteardoesnotknowwhattheleftearishearingandtherighteyedoesnotknowwhatthelefteyeisseeing.Inshorttherearesubspecialtiesinthesetwomajorspecialties.

The advancement in instrumentation is takingENT surgerybeyond theconfinesofEarNoseandThroat.NowPituitarytumors are removed through endoscopic Trans sphenoidapproach,reducingthemorbidityofthepatient.DCRisdoneTransnasallyeliminatingtheskinscar.CSFleaksarerepairedthrough nasal endoscopes. Clivus tumors are also removedendoscopically.

Humanshaveafewfadsi.e.,cleanliness.JohnsonandJohnsonabignameinpharmaindustrycameoutwithearbudsandpeoplestartedusingthem.Theyaredoingmoreharmtotheirearsbypushingthewaxinsidetheearcanalandbycausingexcoriationoftheearcanalwall;whichleadstoinfection.TheOTCdrugsforcommoncoldcontainantiallergicagentswhichthicken the nasal secretions; it relieves the patient on dayone from excessive nasal discharge but prolongs the agony.Rhinorrhoeaisnature’swaytowashouttheoffendingagentstoget ridof infectionof thenose.Theearwaxprotects theear fromwater,dustandsmall insects toenter theear; thiswaxisexpellednaturallyfromtheearsintheformofsmalldriedlumps.Ifwedonotinterferewithnatureinitscleansingcycles; lifewillbemorecomfortable.After therampantuseofEarbudsthenumberofpatientswithearcomplaintshasincreased.

1in1000livebirthshavehearinghandicap.Cochlearimplant–Anewdimensiontoseverehearinglossisaboontomanyhearinghandicaps.Thecochlearimplantshaveimprovedalotinthelast20yearsfromjustperceptionofsoundtoenjoyingmusic.

Similar work is going on visual cortex stimulation forblindness.

ThetopicswhichcanbecoveredinthisissueareenormousbutwehavetriedtotouchafewtopicstoshowwhereweareheadingandEyeandE.N.T.arenomoreaminorspecialty.

Dr. L.D. Sota Dr. Atul Jain

Vol. 5, Issue 3 & 4 April - Sept 2007

EDITORS SPEAK

CONTENTS

1. EyeFlu 52. DiabetesandEye 83. AestheticallySpeaking: 11

BotoxandBlepharoplasty4. FracturePenis–ARareCase 135. HowtoManage– 15

DifficultPatientEncounters6. AllergicRhinitis:CurrentConcepts 17 inDiagnosisandManagement7. EndoscopicDacryocystoRhinostomy 258. EarlyHearingLoss: 27 DetectionandIntervention9. CochlearImplants 2910.UterineBalloonTherapy: 31

AReasontoSmileforDUBCases11. IntraoralRemovalofDermoidCysts 33

bySublingualApproach12.PushpanjaliFamilyPhysicians 37

Forum(PFPF)13.PushpanjaliHealthcareEvents 39

andInitiatives14.Guidelinesforsubmissionof 43

Manuscripts

Vol. 6, Issue 1 October - December 20072

EMPANELLED ORGANISATIONS

1) GeninsIndiaLtd2) UnitedHealthcarePvt.Ltd3) MDIndiaPvt.Ltd4) MedicareServiceClub5) ParkMediclaimConsultantsPvt.

Ltd6) ParamountHealthcare

Management7) AlankitCapsec.Pvt.Ltd.8) VipulMedCorp.Pvt.Ltd9) E-meditekSolutionsLtd10) TTKHealthcareServicesPvt.Ltd.11) HeritaggeHealthClub12) MediAssistLicensedTPA13) MedSaveIndiaPvt.Ltd14) FamilyHealthPlanLtd15) RakshaTPA16) EastWestAssist17) BSESYamuna/Rajdhani/IPGCL

(Genco)PowerLtd18) BajajAllianzLifeInsuranceCo.

Ltd.19) GoodHealthPlanLtd.-20) PawanHansHelicoptersLtd21) HeritageHealthServicesPvt.Ltd22) BajajAllianzLifeInsuranceCo.

Ltd.23) HygeniceCare(OPD)24) CentralElectronicsLimited(OPD)25) MotherDairy26) NationalTextileCorporation

(NTC)27) NationalBuildingConstruction

CorporationLtd.28) Dabur&Excelcia29) ArankariPlacementServicesPvt.

Ltd.30) MicromaticMachineToolsPvt.

Ltd.31) GopalIndustriesPvt.Ltd.32) NationalIndustrialDevelopment

CorporationLtd.33) MarutiUdyogLtd.34) NationalProjectsConstruction

CorporationLtd.35) BharatHeavyElectricalsLtd.

(BHEL)36) NationalAgriculturalCooperative

MarketingFederationofIndiaLtd.(NAFED)

37) UniversalMedi-AidServicesLtd.38) HealthIndiaPvt.Ltd.39) MetLifeIndiaInsuranceCo.Pvt.

Ltd.40) MedicareServicesPvt.Ltd.41) M/sVenusMedicareServices42) MedicareFoundationPvt.Ltd.43) IndiaTradePromotion

Organization44) HealthIndia(BAISPL)45) WHO46) SafewayMediclaimServicesPvt.

Ltd47) ConsortiumforEducational

Communication48) NationalSmallIndustries

CorporationLtd.49) MeconLtd.50) FocusHealthcare51) E-Medlife

LIST Of CONSULTANTS

CONSULTANT RESIDENCE CHAMBER MOBILE DAY/TIMING

MEDICAL DIRECTORDr.VinayAggarwal 22374612 22371818 9811050403

MEDICAL SUPERINTENDENTDr.H.S.Nagi 95120-4125563 9818599722 9.00am-5.00pm(Daily)

PHYSICIANDr.ParkashGera 22375440,22371284 22075641 9810000944 11.30am-1.00pm(Daily)Dr.SangeetaBhargava 42440940 22441900 9810249001 9.00am-10.00am(Daily) 22094921-22Dr.NavinAtal 42408075 22140637 9810115132 8.00pm-9.00pm(Daily)

PHYSICIAN-CHEST SPL.Dr.AshokGrover 22541854 22411236 9810121609 4.00pm-5.30pm(Daily)

PHYSICIAN & NON INASIVECARDIOLOGISTDr.MukeshAjmera 22374502 9811008306 11.00am-1230pm(Daily)

GYNAECOLOGISTDr.ShardaJain 22238838-22238847 22414049-22453724 9312644808 8.00am-9.00am(Daily)Dr.KanikaGupta 22149718,22169718 9810183236 10.00am-12.00noon(Tue,Wed,Fri)Dr.BakulArora 22750757,22750551 9810089120 7.00pm-8.00pm(Mon,Fri)Dr.AnitaJain 95120-4112881,2640397 22582002 9810262229 1.00pm-2.00pm(Daily) Dr.RekhaSarin 65261328 659014833 9818088114 9.00am-11.00am(Mon,Thur,Sat)Dr.SunitaLal 9810630691 5.00pm-6.00pm(Mon,Thur)

SURGEONDr.YogeshJhamb 22378281 9811168281 11.30am-1.30pm(Daily)Dr.SameerParuthi 9810061958 OnCall

CHILD SPECIALISTDr.DeepakPande 22243742,42182025 22432218 9810366571 11.30am-1.00pm(Daily)Dr.VineetJain 95120-4112881,2640397 22582002 9810121098 10.00am-12.00noon(Daily)Dr.AlokGupta 65374625 9910227227 9312248808 5.00pm-6.30pm(Daily)

PAEDIATRIC SURGEONDr.AnuragKrishna 24112687,24114887 9810060565 1.00pm-2.00pm(Sat)

ORTHOPAEDIC SURGEONDr.B.K.Malik 9811703004 6.00pm-8.00pm(Daily)Dr.GirishChhabra 95120-2628200,2625200 22507728 9810025926 9.30am-12.30pm(Tue,Thu,Sat)Dr.P.K.Dhar 22244801 9810038879 10.30am-12.00noon(Daily)Dr.AshishSao 9312010421 9.30am-12.30pm(Mon,Wed,Fri)Dr.R.K.Sachdeva 22162135 22094892 9811073613 5.00pm-6.00pm(Daily)Dr.AlokSharma 9312070380 6.00pm-8.00pm(Daily)Dr.DaulatSingh 22120442 22111872 9810244149 OnCall

ANAESTHETISTDr.RajeshDhall 22167122 9810110405 OnCall(Tue,Thu,Fri,Sun)Dr.SwarajGarg 22543003 22548796,22519888 9811441064 OnCall(Mon,Wed)Dr.RakeshAtray 22152245,22157745 9810272563 OnCall(Sat)

ENT SURGEONDr.AtulJain 22376205 22545000 9811120545 12.00noon-1.30pm(Daily)Dr.AnuragJain 22720901 9810249015 8.30pm-9.30pm(Daily)

GASTROENTEROLOGISTDr.NeerajJain 22371024 22545000 9810166989 4.00pm-6.00pm(Daily)

ONCOLOGISTDr.SudersanDe 26252065 9810227340 OnCallbyappointment

ONCO SURGEON Dr.UmangMittal 95121-2668149 9412201474 4.00pm-6.00pm(Wed) 11.00am-12.00noon(Sat)Dr.PraveenJain 22146173 22149256 9810139314 Oncall

EYE SPECIALISTDr.L.D.Sota 26016636 9312876694 10.00am-1.00pmDaily(exceptWed) 4.00pm-7.00pm(Wed)Dr.P.C.Bhatia 26515263,26863998 9810064554 OnCall


LIST Of CONSULTANTS

CONSULTANT DAY / TIMINGS

PHONE NO

PHYSICIAN

Dr.RubyBansal 9.00am-11.00am

R)2614076 (Daily)

M)9891376756

CHILD SPECIALIST

Dr.(Mrs.)VTDophal9.00pm-10.00am

M)9811161590 (Daily)

SURGEON

Dr.VijayS.Pandey 11.00am-1.00pm

R)95120-2628254 (Mon,Thur)

M)9818492809

ENDOCRINOLOGIST

Dr.S.K.Wangnoo 7.00pm-9.00pm

R)22618242 (Mon,Wed)

22621357

M)9810113922

CARDIOLOGIST

Dr.Dhirender 7.00pm-9.00pm

Singhania

M)9871650111 (Mon,Sat)

ORTHOPAEDIC SURGEON

Dr.AshishSao 6.30pm-8.30pm

M)9312010421 (Tue,Thur,Sat)

DERMATOLOGIST

Dr.RituGupta 7.30pm-9.00pm

R)22371114 (Wed,Fri)

M)9891063467

ENT

Dr.SaketAggarwal 11.00am-1.00pm

M)9811231599 (Mon,Thurs)

PHYSIOTHERAPIST

Dr.Md.MajidKhan 1.00pm-4.00pm

M)9873207660 (Daily)

Dr.SonikaSaraswat 8.00am-3.00pm

M)9899649920 (Daily)

CONSULTANT RESIDENCE CHAMBER MOBILE DAY/TIMINGURO-SURGEONDr.C.M.Goel 95120-2630717 951202630365 9811047047 1.00pm-2.00pm(Mon,Thu)

PATHOLOGISTDr.VandanaArora 22246806 9811009938 9.00am-4.00pm(Daily)Dr.ArchanaSood 22096401 9312319887 OnCall

MICROBIOLOGISTDr.NarinderSaini 22376289 22381445 9810252127 8.00am-9.00am(Daily)

RADIOLOGISTDr.MukeshKoshal 22546704 9810062179 12.00noon-1.30pm(Daily)

NEUROLOGISTDr.B.K.Gupta 22371675,22371033 9811084263 OnCallDr.NirmalaLahoti 22540271,22526601 30946399 9810061981 OnCallDr.Aditya 9810556353 9.00am-11.00am(Tue,Thur,Sat)

NEURO SURGEONDr.J.Kumar 9810273684 OnCall

NEPHROLOGISTDr.NeeruAggarwal 95120-2724591 95120-2780736 9810266275 1.00pm-2.00pm(MontoFri) 9.00amto10.00am(Sat)PSYCHIATRISTDr.RamanJeetJaswal 22526533 9810526533 OnCallDr.VikasMohanSharma 22623183 9810412911 6.00pm-8.00pm(Fri)

PSYCHOSEXUAL DISORDERSDr.(Col.)V.K.Wadia 55469686 26140058 9891192777 6.00pm-8.00pm(Fri)

PSYCHOLOGISTDr.DeepaliBatra 9818425297 4.00pm-6.00pm(Wed,Fri)

CARDIOLOGISTDr.DhirendraSinghania 9871650111 6.00pm-8.00pm(Mon-Sat.)

ENDOCRINOLOGISTDr.S.K.Wangnoo 22618242,22621357 95120-2921446 9810113922 OnCall

DENTISTDr.GeetaPaul 9811415489 9810292498 10.00am-2.00pm(Daily) 5.00pm-8.00pmPHYSIOTHERAPISTDr.Md.MajidKhan 9873207660 9.00am-1.00pm(Daily)

HOMOEOPATHIC PHYSICIANDr.M.M.Aggarwal 22434770 22094879 22513835

PLASTIC SURGEONDr.R.K.Sandhir 95120-2458588 22592073,22169732 9810033525 OnCallDr.ManojBansal 22155057 22097417,22093107 9810003628 11.00am-1.00pm(Daily)

SKIN SPECIALISTDr.V.K.Upadhyaya 22152084 22091758 9810033882 OncallDr.MukeshGirdhar 95120-2625544 22372484 9810078198 OncallDr.RituGupta 9891063467 10.00am-11.00am(MontoFri)Dr.RitikaGupta 9818560759 OncallCHEST SURGEONDr.R.C.Jain 26803436,26808035 9811106203 OncallRHEUMATOLOGISTDr.AnishAggarwal 95120-2753546 9810073795 4.00pm-7.00pm(Fri)Courtesy consultantsDr.PoonamGupta 22095708 22161397 9811744426Dr.S.P.Singh 22152036 9811152254Dr.JyotiAggarwal 22238871 9910081484Dr.DeepakLahoti 9810123067Dr.MadhuAhuja 22516733 22541842 9810067539Dr.DeepakSarin 65901485 22147652 9811022434fAMILY PHYSICIANSDr.V.K.Malhotra 22157127 9313100602 OnCallDr.AjayAggarwal(B/oMD) 9810130292 OnCallDr.AjayArora 22156672 22510904 9810049714 OnCallDr.VipinJain 22372065 22412008 9811047912 OnCallDr.K.B.Bhatia 22372727 22372728 9811319070 OnCallDr.HariHaran 22549804 22540624 9810197049 OnCallDr.AtulAggarwal 22459608 9811137098Dr.D.R.Rai 9312504480Dr.V.P.S.Chawla 9811305435Dr.SangeetaGupta 9810395657Dr.AshwaniGoyal 22112343 9811112688Dr.A.K.Jain 9871803070Dr.RakeshGupta 22155979,55298198


Rachna AgarwalJunior ResidentMohanEyeInstituteNewDelhi

Sachin Raj KumarAssistant ProfessorKasturbaMedicalCollegeManipal

Eye Flu

Rachna Agarwal and Sachin Raj Kumar

Eye flu is the common name for Infectiveconjunctivitis.Approximately2%ofallprimarycarevisitsand1%ofemergencyroomvisitsarerelatedtoconjunctivitis.

Definition and EpidemiologyConjunctivitis is an inflammation of theconjunctiva which is a thin transparent layercoveringthesurfaceoftheinnereyelidandthefrontoftheeye.

v Eyefluorredeyesismostcommonlyviralinnaturecausedbyadenovirus

v Affectsmalesandfemalesequally

v Noracialpredilectionisobserved

v Commonlyseenin20-40yrsagegroup

v It is highly contagious – outbreaks cansometimesbetracedtoinfectedindividualsorlocations.

Causative virus / Mode of spreadIt is most frequent caused by Adenovirus,8,19butseveralotherserotypeslike37,22mayberesponsible.

v Itisadeoxyribonucleicacid(DNA)virus.

v Incubation period is 4-10days. Followingtheonsetofconjunctivitisthevirusisshedforabout12days.

It is highly contagious; as the virus is readilytransmitted by hand to eye and ophthalmicsolutions and instruments (conometers) arepotential causes of contamination. The virusis readily transmitted in respiratory or ocularsecretions, contaminated fomites (includingeye droppers and mascara bottles) and evencontaminatedswimmingpools.

The disease commonly occurs in individualswho are in close contact with others e.g. inschools,nursingfacilities,personsetc.

Types 1. Pharyngo conjunctional fever (PCF) is

most commonly caused by adenovirustypes 3, 4 and 7 and occasionally by type5.Itistransmittedbydropletsandtypicallyaffectschildrenwhoalsodevelopanupperrespiratorytractinfection.Keratitisdevelopsin30%ofcasesbutisseldomsevere.

2. Epidemic keratoconjunctivitis (EKC) ismostfrequentlycausedbyadenovirustypes8 and 19, but several other types may beresponsible. The infection is transmittedby hand to eye contact, instruments andsolutions. In contrast to PCF it does not

v

cause systemic symptoms. Keratitis whichmaybeseveredevelopsin80%ofcases.

Signs and Symptoms Symptoms

Redeyenotedbythepatient

Wateringeyes

Swollenlids

Patients notice it in one eye perhaps withlaterspreadtotheothereye.

Inpharyngoconjunctivalfever-sorethroat,feverandheadachemaybepresent.

Signs

Follicular conjunctivitis (seen particular ivinferiorpalpebialconjunctiva)

Watery,mucoiddischarge

Crustingmaybeevidentonlashes

Edematouslids

Palpebialprecircularlymphadenopathy

Pinpointsubconjucntivalhemorrhage

Inepidemickeratoconjunctivitis–pseudomembranes and subepithehal (stromal)infiltratesseen.

Stages of Keratitis Stage I – occurs within 7-10 days of onset ofsymptoms and is characterized by a punctateepitheial keratitis which resolves within 2week.

Stage II – is characterized by focal, with subepithelial opacities sub epithelial lesion arethoughttorepresentimmuneresponsetovirusand may be associated with mild transientanterioruverlis.

Stage III characterized by anterior stromalinfiltrateswhichgraduallyfadeovermonthstoyears.

ManagementTestsnellensV/A

Lookforconjucntivalhypermia,chemosis,superior and inferior sub conjucntivalhemorrhages, follicles and waterydischarge.

Palpateforpreauricularlymphadenopathy.

Refer the patient to an ophthalmologistfor examination of corneal surface withflourescein dye and slit lamp if there isanyblurredvision, foreignbodysensationand photophobia suggestive of cornealinvolvement.

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v


History and Physical Examination for Viral ConjunctivitisCategory Element Notes History Pinkeye Usuallystartsinoneeyeandcanspreadto2ndeyewithin2-4 days.Acuteinfectionlastfor7-10days.

History Waterydischarge Indicatesviralinfectionmayindicatecornealinvolvement

History lightsensitivity

History Clinicalcontents Indicatesepidemicnatureofdisease

PhysicalExamn Conjunctivalinfection Indicatesconjunctivalinflammation

PhysicalExamn Bilaterally Maypresentinbotheyessimultaneouslyorsecondeye involvementafter3-5days

PhysicalExamn Conjunctivalfollicles Folliclesareaccumulationoflymphocytesandother inflammatorycellsformingalittlemoundwithvascularfrill aroundthebaseindicatingviralinfection

PhysicalExamn Pseudomembraneformation Exudativeresponsecausetheformationofpseudomembrane inpalpebralconjunctival ofupperandlowerlids

PhysicalExamn Subconjunctival Indicatesseverityofthedisease hemorrhage

PhysicalExamn Preauricular Consistentwithadenoviralinfection lymphadenopathy

PhysicalExamn Cornealinfiltrates Typicallyseeninepidemarkeraticconjunctivitis.Referto ophthalmologistwithslitlamporhighmagnificationwith directophthalmoscopy

PhysicalExamn Mattingoflashes Indicatessuperaddedbacterialinfection.Refertoanophthalmologist

TESTS NOTES

1)Conjunctivalscrapingandcytology Eosinophilseeninallergicconjunctivalandintracytoplasmic inclusionbodiesinChlamydiaconjunctivitis

2)Viralcultures arenecessarytodocumentetiology.Inadenoviral,picornaviraland HSconjunctivitis

3)Bacterialcultures Indicatedinpurulentconjunctivitise.g.,gonorrheas

4)Conjunctivalbiopsy Granulomasseeninsarcoid;basementmembrane immunoflorcenceinocularcicatricialpemphigoid

Lab Diagnosis Conventional lab identification can be expensive and timeconsuming but may be helpful in certain circumstances. Useof selected testes should be done to assist in the differentialdiagnosisofunusualformofconjunctivitis.

Consider obtaining

Cytologyspecimenofconjunctival epithelium,whichmayshowintracytoplasmicinclusionsinsuspectedchlamydialconjunctivitis.

Cytologyspecimen,whomayshoweosinophiliainsuspectedallergicconjunctivitis.

Culture of conjunctiva in suspected chlamydia or herpesvirus

Bacterialculture if there ispurulentdischargeparticularlyinpatientswithhyperacutepurulentconjunctivitis,whichmayrevealN-gonorrhea.

Conjunctival biopsy specimen in patient with suspectedsarcoidandocularcicatricialpemphigoid.

v

v

v

v

v

Management

Adenovirus isaveryrobustvirus thatcansurviveoutside thebodyonhardsurfacesandhasbeenculturedfromsuchsurfacesup to 7 weeks after an infection. It is somewhat resistant toalcoholdisinfectionandisrecommendeddilutedbleachbasedcleanerifforproperdisinfection.Notreatmentisanoptionformilddisease.Thetearscontainchemicalsthatfightoffbacteriamany symptoms get cleared on the own in 2-5 days withouttreatment.

General measuresInfectiveconjunctivitisiscontagious.Thelikelihoodofpassingit on is not high unless contact is direct. Patients should beinstructedto:

Washhandsregularlyespeciallyaftertouchingeyes.

Nosharingoftowels,pillows,utensils

Applicationofcoldcompresstotheinfectedeye(s)3-4timesper day for 10-15 minutes using clean washed cloth eachtime. This should help reduce itching and swelling andprovidesomecomfort.

v

v

v


Avoidrubbingeyestodecreaseirritation

Wearsunglassesifeyesaresensitivetolight

Avoid exposure to irritants that may be causingconjunctivitis

Avoidwearingcontactlenseswhichyouareusingorifeyesareuncomfortable

Cleancontactlensthoroughly

Temporaryleaveofabsenceshouldbeconsideredforpatientswhoworkwiththepublicandhaveacuteinfection

Noantibioticorantiviraldropsareroutinelyused.Incaseswhere bacterial or super infection is suspected, antibioticdropsareindicated

There are no anti viral drugs approved for adenoviralconjunctivitis

InEKConly:pseudomembranesshouldbemanuallypealedafter2-3days

Topicalcorticosteroidmaybeneededtopreventscarring.

Medications Topicalartificialtears:4-8times/day

Vasoconstrictor/antihistamine: 4 times/day for severeitching

Topicalantibioticspreventbacterialsuperinfection

Commonly asked questionsQ1 Isadenoviralconjunctivitisspreadbyhandtoeyecontact?

A) Yes.

Q2 Canadenoviralconjunctivitiscausevisionloss?A) No, it cannot cause vision loss but definitely when

cornea is infected then blurring of vision is present.This keratitis can last from days to weeks and mayclearspontaneously,ormaypersistwiththeformation

v

v

v

v

v

v

v

v

v

v

v

v

v

of larger epithelial infiltrates. These sub epithelialinfiltrates generally disappear in 2 weeks but thesubepithelial lesions mostly located centrally remainforvaryingperiodsusuallyweekstomonths.

Q3 Canitspreadfrommothertochild?A) No, not transplacentally but definitely it can spread

frommothertothechildastheyareinclosecontactbyhandtoeyetransmission.

Q4 Can it spread during antenatal period from mother tochild?A) No.

Q5 Shouldpatientswitheyeflubeexcusedfromwork?A) Yesiftheyhavesuchajobconcernedwhichinvolves

withpubliccontacttheycanbeexcusedforabout10days.

Q6 Whenisapatientnolongerinfectious?A) After10days.

Q7 Areantibioticsbeneficialineyeflu?A) Antibioticshavenoroletoplay.

Q8 Can personal hygiene prevent the spread of adenoviralconjunctivitis?A) Yes,ofcourse.Asalreadymentionedeyefluhashand

toeyetransmissionsoaninfectedpersonshouldhaveseparate handkerchief, towel, bed sheet, bed spread,pillowcoverforhimself.Frequentwashingofhandsisamust.

Q9 Shouldpatientdiscardcontactlensesaftertheboutofviralconjunctivitis?A) Yes.

Q10Can adenoviral conjunctivitis be associated with chronicvisualdisturbances?A) Notusually.

Vol. 6, Issue 1 October - December 2007�

Sachin Raj KumarAssistant ProfessorKasturbaMedicalCollegeManipal

L.D.SotaEye Surgeon and Contact Lens SpecialistPushpanjaliMedicalCentreDelhi

Diabetes and Eye

Sachin Raj Kumar and L. D. Sota

Diabetes is a chronic disease in which thereis deficiency or ineffective utilization ofinsulin. It results in hyperglycemia which inturn damages the end organs with specialreference to nerves and blood vessels. Thisultimately leads to increased morbidityandmortality.

It isestimatedthatthenumberofpeoplewithdiabetesislikelytoincreaseto366millionbytheyear2030from171millionattheturnofthecentury.InIndiatherewillbe79millionpeoplewith diabetes by 2030 making it the diabeticcapitaloftheworld.

Diagnosis of DiabetesAs per the American Diabetes Association(ADA)thediagnosisofdiabetes ismadewhenthecasualplasmaglucoseis200mg/mlwiththesymptom of polydypsia, polyphagia, polyuriaor weight loss. Casual plasma glucose level isdefinedasplasmaglucoselevelatanytimeofthedaywithoutregardtothetimeoflastmeal.Fastingglucoselevelisdefinedasplasmalevelofglucosewithnocaloric intake forat least8hours.Fastingplasmaglucoselevelispreferredovercasualplasmaglucose.In1977,ADAaddeda new entity called impaired fasting glucose(IFG).

Persistenthyperglycemiaprogressivelydamagesevery system of the human body. The excessglucose and fatty acid exert their toxic effecton various organs. The nerves, retina andkidney are the main organs that are affected.Hyperglycemiainducesvarioushemodynamic,biochemicalandendocrinologicalalterations.

Diabetic eye disease refers to a group of eyeproblemsthatpeoplewithdiabetesmayfaceasacomplicationofdiabetes.Diabeticeyediseaseincludes diabetic retinopathy, cataract andglaucoma.

Risk factors for Diabetes Retinopathy:Fordiabeticretinopathythemajorriskfactorofcourse is diabetes. However, number of otherfactorsmaymodifytherisk.

1. Duration: The single most importantfactor is the duration of diabetes. A numberof studies have shown that the durationof disease is the best predictor of diabeticretinopathy. Type 1 diabetic patients do notdevelop diabetic retinopathy during the firstfiveyearsofthediseasebutafter20years50%of the patients develop Proliferative Diabetic Retinopathy (PDR). Intype2diabeticpatientsthe time of onset and the duration of thedisease are difficult to predict precisely andit has been found that 3-4% of these patientswouldhavediabeticretinopathyatthetimeofpresentation.

2. Control of blood glucose: The two largemulticentric trials Diabetic Control andComplications Trial (DCCT) and UnitedKingdomProspectiveDiabetesStudy (UKPDS)haveshownthatintensivetreatmentofdiabetesdelaystheonsetandreducestheprogressionofretinopathybothinType1andType2diabetesmellitus,respectively.

3. Puberty:Progressionofretinopathyhasbeenfoundtobeassociatedwiththeonsetofpuberty.Theexactmechanismisnotknown.

4. Type of Diabetes: Proliferative retinopathyis more prevalent in type 1 than in type 2diabetes. The incidence of macular edemaover a period of 10 years follow up has beenfoundtobe20.1%intheyoungeronsetgroup,25.4% in the older onset group taking insulinand13.9%intheolderonsetgroupnottakinginsulin.

5. Nephropathy: A diabetic patient withretinopathy is at a moderate risk of havingnephropathy, but the patient who hasnephropathyisatamuchhigherriskofhavingretinopathy. Both proteinuria and serumcreatininelevelsareassociatedwithincreasingseverityofretinopathy.

6. Hypertension: Astrongcorrelationbetweenhypertensive retinopathy and diabeticretinopathyexists.

7. Pregnancy: Pregnancy causes increase inDiabeticretinopathy.

Fundus shows Proliferative Diabetic Retinopathy (PDR)


8. Genetic factors:Strongassociationhasbeenfoundbetweenproliferative retinopathy and presence of HLA-DR phenotypes4/0,3/0andX/X.

factors reducing the prevalenceVariousfactorsareglaucomamyopiacarotidarterystenosisandeyeswithinflammationdisorder.

Treatment AccordingtotheAmericanAcademyofOphthalmology,95%ofthosewithsignificantdiabeticretinopathycanavoidsubstantialvision loss if they are treated in time. The possibility of earlydetectionispreciselywhyitissoimportantfordiabeticstohaveadilatedeyeexamatleastonceayear.

Diabeticretinopathycanbetreatedwithlaserphotocoagulationtosealoffleakingbloodvesselsanddestroynewgrowth.Laserphotocoagulationdoesnotcausepain,becausetheretinadoesnotcontainnerveendings.

Insomepatients,bloodleaksintothevitreoushumorandcloudsvision.Theophthalmologistmaychoosetosimplywaittoseeifthecloudingwilldisappearonitsown,aperiodcalled“watchfulwaiting”.Aprocedurecalledvitrectomyremovesbloodthathasleakedintothevitreoushumor.Thebodygraduallyreplaceslostvitreoushumor,andvisionusuallyimproves.

Small studies using investigational treatments for diabeticretinopathyhavedemonstratedsignificantvisionimprovementfor individuals who are in early stages of the disease. Twotreatments that are closely related, Lucentis and Avastin, maybeabletostoporreversevisionloss,similartoverypromisingresultsthathavebeenreportedwhenthetwodrugshavebeenusedastreatmentsformaculardegeneration.

PreventionThe key to preventing diabetes-related eye problems is goodcontrolofbloodglucoselevels,ahealthydietandgoodeyecare.

TheDiabetesControlandComplicationsTrial(DCCT),a10yearstudywhichendedinJune1993,provedamongtype1patientsthatimprovedbloodglucosecontrolpreventsordelaysdiabeticretinopathy. Therapy that keeps blood sugar levels as close tonormalaspossiblereduceddamagetotheeyesby76%.Sinceapersonwithdiabetescanhaveretinopathyandnotknowit,aregularcheckupwithanophthalmologistcandetectretinopathyearlyandpossiblypreventblindness.

Health care team education is vital:

Diabetesisamulti-systemchronicdisease,andisbestmonitoredandmanagedbyhighlyskilledhealthcareprofessionaltrainedwith the latest information on diabetes to help ensure earlydetectionandappropriatetreatmentoftheseriouscomplicationsofthedisease.Ateamapproachtotreatingandmonitoringthisdiseaseservesthebestinterestofthepatient.

Patient education is critical:

Peoplewithdiabetescanreducetheirownriskforcomplicationsiftheyareeducatedabouttheirdisease,learnandpracticetheskills necessary to better control their blood glucose levels,as well as blood pressure and cholesterol levels, and receiveregularcheckups fromtheirhealthcare team.Smokersshouldstop smoking and those who are overweight should developamoderatedietandexercise regimenunder theguidanceofahealthcareprovidertohelpthemachieveahealthyweight.


Dinesh BhargavaANewYou,AestheticPlasticSurgeryCentre,PushpanjaliHealthcare

Aesthetically Speaking :Botox and Blepharoplasty

Dinesh Bhargava

Blepharoplasty: Bleph = eyelids : Plasty= tocorrect

Surgery of the eyelids to correct the agingchangesintheeyelids

Theagingchangesintheeyelidsarenoticeableinthelate30sandearly40sbutarenotofconcernstomanyatthatage.Thepuffinessofthelowereyelidsisthefirsttoattractattentionwhichmaybepresentinsomeinteenageyearsaswell.

With years the upper lid redundancy and thepuffinessofthelowerlidcontinuestoprogresstill such time that theupper lidcomes to restontheupperlashesproducinganundueweightontheupperlidmusclewhichoftenisreportedasearlytirednessintheeveningandespeciallyafterattemptingtoread.Thelowerlidpuffinesscreatesshadowsundertheeyelidscontributingtothetiredappearanceoftheperson.

These changes are will concern some peopleearlyandotherslateintheirlife.ItsrecognitionisafteraLASIKprocedureisintriguinginthatfor thosewhohavebeenwearingglasses foralongtimetheseagingchangesgohiddenbehindtheframesandoncethoseareremovedasuddenchangesthattheywitnessaredisturbing.

Theoperationcalledblepharoplastyisdesignedto correct these and other changes that occurwithagingprocess.

A relatively simple procedure done generallyunder local anesthesia and sedation. In thisthe upper and lower lid excess skin and thepuffiness is removed giving the eyelids ayouthfulappearancewhenthehealingprocessis complete.While the initialprocess isquickthe final results may take several months toevolve. As with any surgery the risks andconcernsneedtobediscussedwiththesurgeonwhowillbeabletosharethesewithyouonyourconsultationandbeabletogivespecificdetailsaboutthesurgicalprocedureyoumayneed.

Notwithstandingthereasonsforwhichpeopleseek the correction this operation can undoseveralyearsofagingforthosewhoelectdoso.

Findoutifthisoperationisforyouandhowyoucanbenefitfromit.

Letushelpyoudiscover‘ANewYou’

About Botox Foralongtimeanattempttoreversetheprocessof aginghadbeenassigned to ‘the face lift’ or‘Rhytidectomy’.Whilesurgeryhasitsplaceanditsindications,theadventofBotoxandthesofttissue fillershaschangedthe landscapeof thepatientrequestingrejuvenation.

Earlychangesofaginginformof ‘crow’sfeet’,the‘frownlines’andthe‘foreheadcreases’thatdistractfromyouthfulappearancecanbeeasily,effectivelyandsafelyaddressedbyBotox.

Botoxisamedicationderivedfromthebacteria‘Clostridium botulinum’. While long knownfor its poisonous properties, botulinum toxininrefinedandcontrolleddosesitisapowerfulmedicine that has been used in variousneurological and spastic disorders. Its use inaesthetic surgery is, however, recent. Sinceits approval by FDA in US about 5 years ago,

it caught on as a number one procedure inplastic surgery, pushing the need for surgicalprocedurestilllaterinlife.

Thebenefitoftheprocedureisthatittakeslessthanhalfanhourtoperform,withnoscarringandminimalrisks.Thereisaroleofadequatepractice and proper technique to produce theappropriateresultofwhichtheconsumermustbeaware.

Aswithanyprocedurethereareriskswiththistreatmentbutthesecanbemitigated


Dr. Manoj BansalSenior Plastic SurgeonPushpanjaliMedicalCentreDelhi

Fracture Penis – A Rare Case

Manoj Bansal

A 42 year old healthy male presented in theemergency room at early hours of morningwithcomplaintsofsomethingsnapping in thepenisfollowedbyswellinganddistortionwhilehavingintercourse.Atthetimeofpresentationpatientwasfullyconsciousandhisvitalswerestable. On local examination he was found tohavehugeswellingofpenis,scrotumandpubicarea.Peniswasdistortedanddeviatedtorightside.Hewasclinicallydiagnosedtobehavingfractureofpenis.

Preparative photograph

Patient was prepared and taken to operatingroom. Patient was catheterized and the urinewas clear indicating that urethra was intact.Deglovingofpenileskinandfasciawasdonebyacircumcoronalincision.Onexplorationtherewas found to be teat of tunica albungrinea ofRtcorporacavernosawithcollectionofclotsinthearea.Allclotswereevacuated,thetearwas

foundtobegoingproximallyuptothebaseofpenisandforcompleteexposureanadditionallinearincisioninthemidlineofventralaspectof penis was given. The tear in the tunicaalbunginea was repaired with absorbablesutureswithsecondlayerofreinforcementwithBuck’s fascia. Incisions were closed in layersandapressuredressingdone.

Operative photographs Post operative period was uneventful urinarycatheterwasremovedafter7daysandsutureswereremovedon10thday.Patientwasadvisedsetz bath and local cream for a week. He wasalsoadvisedtoabstainfromhavingintercourseforsixweeks.

Post Operative Photographs

Review of Literature

Althoughrelativelyuncommon,penilefractureis interesting. According to one estimate, itoccurs once in 1,75,000 hospital admissions.Knowledge to recognize this condition andmanage it properly is important to avoid latesequelae.

The injury typically is a consequence ofexternal trauma to erect penis, causing a tearinthetunicaalbungrineaofoneofthecorpora.Itmayoccurduringintercourse,rollingoverinbedovererectpenisorother forceful injuries.The patient reports bearing a cracking sound,followed by flaccidity. Painful swelling,ecchymosisandpeniledeviationrapidlyoccur.Urethralruptureoccursinperhapsone-thirdofreportedcases.

If adequate facilities are available, peniledeformity and impairment of erections maybe avoided by surgical exploration drainageof hematoma and repair of corpora. Penileshaft should be approached through either acircumferential coronal incision, underminingof theskinproximallyoradirect longitudinalincisionover the injury if the site is localizedeasily.


How to Manage – Difficult Patient Encounters

an Article by:Sharon K. Hull, MD, MPH; Karen Broquet, MD American Academy of Family Physicians

IntroductionAbout 15% patient-physician encounters arerated as “Difficult”. Presence of depressiveor anxiety disorders, more somatic symptomsand greater symptom severity are suggestiveof likelihood of difficult encounters. Notall difficult encounters can be blamed onthe patient side of the interaction. Thephysicians’ attitude about care, fatigue,stress and burnout can create circumstancesin which physicians are responsible for thedifficulties. Language barriers, and crosscultural issues can also make for challengingencounters.

Patient Characteristics/factorsAngry, Defensive, frightened or Resistant

Signs

Clenched fists, furrowed brows, wringing ofthe hands, restricted breathing patterns andwarnings

How to handle

Try to uncover the source of difficulty forthepatientandpayattentiontothewayhis/heremotionsrelatetothemedicalissueathand.

Empathizewiththepatient.

Use reflective statements such as “I canunderstandwhyyoumightfeelthatway”.

A patient in pain waiting for long time maysay “My time is precious”. Don’t be angry,takeadeepbreath,offerasincereapologyandrespond “I canunderstandwhyyouareupsetandappreciateyourwaitingforme”.

Manipulative Patients

Signs

Threatening rage, legal action or suicide,Impulsivebehaviordirectedatobtainingwhattheywant.

It is often difficult to distinguish betweenborderline personality disorders andmanipulativebehavior

How to handle

The key is to be aware of your ownemotions.

Attempt to understand the patient’sexpectations.

Realize that sometimes you have to say“No”

v

v

v

v

v

v

Somatizing Patients

Signs

Thesepatientspresentwithachroniccourseofmultiple vague or exaggerated symptoms andoftensufferfromcomorbidanxiety,depressionandpersonalitydisorders.

They often have “doctor-shopped” and likelyhavehistoryofmultiplediagnostictests.

How to handle

Describe the patient’s diagnosis withcompassion.

Empathizingthatregularlyscheduledvisitswillhelptomitigateanyconcerns.

Effectively manage any comorbidpsychologicalconditionsaswell.

Refrainfromsuggestingthat“itisallinyourhead”.

Grieving PatientsRecognizingtheeffectofgriefonsomepatient’shealth requires familiarity with the normalstagesofgriefandtheculturalcontextinwhichitoccurs.

How to handle

Look for vegetative signs of depressionand maladaptive behaviors that preventprogression through the normal grievingprocessandtreatthem.

Help grieving patients by validating theiremotionalexperience.

Encourage open communication andcautionagainstmajor lifestylechanges tooearlyintheprocess.

frequent fliers

Signs

Frequent fliers may sand out due to the sheerbulk of their medical charts. They may belonely,dependentortooafraidorembarrassedtoaskthequestiontheyreallywantanswered.

How to handle

Indulge with patient to identify theunderlyingreasonsforthefrequentvisits.

Acknowledgethatyounoticethepatternoffrequentvisits.

Showing understanding of the patient’sreasonsoftenwillfosteranopendiscussionofthe“reasonsbehindthereasons”

Contractwithpatientforregularlyscheduledvisits.

v

v

v

v

v

v

v

v

v

v

v

ContributedbyAtul GandotraGM - Marketing and Business Development PushpanjaliHealthcareDelhi


Well-honedpain-managementskillsmayalsocomeinhandyfor patients who schedule frequent appointments due tochronicpain

Physician Characteristics/factorsAngry or Defensive Physicians

Signs

Physicianswhoareburnedout,stressedandgenerallyfrustratedover long termconcerns aremore likely to react negatively topatients

How to handle

Recognizing own trigger issues and knowing what personalbaggage we bring into the examination room/place can bevaluablewaytomanageself, intheprocessavoid,whatcouldhavebeenapossibledifficultpatientencounter.

fatigued or Harried Physician

Signs

Overworked (extremely common situation), sleep deprived,generallybusierthanneeded,overcommitment(commontraitamonghighachievingprofessionals).

How to handle

Itisimportanttobesensitivetotheimpactofphysicianfatigueonmedicalerrorsandpatientsafetyandsetareasonablelimitforself.

Diplomatically bow out of commitments, delegate to othersas appropriate and seek work environments that value settingappropriatelimits.

Dogmatic or Arrogant Physicians

Signs

Eachoneofushasthingswefeelstrongabout.Personalbeliefsand values, as well as beliefs and values about medical care,cansometimesleadtooveremphasizeownbeliefsandemotionsinwaysthatdisempowerpatientsandmaypreventthemfromprovidingwithadequateinformationabouttheircare.

How to handle

Identifyyourtriggerissuesandavoidsituationsinwhichyourbeliefs may inappropriately close off adequate exchange ofinformation that ultimately could emerge as difficult patientencounter.

Situation Characteristics/factorsLanguage and literacy issues

We have a diverse population, accordingly a physicianincreasingly find himself needing to communicate withindividualswhoseprimarylanguageisdifferentfromhisown.Trytoallowextratimefortheseencounters.Whereverpossible,workwithamiddleman.Directyoureyesandspeechtowardthepatientratherthanthesupportperson.Workingacrossculturesrequiressensitivitytodifferentbeliefsabouthealthandillness,religiousissuesandgenderissues.Yourgoalshouldbetoremain“culturallysensitive”andnot“culturallycompetitive”.

Multiple people in the Examination Room

Ahighpercentofadultpatientshaveacompanionpresentalongwith them. In a situation as above consider: Does the patientwanttheotherindividualintheE.Room-forthehistoryandthephysical examination? Is there aneed to talkwith thepatientalone?

v Willthethirdpersonbeinvolvedinhealthcaredecisions,orarethereculturalreasonsforhimorhertobepresent?

WhenthepatientshavecompanionsintheE.Room,besuretospeakdirectlytothepatient,avoidtakingsidesinanyconflict,andevaluateallparties’understandingof the informationandthemanagementplan.

Breaking bad news

When it is necessary to give patients information that will bedifficultforthemtohear,preparationiscritical.

Know who will be present for the discussion, allow adequatetimeandprivacy,andreviewtheclinicalsituation.

Disclosethenewsdirectly,allowingadequateresponsetimeforthepatientsandothersintheroomtoexperiencetheiremotionsandprocesstheinformation.

Aftergivingthenews,discusstheimplications,offeradditionalresources,agreeonnextsteps,summarizethediscussionandbecertaintoarrangeforfollow-up.

Environmentalissues

Physiciansoftenoverlookthefactthattheirsurroundingsmayincreasethelikelihoodofadifficultpatientencounter.

Iftheenvironmentisnoisy,chaoticordoesn’taffordappropriateprivacy,thepatientsarelikelytobeunhappy.

Thesefactorscanoftenbealleviatedwithabitofforethought.

Communicate with care

Being aware of the factors that contribute to difficult clinicalencountersandbeingprepared toaddress themwillgoa longwaytowardpreventingthem.

Goodinterpersonalandcommunicationskillscanmakepositivedifferencetothesesituations.

AttendingtoyourownphysicalandmentalprocessesasyouseepatientsandremainingawareofyourownemotionalbaggageintheE.Roommaydecreasethenumberandintensityofdifficultencountersyouexperience.

Hard fact

No physician can avoid the difficult clinical encounters, buthaving the tools todealwith these situationswhen theyarisecanmakeabetterexperienceforbothyouandyourpatients.

invites case studies, original, and review articles on

different specialtiesPlease sumit your contributions by email

[email protected], [email protected]

orby post at the address given below

A-14, Pushpanjali, Vikas Marg Extn.,Delhi-110092

Ph: 22162818, 42427641, 22372852-58 Extn. 1602Fax no. 011-22372851


Sanjay SoodENT ConsultantWaliaNusingHomeDelhi

Allergic Rhinitis : Current Concepts in Diagnosis and Management

Sanjay Sood

The word “allergy” means an altered reactivity of the body to otherwise harmless environmental substances.

The allergies such as Hay fever and Allergic Rhinitis are considered to be a trivial and inconsequential disease. Symptoms such as running nose, itchy eyes and nose, with sneezing and blockage are obviously not life threatening, but affect a large volume of the population and are the cause of significant disability and cost to society.

Allergic rhinitis, the most prevalent chroniccondition affects 40-50 million peopleworldwide. It is the commonest allergyencounteredinclinicalpracticeandconstitutesmorethan50%ofallallergiesseeninIndia.Aroughestimatesaysthat1in6peoplesufferfromrhinitisandtheincidenceissteadilyincreasing.Theeffectofnasalsymptomsofallergicrhintison quality of life justifies the aggressive andrational approach in the treatment. Allergicrhinitisandasthmafrequentlycoexistandthatadeqatenasaltreatmentimprovesthepulmonaryfunctions,isalsoawellknownfact.

Theconceptof“allergy”wasintroducedbytheViennese pediatrician Clemens von Pirquet in1906afternotingthatsomeofhispatientswerehypersensitive to normally innocuous entitiessuch as dust, pollen, or certain foods. Pirquetcalled this phenomenon “allergy”, from theGreek words allos meaning “other” and ergonmeaning“work”.

Historically,all formsofhypersensitivitywereclassifiedasallergies,andwereallthoughttobecausedbyanimproperactivationoftheimmunesystem. Later, it became clear that severaldifferentdiseasemechanismswereimplicated,with the common link between these varyinghypersensitivitiesbeingadisorderedactivationoftheimmunesysteminonewayoranother.AnewclassificationschemewasdesignedbyDrPhilipGellandDrRobinCoombstoreflectwhatwere then renamed hypersensitivity reactions.The word “allergy” was then restricted totype I hypersensitivities, which were rapidlydevelopingreactions.

A major breakthrough was the discovery ofthe antibody class labeled immunoglobulinE (IgE) - Kimishige Ishizaka and co-workerswerethefirsttoisolateanddescribeIgEinthe1960s.Systemicallergicresponseisalsocalledanaphylaxis; multiple systems can be affectedincluding thedigestivesystem, the respiratorysystem,andthecirculatorysystem.Dependingon the rateof severity, it cancausecutaneous

reactions, bronchoconstriction, edema,hypotension,comaandevendeath.Thistypeofreactioncanbetriggeredsuddenlyortheonsetcanbedelayed.

Allergicrhinitisinvolvesreactionsinthenasalmucosa from repeated allergen exposures thatcause hypersensitivity. These reactions maybe seasonal or perennial. Allergic rhinitis isclinically defined as a symptomatic disorderof the nose induced by an IgE-mediatedinflammation after allergen exposure of themembranesofthenose.

Etiology:TheexactcauseoftheIgEmalfunctionsthat result in allergic reactions arenot alwaysapparent, but genetic-basis, environmental-basis and intermediate proponents exist withvaryingvalidityandacceptance.

Genetic basis: There is a lot of evidence tosupport the genetic basis of allergy. Allergicparentsaremorelikelytohaveallergicchildren,andtheirallergiesarelikelytobestrongerthanthosefromnon-allergicparents.Itseemsthatthelikelihood of developing allergies is inheritedbutnottoaspecificallergen.

Relationship with parasites:Ithasbeenshownthatcommonparasites,suchasintestinalworms(e.g. hookworms), secrete immunosuppressantchemicalsintothegutwallandhenceintothebloodstream, which prevents the body fromattacking the parasite. This gives rise to the“hygienehypothesis”thatco-evolutionofmanandparasiteshasledtoanimmunesystemthatonlyfunctionscorrectlyinthepresenceoftheparasites. Without them, the immune systembecomesunbalancedandoversensitive.

Increasing use of chemicals: The air qualityis getting worse, indoor as well as outdoor.Adverse reactions to toxins vary considerablyfrom one person to another and cause allergysymptoms. In 2004, a joint Swedish-Danishresearch team found an association betweenallergic symptoms in children and exposureto household dust containing the phthalatesDEHP and BBzP, commonly used in PVCproduction.

It is hypothesized that use of antibiotics andvaccinationaffectstheimmunesystem,andthatallergiesareadysfunctionalimmuneresponse.

PathophysiologyThepathophysiologyof allergic responses canbedividedintotwophases;theacuteresponse,whichcantheneithersubsideorprogressintoa“latephaseresponse”.


Theallergyreactioninthenoseinvolvesacomplexinteractionbetween various inhalant allergens and immune cells. A typeI hypersensitivity reaction against an allergen via the normalhumoral response against a foreign body results after plasmacellssecreteIgEasopposedtootherimmunoglobulinssuchasIgMor IgG. IgEbindstoreceptorsonthesurfaceofmastcellsand basophils, involved in the acute inflammatory responseAn allergen will link to specific IgE antibodies on mast cellsresultingindegranulation.Thesegranulesreleasehistamineandotherinflammatorychemicalmediators(cytokines,interleukins,leukotrienes, and prostaglandins) into the surrounding tissuecausing several systemic effects, such as vasodilation causingswelling and nasal obstruction., mucous secretion, nervestimulation and smooth muscle contraction. This results insymptoms of rhinorrhea, itchiness, dyspnea, and anaphylaxis.

This is termed as the Immediate Allergic Reaction. Otherchemicals released by mast cells include tryptase, kinase andother enzymes. It also has a reflex effect via sensory nervescausingsneezing,itchingandfurthermucusproduction.

Subsequent nasal symptoms that develop between 3 and 12hours after the initial allergen exposure are due to the LatePhaseReaction.Thisisduetothemigrationofleukocytessuchas neutrophils, lymphocytes, eosinophils and macrophages totheinitialsite.Thereactionisusuallyseen4-6hoursaftertheoriginal reaction and can last from 1-2 days. Cytokines frommastcellsmayalsoplayarole inthepersistenceof long-termeffects. Further immune mediator production occurs in thealreadyinflamednasalmembranesandbloodcells(eosinophilsandbasophils)infiltratecausingprogressivenasalblockageandswelling.

Pollens in India vary according to the region and their seasonality. Some major pollen allergens reported in different regions of India are mentioned below (check seasonality and look for pollen forecast).

Common Allergen SourcesGroup Examples Seasonality Air-bornePollensDelhi&Jaipur Helianthus,Amaranthus,Cassia,Cenchrus,Morus,ImperataCynodon, Seasonal Holoptelia,Prospis(Shivpurietal)Bhopal Argemone,Cannabis,Brassica SeasonalKolkata Lantana,Cucurbita,Cassia,Cocosnucifera(Chandaetal) SeasonalAndhraPradesh Cassia,Ageratum,Ricinus,Salvadora SeasonalBangalore Parthenium,Artemisia,Albizia(Agashe) SeasonalMoulds Aspergillusspp.,Cladosporiumspp.,Alternariaspp.,basidiospores, Perennial AscomycetesCerealflours Wheat,rye,oat PerennialPlantproducts Latex,papain PerennialAnimaldander Cat,dog,horse,rabbit,guineapig,mouse,rat,cow PerennialBirdfeathers Parrot,pigeon,duck,chicken PerennialHousedustmite Dermatophagoidesfarinae, PerennialInsects Cockroach,fly Seasonal

Oral Foods Seafood,legumes,peanuts,treenuts,Non-seasonalsesame, Non-seasonal

soya,cereals,dairyproducts,eggs,fruits,tomatoes,mushrooms, alcoholicbeverages,coffee,chocolate

Drugs Penicillins,sulfonamidesandotherantibiotics,sulfasalazine, Non-seasonal carbamazepine

InjectedInsects Beeandwaspstings,antandmosquitobites SummerDrugs Bloodproducts,sera,vaccines,contrastmedia,drugs Non-seasonal

(includinganti-asthmadrugsandantibiotics)

Formoredetailsonpollenaerobiology,referto:SinghABandMalikP.Pollenaerobiologyandallergy.IndJAerobiology1992:5(1-2)

Mechanism of allergic reaction

Initial Allergen contact Stimulates Antibody formation

Antibodies attach to mast cells and basophils

Subsequent Allergen contact

Allergen + antibody reaction

Degranulation of mast cells

Physiologic effects Allergy

Immunologic Mechanisms Involved in Allergic Disease

Adapted from Slide Atlas of Allergy, Holgate ST, Church MK; 1993

sensitization

allergensource

allergenleaching

environment

T helpercell

Bcell

help

submucosa

IgE

provocation

allergenleaching

allergensource

Fc epsilonreceptor

mediators

IgE bindinginflammatory cell

clinical effects,e.g. asthma,hayfevereczema

MHCclass II protein

and epitope

antigenpresenting cell


SYMPTOMS Of ALLERGIC RHINITISFigure 2: Clinical assessment and classification of rhinitis

History •nasaldischarge 2ormore •blockage symptomsfor>1hr •sneeze/itch onmostdays

“sneezersandrunners” “blockers”

sneezing especiallyparoxysmal littleornonerhinorhea watery thickmucus anteriorandposterior moreposterioritching yes nonasalblockage variable oftenseverediurnalrhythm worseduringday constant,day improvingatnight andnight,may beworseatnightconjunctivitis oftenpresent

Lund, V.I et al., International Concerns Peporton the Diagnosis and Management of Rhinitis. International Rhinitis ManagementWorkingGroup.Allergy1994:49(Suppl19:134.

Allergic rhinitis may be either seasonal or perennial:Seasonal allergic rhinitis known as “Hay fever”: Tree andgrass pollens and some fungi trigger seasonal allergic rhino-conjunctivitis (nose and eye allergy) during springtime andearlysummer.Thesepeopledonotdevelopthetypical“allergyface”buthaveseasonalpuffinessof theeyesandeyelidswithassociatednasalmembraneswelling.

Perennialallergicrhinitisora“permanentcold”:Allergenssuchashouse-dustmitedroppings,catanddogdandruff,horsehair,and cockroach droppings result in perennial allergic rhinitiswithsymptomsallyearround.

In 1999, the World Health Organisation introduced a newclassification for Allergic Rhinitis at the initiative of AllergicRhinitisanditsImpactonAsthmagroup(ARIAguidelines).Thepurposewas to tryandcreate similar treatmentguidelines forasthma and allergic rhinitis which often co-exist in the samepatient (80% of asthma sufferers have concomitant allergicrhinitis). ARIA introduced the terms Intermittent AllergicRhinitis and Persistent Allergic Rhinitis. Intermittent wouldreplace the Seasonal (Hay fever) type disease and Persistentwould replace Perennial Rhinitis (but some overlap does takeplace).Thesetwogroupsarethenfurthersub-dividedintoMild

and Moderate/Severe symptoms and treated according to thenewguidelines.

Aims of ARIA:

1. toupdateclinicians’knowledgeofallergicrhinitis

2. tohighlighttheimpactofallergicrhinitisonasthma

3. to provide an evidence-based approach to diagnosis andtreatment

1. to provide a stepwise approach to the management of thedisease.

Signs and symptoms

Nose: Nasal blockage – intermittent, alternating unilateralblockage,

Sneezing–oftenparoxysmal,

Rhinorrhoea – can be anterior resulting in persistent sniffingand nose-blowing, or posterior resulting in a postnasal dripHeadaches–oftenwithoutsinusitis

Eyes: redness and itching of the conjunctiva (allergicconjunctivitis),epiphora,,swellingofeyelids,

Airways: Sneezing, bronchoconstriction, wheezing anddyspnea,

ARIA CLASSIFICATION: Based on both severity & ARIA CLASSIFICATION: Based on both severity & duration of symptomsduration of symptoms

Intermittentsymptoms

• <4 days per week• or <4 weeks

Persistentsymptoms

• >4 days/week• and >4 weeks

Mild• normal sleep

• normal daily activities,sport, leisure

• normal work and school• no troublesome

symptoms

Moderate-Severeone or more items• abnormal sleep

• impairment of dailyactivities, sport, leisure

• problems caused at workor school

• troublesome symptoms

J. Bousquet, Allergy 2002: 57: 841–855

ALLERGIC RHINITIS: COMORBIDITIESALLERGIC RHINITIS: COMORBIDITIES


Ears:feelingoffullness,possiblypain,andimpairedhearingduetoEustachiantubedysfunction,

Skin:variousrashes,eczemaandhives(urticaria),

Others:Reducedsmellortaste,

SleepdisturbanceandImpairedcognition.

Chronic Allergic Rhinitis sufferers often have typical facialfeatures called the “allergy face”. Nasal blockage and sinuscongestionpredispose to thebluishdiscolorationof the lowereyelidscalled“allergicshiners”,thecharacteristiclinearcreasesundertheeyelidarereferredtoas“Denneslines”.Constantnasalrubbingtypifiesthe“allergicsalute”andresultsinaprominent“nasalcrease”acrossthenose.Continuousnasalblockagecauses“nasal”speechandmouthbreathingwithdisturbedsleep.Thisresults in a high arched palate and the “long face syndrome”withdentalcrowdingandmalocclusion(“Buckteeth”).

Diagnosis: Diagnosis is based on history, clinical examinationandinvestigations

Leukocyte count:DLC–Increasedeosinophils

Cytology of nasal secretions: NasalmucussampleistestedforpresenceofeosinophilsusingHansel’sStain.

Radiology: Radiological examination (sinus x-rays and CTscanning)doesnothelpinthediagnosisofallergicrhinitis,butwillidentifycomplicationssuchaschronicsinusitis,infections,nasalpolypsandsinusfluidlevels.

Nasalendoscopy:Fibre-opticnasalendoscopiestovisualizethenasalmembranes,septumandosteo-meatalcomplexofthenasalsinuses.

Specific Allergy Work Up

Aim –toestablishthediagnosis

--toconfirmthecausativeallergens

--toascertainthedegreeofallergencityinacase

In vitro tests:

Total IgE estimation – has limitation in tropical countries dueto high prevalence of the parasitic infestations. Methods usedare Radioimmunoassay (RIA), Paper Radio Immunsorbenttechniques(PRIST)ELISAandChemiluminiscence

Specific IgE Estimation Radio Allergo Sorbent Technique(RAST).

EstimationofAllergen specific IgE in the serumof apatient -Onesampleofserumtestsseveralallergens

Limitations

1. SerummustcontainsignificantquantityofthespecificIgE,

2. Allergen must be adequately potent with the antigenprotein,

3. Serum must not contain large quantity of blockingantibodies.

4.Expensivetestnotaroutinetest.

In vivo tests:

Provocationtests–simulatenaturalallergen-antibodyreaction

Nasalchallengetests–Buffersalinebasedallergensareappliedto thenasalmucosa inserially increasingconcentrationsuntilsymptomsofsneezing,rhinorrheaandobstructionappear.

Skintestsforallergy–maintoolforallergydiagnosis

Patchtests–basedondelayedtypeIVreaction

SkintestsfortypeIallergy:

Scratchtests–CharlesBlackley

Skinpricktests–LewisandGrant(1926)andJackPeppy(1970)

Intradermaltests

Skinendpointtitrationtests

Prausnitz-Kustnertests

Aim:Tointroduceanappropriateamountofallergenicmaterialbeneath the stratum corneum epidermis so that it comes incontactwithspecificIgEantibodyboundtomastcells

Advantages:

1. Establishes whether an antigen tested is the causativeallergenornot

2. Doesnotprecipitateactualattackofsymptoms

3. Reliable, safe, convenient and able to assess sensitivity tomanyantigensatasingletesting.

4. OPDprocedureandeconomicalascomparedtoRAST.

Skin Prick /Puncture tests

1. Confirmhypersensitivitytovariedallergens

2. MostconvenientandspecificscreeningmethodfordetectingIgEantibodies

3. Lesssensitivebutmorespecificthanintracutaneoustests

Intra-cutaneous tests

1. Oftenpositiveinabsenceofclinicallysignificantallergy

2. Donewhenprick/puncturetestisnegativetoallergensthatarestronglysuggestedbypatient’shistoryorexposure

Epicutaneous (Patch) tests

1. To determine the causative agent in contact eczematousdermatitis.

2. Approximately 20 to 30 antigens used in the routinescreeningpanelofpatchtestsidentifiesthecausativeagentin50%to70%ofthecases.

Treatment: In Perennial Allergic Rhinitis, treatment shouldbe taken continuously, whilst in Seasonal Allergic Rhinitistreatmentonlyneedstobetakenforsymptomcontrolduringthepeakpollenseason.

Allergen avoidance: Treatment and management of allergiesrevolves around avoiding the allergen or otherwise reducingexposure toallegernbut itmaynotbepossible for thosewithpollenorsimilarair-borneallergies.Itmaybeeasyforpatientstoavoidallergen,ifonly1-2allergenshavebeenidentifiedandif thesensitivity ismild.However,mostpatientssuffer fromacombinationofallergensensitivities.Ifaspecifictriggercannotbeavoided(dustandmoldaregoodexamples),managementoftheenvironmentmustbeconsidered.Someofthemeasuresare:

• Encasingallmattresses,pillows,andboxspringsinallergen(mite)-impermeablecovers;

• Washingallbeddingandstuffed toys inhotwater at leastonceaweek;

• Removing animals (pets and stuffed) and carpets frombedrooms;

• Minimizingupholsteredfurniture;

• Usingair-conditioning;

• Using HEPA (high-efficiency particulate air) filters inbedroom;


• Dryingclothesinventeddryers--notoutside;

• Stay indoors during the midday and afternoon when thepollencountishigh;

• Avoidsourcesofmould(wetleavesandgardendebris);

• Usecockroachtraps,insecticidesprays;

• Removeallindoorplants;

• Useofvacuumcleanerespeciallywithafilter;

• Carefulassessmentoftheworkplaceisessential;

• Theuseoffacemasknearchemicalsandpaints;

• Thepresenceoftobaccosmoketobeavoided.

Pharmacologic treatment: Many patients need medicationin addition to allergen avoidance and environmental controlmethods.

Antihistamines:Antihistaminesarethemainstayoftreatmentinseasonalallergicrhinitis.Theycontrolnasal itching,sneezing,runnynoseanditchyeyes.Thereare2generationsofavailableantihistamines.

The first-generation agentscausesedation.However,theyremainhighly effective in symptomatic treatment, chlorpheniramine(Piriton).

The second-generation antihistamines are favored by ARIAfor their efficacy/safety ratio and rapid onset of relief. Theseantihistamines are not very effective against nasal congestion.The newer non-sedating antihistamines are Loratadine,desloratadine, fexofenadine, Mizolastine and cetirizine , orlevocetirizine.

Localantihistaminenasalspraysuchasazelastineandvariousocularantihistaminesarealsoeffectiveforsymptomcontrolofnasalandocularitching.Theyhavenoeffectonnasalblockageandhaveanunpleasanttaste.

Intranasal corticosteroids:Steroidspraysapplieddirectlytothenasalmembraneshaverevolutionized the treatmentofallergicrhinitis - particularly the chronic perennial type. Intranasalcorticosteroidsarethemosteffectiveagentsforthemanagementof allergic rhinitis because of their direct reduction of nasalinflammationandtheirabilitytoreducenasalhyperreactivity.All agents are safe touse forprolongedperiodsof timeat therecommendeddosagesandimprovesthepatient’squalityoflifeifthepatientusesthemonadailybasis.Manypatientsdonotliketheodorortasteassociatedwithspecificagents.Theyactonvariouscomponentsofthenasalinflammatoryprocess,causingblood vessel contraction, reducing blood vessel leakiness andreducinginflammatorycellnumbers.

Nasal steroids such as Flunisolide (Syntaris), Budesonide(RhinocortAqua)andBeclomethasone(Beconase)areparticularlyuseful for their preventative effects and newer preparationssuch as Fluticasone (Flixonase), Triamcinolone (Nasacort)and Mometasone (Nasonex) can be used effectively on a oncedailybasis.Betamethasone(Betnesol)nosedropsalthoughveryeffective,maybeabsorbedintothecirculationandshouldnotbeusedcontinuously.Oncesymptomcontrolisachieved,thedailydosageshouldbeslowlyreduced.

Intranasal corticosteroids can be used with asthmatic patientsandwiththosewhohavecomorbidnasalpolyposis.Theymaycauselocalnasalirritationandnosebleeds.Theydonotrelievepalateandeyeitch,soantihistaminetabletsmayalsoneededtobeused.Ifsignificantnasalobstructionispresentatcommencementoftreatment,thenpre-treatmentwithadecongestantspraywillbenecessaryforafewdays.

Oral corticosteroids:Thesedrugsreducenasalinflammationandhyperreactivitybuthavepotentiallyserioussideeffectswhenusedoveralongperiod.Ashortcourseoftaperedcorticosteroidsis advisable only for moderate-to-serious exacerbations ofallergic rhinitis. An oral steroid such as Prednisilone hassignificantgeneralizedsideeffectsandshouldthereforeonlybeusedinseverediseaseforshortperiodsof5to14days.Useofinjectionlong-actingsteroids(DepotMedrone,Kenalog)shouldbediscouragedastheycanleadtoosteoporosis,muscledamage,raised blood pressure, diabetes, glaucoma, cataracts, stomachulcerationandchronicinfections.

Mast cell stabilizers:Theseagentsareparticularlyeffectiveinpatients with intermittent allergies, especially when prevalentinonlyoneseasonoftheyear.Theyshouldbestarted3-4weeksbeforeapeakallergyseasonoccurs.Theireffectonthenoseisshort-actingandmakescompliancemoredifficultasseveraldosesareneededperday.Intraocularagentsarealsoveryeffective.

Cromolyn in the form of sodium cromoglicate, has anti-inflammatoryactivityandrelievesnasal itch,sneezing,mucusproduction and congestion particularly in seasonal allergicrhinitis. It is an extremely safe product but must be used 4timesaday,andisveryeffectiveintheeyesfortreatingallergicconjunctivitis.

Olopatadineeyedropsareveryeffectiveforgrasspollen-inducedeye allergies when used twice daily. This eye drop has bothantihistaminic and mast cell stabilising properties and has asimpletwicedailydosage.Olopatadineoralpreparationisusedforallergicrhinitis.

Oral decongestants: These common drugs, widely availablewithout prescription, are very effective in treating nasalcongestion. Oral decongestants such as pseudoephedrinetreat nasal blockage by constricting blood vessels in the nasalmembranes and throughout the body to some degree. Theyhave significant side effects likebloodpressureproblems,drymucusmembranes,causeurineretentionandtriggerglaucoma.Somepatientsexperienceinsomnia,restlessness,headacheandpalpitations.

Intranasal decongestants: Decongestant sprays/drops can beusedinthenoseforreliefofnasalblockageandcongestionbutover-useoftheseephedrinecontainingspraysisassociatedwithrebound nasal congestion and “rhinitis medicamentosa”. ThesafestpreparationsareOxymetazolineandXylometazolinebutcontinuoususeshouldbelimitedto7-10daysatatime.Usedin combination, the decongestant often compensates for thesedativeeffectoftheanti-histaminealthoughthismayresultinthesideeffectofrestlessnessandinsomnia.

Intranasal anticholinergics:Thesedrugsareusedbypatientswithgustatoryrhinitis,astheypreventrhinorrhea.Theyareeffectiveagainst nasal discharge only and have no anti-inflammatoryeffects. Ipratropium bromide, a spray derived from atropine,provides good relief for the profuse watery nasal dischargeincluding non-allergic or “vasomotor” rhinitis. Ipratropium isverysafetouse,withrapidonsetofactivityandminimalsideeffects.Ithasnoeffectonnasalblockage,itchorsneezing.

Antileukotrienes: The leukotriene antagonists Zafirlukast andMontelukast are useful additions in treating allergic rhinitis,especially in aspirin-sensitive people. They have beneficialeffects in treating patients with asthma and co-existentallergic rhinitis as they block the activity of Leukotrienes inthe nasal membranes. ARIA recommends antileukotriene usein combination with other therapies, especially when nasalcongestionisnotamelioratedbyothermodalities.


TREAT IN A STEPWISE APPROACH(adolescentsandadults)

Diagnosisofallergicrhinitis(history±skinpricktestsorserumspecificlgE)

Allergen avoidance

Intermittent symptoms Persistent symptoms mild moderate severe mild moderatesevere

Notinpreferredorder Notinpreferredorder •oralH1–blocker .oralH1blocker •intranasalH1blocker .intranasalH1–blocker •and/ordecongestant .and/ordecongestant .intranasalCS .(chromone)

inpersistentrhinitis reviewthepatient after2-4weeks iffailure:step-upif improved:continue for1month

Immunotherapy: Immunotherapy is indicated in patients whopresentwithanyofthefollowingcharacteristics:

• Insufficientcontrolbypharmacotherapy;

• Insufficientcontrolofsymptoms;

• Non-compliancetoprescribedmedication;

• Undesirablesideeffects;

• Adesiretoavoidlong-termpharmacotherapy.

Immunotherapy, also known as hyposensitization ordesensitization,isatreatmentinwhichthepatientisgraduallyvaccinatedwithprogressivelylargerdosesoftheallergen.Thiscan either reduce the severity or eliminate hypersensitivityaltogether. It relies on the progressive skewing of IgG (“theblocking antibody”) production, as opposed to the excessiveIgEproductionseeninhypersensitivitytypeIcases.Inasense,the person builds up immunity to increasing amounts of theallergen. Studies have demonstrated the long-term efficacyand the preventive effect of immunotherapy in reducing thedevelopment of new allergy. A randomized trial demonstratedthat injection immunotherapy reduces the risk of developingasthma. Allergen immunotherapy is safe and effective forallergicrhinitisandconjunctivitis,allergicformsofasthma,andstinginginsecthypersensitivity.Theconclusionstates:“Allergen

immunotherapyshouldbestronglyconsideredforpatientswithpoorsymptomcontroloradversereactionstomedications”.

A second form of immunotherapy involves the intravenousinjectionofmonoclonalanti-IgEantibodies.ThesebindtofreeandB-cellIgE,signallingsuchsourcesfordestruction.Theydonotbind to IgEalreadybound to theFc receptoronbasophilsandmastcellsasthiswouldstimulatetheallergicinflammatoryresponse.Thefirstagentinthisclassisomalizumab.

Sublingual immunotherapy is an orally-administered therapywhich takes advantage of oral immune tolerance to non-pathogenic antigens. This therapy currently accounts for 40percent of allergy treatment in Europe. In the United States,sublingualimmunotherapyisgainingsupportamongtraditionalallergists and is endorsed by otolarygologists who practiceallergytreatment.

Unprovenorineffectivetreatments:Anexperimentaltreatment,enzyme potentiated desensitization (EPD), has been tried fordecades. EPD uses dilutions of allergen and an enzyme, beta-glucuronidase,towhichT-regulatorylymphocytesaresupposedto respond by favouring desensitization, or down-regulation,rather than sensitization. EPD has also been tried for thetreatment of autoimmune diseases but again is not of proveneffectiveness.

q

qq

qq

q

q

q qq

qq

intranasalCS

reviewthepatientafter2-4weeks

improved

step-downandcontinuetreatmentfor1month

reviewdiagnosisreviewcompliancequeryinfectionsorothercauses

failure

rhinorrheaaddipratropium

increaseintranasalCSdoses

blockageadddecongestant

ororalCS(shortterm)

failure

surgicalreferral

qq

q q

qq

itch/sneezeaddH1blocker

q

q

qq

q

Ifconjunctivitisadd:•oralH1-blocker•orintraocularH1blocker•orintraocularchromone•(orsaline)

considerspecificimmunotherapyincaseofimprovement:stepdown.Incaseofworsening:stepup.


Treatmentofallergicrhinitiswithlacticacidbacteria:

Heat-killedLactobacillusparacaseifortreatmentofperennialallergicrhinitisinducedbyhouse-dustmite;

Lactobacillusrhamnosusininfantswithmoderatetosevereatopicdermatitis;

Long-term consumption of fermented milk containinglactobacillus casei in pre-school children with allergicasthmaand/orrhinitis;

Probiotics are perceived to exert beneficial effects in thepreventionandtreatmentofallergicdiseasesbymodifyingthegutecosystem.

Surgery: Surgery is indicated in select cases of severe nasalblockage due to hypertrophied turbinate and nasal polyps orchronic sinusitis associated with the allergic rhinitis. Varioussurgical procedures used are Antral wash out, Chemo-cauteryand Eletro-cautery, Submucosal diathermy, Turbinectomy,Septoplasty,LaserandCryuosurgeryandFunctionalEndoscopicsinussurgery(FESS)

Other measures: Nasal douching: Normal saline douchingwithatouchofbicarbonateofsodaaddedisausefulnon-drugtreatmentforclearingthenasalpassagesinallergicrhinitis.

Mentholnasalpreparationsalsogive somesymptomreliefwhilesteaminhalationsusingaEucalyptusextractwillhelpdecongestthenasalpassages.

ApplicationofasmallamountofPetroleumJelly(Vaseline)to the lower nasal passages with a cotton bud also helpsrelievesymptoms.

Alternative therapies: In alternative medicine, a number oftreatmentmodalitiesareconsideredeffectivebyitspractitionersin the treatment of allergies, particularly naturopathic, herbalmedicine, homeopathy, traditional Chinese medicine andkinesiology.Thesemodalitiesarefrequentlyofferedastreatmentfor those seeking additional help when mainstream medicinehasfailedtoprovideadequaterelieffromallergy.MostrecentlytheherbButterburwasshowntohavesomebeneficialeffects.

Antioxidants: Vitamin C, Vitamin E, Beta-Carotene, Seleniumand Zinc are included in this category. There is no evidencethattheseproductshaveanybeneficialeffectintreatingallergicrhinitis. N-acetyl cysteine (Solmucol) a mucus reducer withantioxidantactivitymaybeofsomebenefit.

Othermedicationssuchascarbocisteine,whichisusedinCysticFibrosis,isoftenco-prescribedinallergicrhinitis.

Role of dietary restriction: Some people will benefit fromdietary exclusion of common food allergens such as cow’smilk and food additives (benzoate, sulphites, colouring andnitrite)fromtheirdiet.Foodadditivesuchassodiumbenzoate,sulphite, tartrazine and nitrites have been implicated astriggers for chronic non-allergic rhinitis and avoidance maybenefitrhinitissufferers.

Patient education: A comprehensive and individualizededucational program is essential to the treatment of allergicrhinitis.Educationshouldinclude:

Learning about specific triggers and mechanisms foravoidanceandcontrol.

Understandingallthereasonsandoptionsfortreatment.

Learninghowtomanageallergicproblemsathomeandatwork.

Having an emergency-action plan available to familymembers.

v

v

v

v

v

v

v

v

v

v

Stepwise Approach to Long-term TherapyOnce the patient’s symptoms are under control, ARIArecommendsthatmaintenancebebasedonaminimumquantityofmedicationsothatexacerbationscanbeeasilymanaged.Thisstepped approach is similar to the approach used in asthmamanagementandfacilitatespatientunderstandingwhenthereisco-morbiditypresent.

Conclusion

TheARIAguidelinescreateanimportanttoolforthesuccessfultreatment of allergic rhinitis. The conclusions drawn fromthe panel have important implications for decreasing theseverityofasthmaticsymptoms.Ithasrecentlybeenproposedthat the prevention or early treatment of allergic rhinitismay actually help prevent the occurrence of asthma, butmore data are needed. Nurses in advanced practice are ina position to develop and oversee comprehensive allergicrhinitis treatment plans for their patients that will help toclarifythisissue.

References

1. Allergicrhinitisanditsimpactonasthma.ARIAguidelines.z1999.

2. American Academy of Allergy, Asthma, and Immunology.Theallergy report:diseasesof atopicdiathesis.Theallergyreport:volumes1-3,2001.

3. AtlasofAllergy,HolgateST,ChurchMK,1993.

4. Fromer L. Allergy avoidance. Program and abstracts of theAmericanAcademyofFamilyPhysiciansAnnualScientificAssembly; October 13-17, Orlando, Florida. Session 122,2004.

5. Guei-Cheng Peng and Ching-Hsiang Hsu. The efficacy andsafety of heat-killed Lactobacillus paracasei for treatmentof perennial allergic rhinitis induced by house-dust mite.Pediatric Allergy and Immunology, Volume 16, Issue 5, Pp433-438,Aug2005.

6. Lund, V I. et al. International consensus report on thediagnosisandmanagementofRhinitis.InternationalRhinitisManagement Working Group. Allergy, 49 (suppl 19): 1.34,1994.

7. LynchJS.Whatarethenewguidelinesforclassifyingallergicrhinitis? Medscape Advanced Practice Medscape Nurses.2004;6(1).

8. MollerC,DreborgS,FerdousiHA,etal.Pollenimmunotherapyreducesthedevelopmentofasthmainchildrenwithseasonalrhinoconjunctivitis(thePAT-study).JAllergyClinImmunol.2002;109:251-266.

9. Boyle RJ and Tang MLK. The role of probiotics in themanagement of allergic disease. Clinical & ExperimentalAllergy2006:36:5,568–576.

10. Satya Prakash, Jasmine Bhathena. Live bacterial cells asorallydelivered therapeutics.ExpertOpiniononBiologicalTherapy2005:5:10,1281

11. ShaikhWA.AllregiesinIndia:Ananalysisof1619patientsattendinganallergyclinicinBombay,India.IntRev.Allergol.Clin.Immunol.1997;3(2):101-104

12. Shaikh WA. Allergic rhinitis: Current concepts andmangementguidelines.Ind.J.Clin.Pract.1997;7(10):37-44

13. Singh,AB.andMalik,P.Pollenaerobiologyandallergy.Ind.J.Aerobiology,1992:5(1-2).

14. WangMF,LinHC,WangYY,HsuCH.Treatmentofperennialallergic rhinitis with lactic acid bacteria. Pediatr AllergyImmunol2004:15:152–158.©2004BlackwellMunksgaard.


Atul JainSenior Consultant ENTPushpanjaliMedicalCentreandFortisHospital,Noida

Endoscopic Dacryocysto Rhinostomy

Atul Jain

EndoscopicdacryocystorhinostomyorDCRhastraditionally been performed for nasolacrimalduct obstruction via an external approach.Eighty per cent of lacrimal pathways belonganatomicallytothenose.Itisthereforefeasiblethat dacryocystorhinostomy (DCR) may beperformedthroughanendonasalapproach.

HistoryCaldwellin1893wasthefirsttotryendonasalDacryocystorhinostomy. In 1895 he presentedhis experience with the endonasal approach.Duetopaucityofinstrumentstheresultswerenotgood&thetechniquefellintodisrepute.

Toti in 1904 started the external approach. In1989, McDonogh and Meiring described theendoscopic trans nasal DCR. Rice in 1990reported his experience using endoscopicinstrumentstocreatethisneo-ostiumandsincethentherehasbeenquiteabitofliteratureonthesubject.

AnatomyThe lacrimal system consists of superior andinferior puncta, which turn into the superior

and inferior canaliculi, which then join intothecommoncanaliculus.Thisregionisknownas the upper lacrimal system. The commoncanaliculus turns into the nasolacrimal sac,

whichisabout12-15-mmlong,whicheventuallynarrows into the nasolacrimal duct, which isabout18-mmlong,andthateventuallyemptiesintotheinferiormeatus.Thesacandtheductcomprisethelowerlacrimalsystem.Tearsmovefromtheeyeintothenosethroughamechanismcalledthelacrimalpump.Lidmovementcausesthepunctatocloseagainsteachother,pushingtears into the lacrimal sac which contains thelacrimal lake. When the eyes open a negativepressureiscreatedinthelacrimallake,pushingitdownfurtherintothenose.

IndicationsEndoscopic dacryocystorhinostomy (DCR)is indicated for patients with lacrimal sacobstruction or nasolacrimal duct obstruction(NLDO). NLDO is common, and presentingsymptoms include watering of the eye anddacryocystitis (infection). Endoscopic DCR isusuallyconsideredforpatientswhohavebeenrefractory to conventional treatment such aswarmcompresses,massageandprobingofthenasolacrimalduct.IfNLDOisleftuntreated,thesymptomspersistandmaybedistressingforthepatient.

In the patient’s history it is important to notewhether or not the epiphora is unilateral orbilateral, and whether the tearing is constantor intermittent. Unilateral constant tearingwillusuallydirectyou towardsanobstructivephenomenon. The nature of the discharge isalsoimportant:clearorpurulent.

The key for a correct indication is to excludea presaccal stenosis, which is not suitable foran endoscopic procedure. The best method toassessthesiteofobstructionconsistsofprobingthelacrimalpathways.Ifitispossibletopasstheproximalcanaliculi(superiorandinferior)andto enter the superior third of the lacrimal sacthrough the common canaliculus, a presaccalobstruction can be excluded. Fluorescein dyetests(JonesIandII)ordacryocystographies(of

Fig 2. Axial section of Lacrymal system with pumping action of the Orbicularis muscle.

Fig 1. Coronal section of Lacrymal system


any type) are no longer performed. Since dacryocystographiesuseaprobetoapplythecontrast,thereisnofurtherneedforaRadiologicalevaluationiftheprobepasses.

Youcanimagethenasolacrimalsystemusingadacryocystogram.Youcanalsouseadacryoscintigraphywithradiolabeledmaterials,andcertainlyyouwouldnotproceedwithanendoscopiccasewithout performing computed tomography. A CT can be veryuseful to find extrinsic tumors, lacrimal sac mucoceles, showthestateofthesinusesandfinddacryolithsforyou.Theexternalincisionismadejustinferiortothemedialcanthus,takingcaretoavoidtheangularartery.Thelacrimalsacisexposed,andyoudrill through the lacrimal fossa through the frontal process ofthemaxillaryboneuntilyouenterthenasalcavity.Youcanalsocreatemucosalflaps,whichwillkeeptheostiumopen.

The introduction of rigid nasal endoscopes enabled anendoscopicapproach.Inacadaverstudy,Ricedemonstratedthefeasibility of endoscopic intranasal DCR and the first clinicalstudywaspublishedbyMcDonoghandMeiringin1989.“Thesearchforanalternativeto theexternalapproachismotivatedbythedesiretoimprovethisDCRsuccessrateandtoaddotheradvantages,suchasabetteraestheticresultorbettercomplianceby the patient. The endonasal DCR is a one-stage procedurethatpermits correctionof associatedpathology, suchas septaldeviationorchronicparanasalsinusitisthatmaybeacausativefactorinlacrimalobstruction.Sinceanexternalincisionisnotused,thepossibilityofpathologicscarformationand/orinjurytothemedialcanthusisavoided.Furthermore,itpreservesthepumpingmechanismoftheorbicularismuscle.Activeinfectionof the lacrimal system is not a contraindication to intranasalDCR, as it drains mucus or pus into a contaminated nasalcavity.EndoscopicDCR requires special training in theuseofendoscopes,butitcanbeconsideredaroutinesinceendoscopicsinussurgerywasintroduced.ForrevisionDCR,theendoscopicapproach is especially superior to the external approach. Thenormal scarring produced after the external incision makes arevisionprocedureveryuncomfortable,andthe finalaestheticandfunctionalresultsareusuallypoor.Incontrast,endoscopicrevisionDCRisaneasyprocedurewithmainlygoodresults.

ProcedureThesurgery isperformedeitherunderGeneralAnaesthesiaorLocalAnaesthesia.

After infiltrating the mucosa anterior to the attachment of themiddle turbinate with 2% Xylocaine with Adrenaline; a “C”

shaped incision is madeanterior to and above theattachment of the middleturbinate. The mucosa iselevated and the junction ofthe lachrymal bone with theuncinate and the ascendingprocess of the maxilla areidentified.

The lachrymal bone alongwiththeascendingprocessofthemaxillaisnibbledwithabonepunchtoexposethelachrymalsac.

Thesaccanbemadeprominentbypressingthesacareafromoutside or it can be made prominent by passing a lachrymalprobethroughtheinferiororthesuperiorcanaliculi.Anincisionismadeneartheanteriorendofthesacandpurulentmaterialcan be seen to be draining out. The medial wall of the sac isexcised.

Asiliconelachrymalstentmaybepassedthroughthecanaliculiandbroughtoutthroughthenose.Themucosalflapisfashionedtocovertherawarealeavingtheneo-ostiumexposed.

TherearecertaincomplicationstoanexternalDCR.Thereisanexternalscar,whichisavoidedwiththeendoscopicprocedure.

There is also danger ofinjury to the medial canthalstructures,anddamagetothepumpingaction.

There are certain advantagesoftheendoscopicDCR.Thereisnoexternalscar.Itpreservesthe lacrimal pump system.Anyintranasalpathologythatmight have caused failure

of the first procedure can be addressed, including adhesions,enlargedmiddleturbinateandseptal deviation. More of thelacrimalsacispreservedwiththe endoscopic procedure.There is actually only a 1 in40instanceofairregurgitationduring nose blowing notedafter endoscopic procedures,while the incidence ishigherwiththeexternalprocedure.

ConclusionsTheintranasalapproachhasbeenshowntobeasafealternativetotheexternalapproachforendoscopicDCR.Theintroductionofamucosalflaptopartlycoverthelateralwallseemstoprovidequickerhealingand topreventhaematomasof thecheek.TheresultsofintranasalDCRarecomparabletothoseobtainedusingthe external approach, and the cosmetic advantages are clear.In thenear future,moreear,noseand throat surgeonswillbeperformingthissurgery.

References1. M McDonongh and H Meiring, “Endoscopic transnasal

dacryocystorhinostomy”, J. Laryngol. Otol., 103 (1989), pp.585–587.

2. M Bernal Sprekelsen and M Tomás Barberán, “Endoscopicdacriocystorhinostomy. Surgical technique and results”,Laryngoscope,106(1996),pp.187–189.

3. R M Bumsted and L V Lindberg, “Externaldacryocystorhinostomy”,Arch.Otolaryngol.,108(1982),pp.303–307.

4. D L McLachlan, G M Shannon and J C Flanagan, “Resultsof dacryocystorhinostomy: analysis of the reoperations”,OphthalmicSurg.,11(1980),pp.427–430.

5. JokinenK,Karja J.Endonasaldacryocystorhinostomy.ArchOtolaryngol1974;100:41-44.

6. WhittetHB,Shun-ShinGA,AwdryP.Functionalendoscopictransnasaldacryocystorhinostomy.Eye1993;7:545-549.

Fig. 3. Endonasal incision.

Fig. 5. Lacrymal sac

Fig. 6. incision of sac with purulent secretions.

Fig 7. Neo ostium after 8 weeks

Fig. 4. Punching the ascending process of maxilla


Meenakshi Wadhera Audiologist and Speech Language TherapistMeenakshiSpeech&HearingClinic

Meenakshi Wadhera

Significant hearing loss is one of the mostcommon major abnormalities present at birthand,ifundetected,willimpedespeech,language,andcognitivedevelopment.Significantbilateralhearinglossispresentin1to3per1000newborninfantsinthewell-babynurserypopulation,andin2 to4per100 infants in the intensivecareunit population. Ninety percent of childrenwith hearing loss are born to normal-hearingparents.Over50%ofbabiesbornwithhearinglosshavenoknownriskfactorsforhearingloss.Hearing loss is the most frequently occurringbirth defect, occurring more frequently thanall metabolic disorders screened for at birthcombined. In addition, the screening cost perconfirmed diagnosis of hearing loss is far lessthanthecostperconfirmedPKUdiagnosis.

Hearing loss is the inability to detect sound.It is important tounderstandthathearing lossdoesnotnecessarilyequaldeafness.Therearevarying degrees of hearing loss, ranging frommildtoprofound(deaf).

Effects of Hearing ImpairmentHearing impairment (which is an invisiblecondition), not only restricts speech languagedevelopment but also adversely affectseducational,social,intellectual,emotionalandcognitivedevelopment.Achildwhoisidentifiedlatemayneverbeatparwithhishearingpeersintermsofacademicperformance,intellectualdevelopment, or later in the work place. Theseverityoftheselearningdisabilitiesisgenerallyrelatedtothelengthoftimethehearinglossisleftuntreated.Hence,withhearingimpairmenta “wait and watch” attitude hoping that thechild “will growoutof it” cannotbe adopted.Toreducethenegativeeffectsofhearingloss,itisimportanttoidentifyhearingimpairmentandbeginamplificationandhabilitationasearlyaspossible.

Benefits of Early ScreeningTherationaleforscreeningisbasedonthefactthat early diagnosis, followed by interventionwill either prevent or diminish the severityof the disability. There is general agreementthat early identification and interventionensures better parent-child bonding, and hasa greater potential for normal/near normalspeechlanguageandsocialdevelopment.Thus,intervention enhances the potential of mosthearing impaired children to become adultswho are fully independent, participating andcontributingmembersofsociety.

Several national committees, including theNational Institutes of Health, the AmericanAcademy of Otolaryngology/Head and NeckSurgery,andtheAmericanAcademyofPediatrics,haverecommendedthathearinglossininfantsbeidentified,andwhenpossibletreated,priortosixmonthsofage.Thisrecommendationisbasedonstudiesthathaveshownthatchildrenidentifiedwithhearinglosspriortosixmonthsofagehaveabetterchanceofdevelopingskillsequivalenttotheirpeersbythetimetheyenterkindergarten.Childrennotidentifieduntillater(forexample,itisverycommontofirstidentifyhearingimpairedchildrenatage2to3years)mayultimatelysufferfromirreversibleandpermanentimpairmentsinspeech, language,andcognitiveabilitieswhencomparedtotheirpeers.

Importance of Universal Neonatal Hearing Screening Screeningprogramsforhearingimpairmentmaybe either “universal” or “highrisk” populationbased.Highriskmeansthosenewbornswhohadknownsignificantriskfactorsforhearingloss.Thisgroupincludesinfantswiththefollowingconditions:

Familyhistoryofchildhoodhearingloss

Parentalorcaregiverconcern

Acongenitalinfection,suchasCMV

Asyndromeassociatedwithpermanentorprogressivehearingloss.

Craniofacial anomalies, including thosewithanomaliesofthepinnaandearcanal

Chronicmiddleearproblems

Birthweightoflessthan1500grams

Severe hyperbilirubinemia requiringexchangetransfusion

Exposuretoototoxicmedications

Bacterialmeningitis

APGARscoresof0-4at1minuteor0-6at5minutes

Mechanical ventilation for greater than 5days

AstayinaNICUforlongerthan48hours

Headtrauma

However,despitethetestingofallinfantswhofall into this “high risk registry,” over half ofallnewbornswithhearing lossaremissed!Soinorder to identify this largegroupofhearingimpaired infants not identified with high riskprotocols, it becomes very important that allnewbornshaveahearingtest.Thegoalofthisprogram is to identify all hearing impairedinfants at an early age i.e shortly after birth.

v

v

v

v

v

v

v

v

v

v

v

v

v

v

Early Hearing Loss:Detection and Intervention


References1. Northern JL, Downs MP. Hearing in Children. 3rd ed.

Baltimore,MD:Williams&Wilkins;1984:892. Yoshinaga-ItanoC,SedeyAL,CoulterDK,MehlAL.Language

of early and later-identified children with hearing loss.Pediatrics.1998;102:1161–1171

3. RobinshawHM.EarlyinterventionforhearingimpairmentBrJAudiol.1995;29:315–334

4. Robinshaw HM. The pattern of development from non-communicative behavior to language by hearing-impairedinfants.BrJAudiol.1996;30:177–198

5. AAP, Joint Committee on Infant Hearing 1994 positionstatement.Pediatrics.1995;95:152–156.

Priortodischarge,eachnewbornhashis/herhearingtested.If,forsomereason,thenewborndoesnotpassthescreen,are-screenisusuallydone.Iftheinfantstilldoesnotpassthesecondhearingtest,he/sheisreferredtoaspecialistforfurthertesting.

Screening Tools for HearingHearing in infants can be tested using two different methods;theauditorybrainstemresponse(ABR/BERA)evaluations,ortheotoacoustic emission (OAE) measures. Both tests are accurate,non-invasive,anddonotrequireanyobservableresponsefromthe infant. For a screening tool, both methods are extremelyeffective.

Otoacoustic emissions (OAE): Otoacoustic Emissions (OAE)can identify infants with hearing loss of approximately >30dBnHL.This techniquemeasures sounds in theearcanal thataregeneratedandemittedbytheouterhaircellsofthecochleainhealthyearsinresponsetoacousticstimuli.Thetestisperformedbyplacingasmallprobethatcontainsamicrophoneandspeakerinto the infant’s ear. As the infant rests quietly, sounds aregeneratedintheprobeandresponsesthatcomebackfromthecochleaarerecordedwiththemicrophoneprobe.Ifthereisanemission present for those sounds that are critical to speechcomprehension,thentheinfanthas“passed”thehearingscreen.

Auditorybrainstemresponse(ABR):AnABRisaphysiologicalmeasureofthebrainstem’sresponsetosound.Itteststheintegrityofthehearingsystemfromtheeartothebrainstem.Thetestisperformedbyplacingfourtofiveelectrodesontheinfant’shead,afterwhichavarietyofsoundsispresentedtotheinfantthroughsmallearphones.Asthehearingnervefires,thesoundstimulustravelstothebrain.Thiselectricalactivitygeneratedbythenervecanberecordedbytheelectrodesandisrepresentedaswaveformsonacomputerscreen.Theaudiologistcanthenpresentdifferentloudnesslevelsofeachsoundanddeterminethesoftestlevelsatwhichtheinfantcanhear.Theclickistypicallypresentedataloudlevelandasoftone.Ifahealthyresponseisrecorded,thentheinfanthas“passed”thehearingscreen.

TheOAEiseasyandmorecosteffective.Thetwotests,however,relyondifferentmechanismsofhearingforthescreening.Forin-depthtestingandacompletehearingevaluationofinfants,thesetestsworkbesttogetherasacomplementtoeachother.

Anewbornwhofailsaninitialhearingscreenmaynotnecessarilyhaveapermanenthearinglossorahearinglossatall.Therearemanypossiblereasonswhyaninfantmayfailahearingscreeningtestlike:

fluidfromthebirthmaystillbepresentintheearcanal.

fluidinthemiddleear

excessivenoiseormovementfromtheinfantduringthetest.

Ifaninfantdoesnotpassthescreeningtest,thenafulldiagnostictest will be necessary to determine the type and amount ofhearingloss.

Intervention of Hearing Loss in Infants Theabilityofaninfanttocompensateforthehearinglosswilldependonboththetypeandthedegreeofhearingloss.Thetypeofhearinglossreferstowhereintheearthehearinglossislocatedandwhatiscausingit.Therearetwobasictypesofhearingloss,conductiveandsensorineural.

Aconductivelossiscausedbyproblemsintheouterormiddleear.Thisisthetypeoflossthatresultswhenachildhasamiddleearinfection,trappedfluidfrombirth,orimpactedwaxintheouterear.Itisusuallycorrectablewithmedicaltreatmentorsurgery.

v

v

v

Occasionally, (due to the age factor) a conductive loss cannotbecorrectedwithsurgery.However,thesechildrentypicallydoextremelywellwithhearingaids.

Asensorineurallossisindicativeofaproblemintheinnerearorsomewherealongthenervetotheear(auditorynerve).Thistypeoflossistypicallypermanentandcannotbecorrectedwithsurgery.Ahearingaidoracochlearimplantmaybeutilizedinthissituation.

Hearingaidsareinstrumentsthatmakesoundslouder.Theyareworninorbehindtheearandcomeinseveraldifferentshapesandsizes.Hearingaidscanbeusedforvaryingdegreesofhearingloss,moderateorsevere.Anaudiologistwillfitahearingaidthatwillworkbestforthechild’shearingloss.

Cochlearimplantsareelectronicdevicesthatrestorepartialhearing to thedeaf. It is surgically implanted in the innerearandactivatedbyadevicewornoutsidetheear.Unlikeahearingaid,itdoesnotmakesoundlouderorclearer.Instead,thedevicebypassesdamagedpartsoftheauditorysystemanddirectlystimulatesthenerveofhearing,allowingindividualswho are profoundly hearing impaired to receive sound. Amicrophone is also worn outside the body as a headpiecebehind the ear to capture incoming sound. The speechprocessor translates the sound into distinctive electricalsignals.These‘codes’travelupathincabletotheheadpieceandare transmittedacross the skinvia radiowaves to theimplantedelectrodesinthecochlea.Theelectrodes’signalsstimulatetheauditorynervefiberstosendinformationtothebrainwhereitisinterpretedasmeaningfulsound.

In addition to the early medical or surgical treatment of thehearingloss,parentalinvolvementisessential.Parentsneedtomonitor the child’s progress and facilitate and encourage theuseofthehearingaidsandothertherapeuticexercisesthataredesignedtohelpthechildbecomeacarefullistenerandtalker.Researchhas foundthat theonecommondenominatoramongsuccessfulhearingimpairedchildrenistheparent’swillingnesstohelpthechildthroughouthis/herlifetime.

ConclusionLeftundetected,hearingimpairmentsininfantscannegativelyimpactspeechandlanguageacquisition,academicachievement,and social and emotional development. If detected, however,thesenegativeimpactscanbediminishedandeveneliminatedthroughearlyintervention.Thedynamicchangesintechnologyandeducationmaysoonmakeinfanthearingscreeningprogramsviableinourcountry.

Successfulhearingscreeningprogramsinvolvecommitmentandsupport from Pediatricians, Health Care Administrators, ENTSurgeons,Physicians,Audiologists,familiesandcaregiversandacommunityeducatedabouttheimportanceoftherelationshipbetweenhearingandinfantdevelopment.

v

v


Cochlear implants, due to their technologicaladvances, have emerged as a boon and awonderful working solution to the millionsof profoundly hearing impaired children andadultsallovertheworld.

Cochlear Implants are the first true bionicsenseorgans.Thehumancochlea is, ineffect,anelectromechanicaltransducer.Similarly,thecochlear implants, like the human hair cell,also receives mechanical sound energy andconverts it intoa seriesofelectrical impulses.Therefore,cochlearimplantsareverydifferentfrom hearing aids, which only amplify themechanicalsoundwaves.

What is hearing impairment?External or middle ear pathology affects theconductive component of hearing whichusually can be corrected by medicines orroutinesurgery.

Whatismorechallengingisseveretoprofoundsensori neural hearing impairment or nervedeafness which usually is not benefited byhearing aids. This is because the hair cells ofthecochleaaredamaged,theydonotfunctionand the hearing of the patient becomesimpaired. Intact auditory nerve fibres capableof transmitting electrical impulses to thebrain become unresponsive because of haircelldamage.Acochlear implantmakesuseofthis intact auditory pathway by bypassing thedamagedhaircellsofthecochlea.

Acochlearimplantisasmall,complexelectronicdevicethatconsistsofanexternalportionthatsitsbehindtheearandasecondportionthatissurgicallyplacedundertheskin(seefigure1).Animplanthasthefollowingparts:

1. Amicrophone,whichpicksupsoundfromtheenvironment.

2. A speech processor, which selectsand arranges sounds picked up by themicrophone.

3. Atransmitterandreceiver/stimulator,whichreceive signals from the speech processorandconvertthemintoelectricimpulses.

4. An electrode array, which is a group ofelectrodes that collects the impulses fromthestimulatorandsends themtodifferentregionsoftheauditorynerve.

An implant does not restore normal hearing.Instead, it can give a deaf person a usefulrepresentation of sounds in the environmentandhelphimorhertounderstandspeech.

How does a cochlear implant work?A cochlear implant is very different from ahearing aid. Hearing aids amplify sounds, sotheymaybedetectedbydamagedears.Cochlearimplants bypass damaged portions of the earanddirectlystimulatetheintactauditorynerve.Signals generated by the implant are sent bywayof theauditorynerve to thebrain,whichrecognizesthesignalsassound.Hearingthrougha cochlear implant is different from normalhearing and takes time to learn or relearn.However, it allows many people to recognizewarning signals, understand other sounds inthe environment, and enjoy a conversation inpersonorbytelephone.

Candidates for a cochlear implantChildrenandadultswhoareseverelyhard-of-hearingcanbeconsideredforcochlearimplantsurgery.Adultswhohavelostallormostoftheirhearing later in life due to meningitis or viralinfections can benefit from cochlear implants.They learn toassociate thesignalprovidedbyanimplantwithsoundstheyremember.Thesesoundsprovidetherecipientswiththeabilitytounderstandspeechsolelyby listening throughtheimplant,withoutrequiringanyvisualcuessuch as those provided by lip reading or signlanguage.

Cochlearimplants,coupledwithintensivepost-implantationtherapy,canhelpyoungprofoundlydeafchildrentoacquirespeech,language,andsocialskills.Mostchildrenbetweentwotosixyears of age can be considered for cochlearimplant.Early implantationprovidesexposuretosoundsthatcanbehelpfulduringthecriticalperiodwhenchildrenlearnspeechandlanguageskills. Presently, the newer implants haveproventobesafeeveninchildrenasyoungasninemonthsofage.Implantsaredesignedonlyfor individuals who attain almost no benefitfromahearingaid.

Sharad Kumar MaheshwariSenior Consultant Ear Nose and Throat SurgeonMaxBalajiHospitalDelhi

Vijay RangachariConsultant Ear Nose and Throat SurgeonSuryaHospitalDelhi

Cochlear Implants

Sharad Kumar Maheshwari and Vijay Rangachari


The process of Cochlear Implant surgery and rehabilitation CochlearimplantsurgeryinvolvesadedicatedteamconsistingofanENTsurgeon,anAudiologistandspeechtherapist,aChildpsychologist, Radiologists, Medical and nursing staff and thepatient’sfamily.

Evaluation and planning for a cochlear implantOtological evaluation: The ENT Surgeon examines themiddleandexternal ear to look for congenitalor acquireddeformities or infections in the external ear, ear canal orother abnormalities that can hamper the success of theimplantsurgery.

Audiological evaluation: The audiologist performs aBrainstem Evoked Response Audiometry which is anextensivehearingassessmenttesttodeterminetheintactnessoftheauditorypathways.

Radiologicalevaluation:TheCTand/orMRIscansevaluatethe temporal bone and the cochlea to rule out anatomicalabnormalitiesorsyndromicabnormalities.

ThoroughSystemicExamination:Thisincludesacompletegeneral,cardiovascularandneurologicalexaminationtoruleoutsyndromiccausesofdeafness.

Psychological evaluation: Some patients may need apsychologicalevaluationtolearniftheycancopewiththeimplant.

Counselling: Proper counselling about the extent of post-operative rehabilitationand themotivationandhardworkrequired after the surgery to achieve optimum benefitsshouldbeexplainedtothepatientsandtheparents.

Cochlear Implant SurgeryImplant surgery is performed under general anaesthesia andlasts from two to three hours. An incision is made behindthe ear to open the mastoid bone leading to the middle ear.The implant is embedded in a well made in the cortex ofthe mastoid bone and then through a conduit, the electrodesare taken towards the inner ear and inserted into the cochleathrough a cochleostomy opening made anterosuperior to theround window. After the electrodes are inserted, the positionof the electrodes is confirmed by mapping. Then, the woundisclosed.Usually, theimplantisswitchedonfourweeksafterthesurgery.

v

v

v

v

v

v

Post-surgical implant switch-on and rehabilitationUsually after four weeks, the signal processor, microphone,andimplanttransmitterareplacedoutsidetheearandsettingsareadjusted.Rehabilitation takes severalweeksof speechandaudiologicaltrainingandlotofmotivationisrequiredonthepartofthepatientandparents.

further advancesBilateral cochlear implantation is also a possibility in theappropriatecandidatesthesedaystogivetheadditionalbenefitsof binaural hearing which is always better appreciated by thecortexovermonoauralhearingthroughasingleimplant.

AmorerecentadvanceistheemergenceofAuditorybrainstemimplantswheretheimplantisplacedinthebrainstemdirectlyinpatientswherebothauditorynervesarealsodamagedduetoVestibularNerveSchwannomasurgery.

ConclusionAppropriate selection of candidates, proper counselling aboutthe benefits and shortcomings, understanding and matchingtheexpectationsofthesurgeonandthepatients,post-operativemotivationandrehabilitationandgoodteamworkaretheessentialingredientsofasuccessfulcochlearimplantprogramme.

Fig 2. An Implantee showing the cochlear implant external components in place.

invites case studies, original, and review articles on

different specialties

Please sumit your contributions by email

at

[email protected][email protected]

or

by post at the address given below

A-14, Pushpanjali, Vikas Marg Extn.,Delhi-110092

Ph: 22162818, 42427641, 22372852-58 Extn. 1602Fax no. 011-22372851


Sharda Jain Consultant Gyanecologist,PushpanjaliMedicalCentre

Secretary General DelhiGyanecolgistForum

Uterine Balloon Therapy : A Reason to Smile for DUB Cases

Sharda Jain

“World over it is now discussed that global Endometrial Ablation Techniques should be tried as an alternative to hysterectomies”.

Dysfunctional uterine bleeding (DUB) is acommongynaecologicaldisorder.

Ifaffects1in5women

Onein20womenaged30-49years,consultadoctorwithahistoryofexcessivebleedingandsurgicalintervention.

One in five women in the UK with presenttrends, need a hysterectomy before the ageof60years, and1:3women inUSAwillhavehysterectomy.

It is awellknown fact that inat least50%ofthose who have undergone hysterectomies,menorrhagia is the main presenting problem.Abouthalfofallwomen (50%)whohavehadahysterectomyformenorrhagia,haveanormaluterusremoved!

DUB describes the spectrum of abnormalmenstrualpatternsthatmayoccurinovulatoryandanovulatorywomenwhohavehadnomedicalillnessorpelvicpathology.Anovulatorybleedingcanbemanagedwith“Medicaltreatment”basedon sound physiologic concepts. The goal ofmedicalmanagementofAnovulatoryDUBistoreversetheabnormalitiesofendometrialgrowthand development associated with chronicanovulationandtoinduceandrestorecycleandpredictable menses. However it is effective in20-30%casesonly.

Ovulatory DUB is most common in parouswomenage30-45years.itisassociatedwithaseriesofvascularandhaemostaticdisturbanceswhichcontribute to increased lossofbloodatmenstruation. Medical treatment invariably isnoteffectiveinthisgroup.

In recent years, a number of new surgicaltechniquesthataimtodestroytheendometriumhavebeendeveloped.

Hystereocopic endometrial resection has beentheresince1983.Butalternativesweresoughtduetothedifficultyinperfectingthetechniques,the risksof fluidoverloadassociatedwith theuse of glycine and the higher incidence ofcomplicationsbypoorlytraineddoctors.

Millions of global ablation cases have beenperformed world wide without the use ofhysteroscopy . With a view to simplifyingand expediting the procedure of endometrialresection, the Uterine Balloon Therapy (UBT)procedure was introduced by Neuwirth in19941.

For newer ablation therapies, it is essentialthat strict criteria for patient selection areimplemented.Theseinclude.

Assessmentofpatientexpectations.

Desiretoconserveuterus.

Absenceofanatomicalabnormalitiesintheuterusincludingpolypsandfibroids.

Uterinecavitydepthnotgreaterthan10-12cm

Exclusion of cervical and uterinemalignancy

Absenceofpreviousuterinesurgery.

ThermachoiceUBTconsistsofa16cmlongand4.5mmwidecatheterwithalatexballoonatitsdistal end, which houses the heater element.Thecatheterisconnectedtoacontrolunitthatmonitors, displays and controls pre-set intra-uterine balloon pressure, temperature anddurationoftreatment.Aftertheballooncatheterinsertion,sterile5%dextroseisinjectedintotheballoonuntiltheintra-uterinepressurestabilizesbetween160and180mmHg.Thefluidwithinthe balloon is heated to approximately 87o Cand the treatment automatically continues atthattemperaturefor8min.Forsafety,thedeviceautomaticallydeactivatesifthepressureorthetemperature fluctuates below or above presetvalues.

Thermachoice UBT is a much simplertechnique. It is easy to learn; and does notrequire an elaborate set-up as one requiresfor hysteroscopic ablation technique. Thecomplicationsarehardlyanycompared to thetraditional ablation therapy using Yag laser orresectoscope.

More than 100,000 women have been treatedworld wide with UBT without using anyadditionalmedicaltreatment.Morethan95%ofpatientshaveremainedsatisfiedwithtreatmentatthe3yearfollowup.

Theeaseofuse,patienttolerance,demonstratedsafety profile and comparable efficacy of non-hysteroscopic endometrial ablation usingTheramachoice UBT system provides a goodalternative to hysterectomy. The introductionofUBTto treatDUBhassignificantlyreducedthe incidence of hysterectomy in USA and inmyownpractice.

v

v

v

v

v

v


Among women with excessive bleeding who undergo anendometrial ablation, 80-90% report significantly reducedbleeding, 25-50% develop amenorrhoea, 70-80% reportmarkedly lesspainandbleeding , over90%are satisfiedwiththeoutcome.

I have personally performed more than 300 uterine balloontherapies over a period of seven years. The ease of operation,safetyoftheprocedureandtheresultsareremarkable..Itisverypatientfriendlyprocedure,thoughnotcheapifnewballoonisused.

Endometrial samplingwith in6monthsofUBT ismandatory.We liberally used Injection Depoprovera post operatively at 3monthlyintervalforfirsttwoyearsinperimenopasualpatients,bothforcontraceptionandprocureamenorrheastate.63%ofourpatientshadamenorrhoea.Thiswassignificantlymoreincasesaftertheageof45years.

No patient required hysterectomy so far . One patient (aged53 years, Principal, College of Delhi University) opted forrepeat Balloon Therapy for post menopausal spotting insteadof hysterectomy after 4 years of initial balloon therapy.The satisfaction level is almost 100%. The reason of verygood results in my practice are strict criteria of patientselection and use of injection Depoprovera. Twenty sevenpatients with 1 or 2 cesarean section were not excludedin my series of UBT. It is a safe technique if properevaluation is done.

Ablationisusuallyperformedduringtheearlyfollicularphaseandaftertheendometriumisfirstattenuatedfor4-6weekspriortoablationusingprogestin,danazolorGbRh-a.Inmypractice,we have not used any such agents for endometrial priming.Eighteenpatienthadhaemoglobinlessthan5gm%.

Thermachoice for high risk patients This procedure is simply a boon for treatment of Heavybleeding in high risk patients for surgery, such as those withmorbid obesity, multiple previous abdominal surgeries, heart,lungorrenaldiseasepatientsandthosewithbleedingdisordersetc.Since thiscanbedoneunder localanesthesia therisksofgeneral anesthesia are eliminated. Also, the procedure has aminimal complication rate, is simple, fast and ideal for thesepatients.

In my own practice, 28 cases have been done with 100%satisfactoryresultsat3-5yearsfollowup.However,itwasmadeamplyclearincounselingsessionthatitispalliativetreatmentin presence of fibroid seedlings only to control bleeding andfollowupismandatory.

1. Renalfailure–3

2. MorbidObesity–7(BMI>40)

3. Bleedingdisorders-3

4. Leukaemia–2

5. Compromisedcardiacstatus-13-LVEF<(30%)

Ten of these patients had heamoglobin of less than 5 gm% as well.

Comparisons and outcomeAnRCTconductedbyVanZonRabelinketal2showedthatuterinethermal balloon ablation is equally effective as hysteroscopicrollerballablationofendometriumattheendof3years.

Barrington3 compared UBT to LNG-IUD and concluded thatbothareequallyeffectiveforthetreatmentofDUB.

Cooley et al4 studied the medium (1-3 year) and long term(3-5 year) outcomes of women who had undergone UBT andfound over 90% success rate after three years with out anyadjuvanttherapy.

factors which affect success of treatment are:Properly chosen cases (No fibroids, polyps or suspectedmalignancy).

Increasedage(>40years)

Shorteruterocervicallength

Goodballoonpressureduringtheprocedure

Cooperetal5studiedthesafetyandeffectivenessdatafromtheFDAonGlobalAblationDevicesandnotedthatatoneyearfollowup, ThermachoiceandNovasurehadthehighestsuccessrates.

According to SolnikJ M et al’s6 study,72% of all cases ofablation in a largeuniversity hospitalwerebeingperformedusing Thermachoiceuterine balloon. Attheendoftwoyears,94% of the womenwere satisfied withthisprocedure.

So,todayUBTappearsto be the chosenmethodfortreatmentofDUB.InUSAthetrendisemergingthatfewinsurancecompanyinsistthatGlobalAblationtechniquetobetriedpriortohysterectomyincasesofDUB.Ihopeitwillbegoodreadingandthebenefitsofthisinformationarepassedontoyourpatients.

GynaecareTherma-choice

HormoneTherapy

D&C Hyster-ectomy

Definitivetreatmentforhemajorityofwomen

Minimallyinvasive

Noovernightstayrequired

Mostpatientsreturntonormalactivitywithin1week

v

v

v

v

References1. NeuwirthRS,ObGynaecol1994;83792-7962. Van Zon Rabelink etal ,EUR J Obs Gynaec Biol 2004 May

10;114(1)97-1033. BarringtonEurJObsGynaecReprodBiol2003May1.108(1)

72-44. CooleyetalEURJObsRepordBiol2005Aug1;121(2)233-55. CooperetalJReprodMed2004April,49(4)267-736. SolinkJMetalAmJObsGynae2005Jul;193(1)98-102


Threecasesofsubmentalcystsremovedthroughthefloorofmouthoutofwhichtwowereyounggirlsaged15and17yearsandoneaboyaged14years.

All cases were done under general anesthesiawith nasotracheal intubation. SublingualIncision was given in the mucosa of the floorof the mouth, posterior to the Submandibularduct (SMD) opening. SMD was identifiedand retracted anteriorly while continuing thedissection. Cyst wall identified and dissectioncontinued. Cyst delivered out per orally andremoved. Incision stitched in 2 layers afterachievingthehomeostasis.

Anatomical considerations

Anatomy of floor of the MouthThe mylohyoid muscles are attached to theinner surfaces of the mandible, the hyoidbone and are also attached to each other inmidline rapnae. The two muscles thus formamuscular slingwhichmarks the floorof theoral cavity. The sublingual salivary glands lieimmediately on top of the mylohyoid muscleand along the inner surface of the mandible.Thesubmandibularsalivaryglandliesposterior

tothesublingualglandandiswrappedaroundtheposteriormarginofthemylohyoidmuscle.Itisfoundinthedigastrictriangleoftheneck.Its long duct runs anteriorly on the medialsurface of the sublingual gland to open intothe sublingual region the lingual nerve liesbetweenthetwosalivaryglands,justlateraltothe hyoglossus muscle. It passes beneath thesubmandibular duct to enter the tongue from

beneath.

Advantages

• Noexternalincision

• Lesschancesofinjurytolingualnerve

Disadvantage

• Exposureislimited

• Timetakenismore

Intraoral Removal of Dermoid Cysts by Sublingual Approach

Sanjay Sood and V. K. Sapra

Cyst delivered per orally

Size of the cyst

Sanjay SoodENT ConsultantWaliaNusingHomeDelhi

V.K. SapraSenior ConsultantHolyFamilyHospitalDelhi

Read

AJournal

for Medical

Practitioners


Unusual foreign Body in OesophagusSanjay Sood

Ayoungboyaged21yearspresented to theENTOPDwithahistoryofdifficultyinpainfulswallowingfor3days.Hegaveahistoryofingestionofmuttonbonethreedaysago.HewastakentotheemergencyroomonthesamedayandadvisedtoreporttoENTOPD.However,hedidnotdosoashewasonafastandhencedidnotfeelanyuntowardeffect.

WhenhedidreporttotheENTOPD,arepeatX-RayneckwasdonewhichindicatedaforeignbodyatthelevelofC-6andC-7vertebrae.

Flexible oesophagoscopy was tried by the Gastroenterologist.Foreignbodywasvisualizedbutcouldnotberemoved.

ManagementThepatientwastakenupforRigidOesophagoscopyandforeignbody removed under general anesthesia. The foreign body, aflat mutton bone with mutton fibers measuring almost 1 inchinsizewasremovedfromtheoesophagus.MildbleedingfromthesitewascontrolledandRylestubeintroducedafteracheckesophagoscopy.Patientwasadvisednilorallyfor48hourswithintravenousantibioticsandfluids.Hestartedtakingoralfluidsfollowed by semisolids anddischarged from the hospital after72hoursoftheprocedure.

DiscussionForeign body in aero digestive tract is very common in smallchildrenanditmayvaryfromcoins,marbles,metallic foreignbodies, button cells etc. In adults common foreign bodies arefishbone,smallchickenandmuttonbones,needles,safetypins,dentures-partialorcompleteetc.Flatbonesarerarelyseenasforeignbodyinesophagus.

RigidEndoscopesstillhavetheroletoplayintheeraofflexibleendoscopes.Earliertheforeignbodyisremoved;thebetteritisforthepatientasitreducesthemorbidity.

Endoscopyshouldbedoneinallcasesofsuspectedforeignbodywithsymptoms.

Unusual Case of Accessory NoseAtul Jain

Nasal Proboscis (Accessory Nose)

A femalenewbornwas seenon the19thdayof birthwith anaccessorynose.ItwasexcisedandtheHistopathoplogyshowedit to be hamartomatous structure. Congenital developmentalanomalyofthenose.

PedunculatedmassontheRtsideoftherootofnosewithapitlikedepression.DischargecameoutonpressingthePedunculatedmass.

Cutsectionof themassshowsa tract in formationalongwithapit.

Microscopic structure show Puncta lined with epithelium &cartilagetissuealsovisualised

HassebaceousglandsandHairfollicle

8daysaftertheexcisionofthemasswithminimalscar

Foreign Body Removed

Fig. 2 Gross Pathology

Fig. 3 Histopathology

Fig. 4 Histopathology

Fig. 5

Fig.1


V. K. MalhotraHead,Department of Family MedicinePushpanjaliMedicalCentreDelhi

Pushpanjali Family Physicians Forum (PFPF)

V. K. Malhotra

6 November 2007: CME seriesTheCMEseriesoftheFamilyPhysiciansForumwasheldon6thNovember2007.TheprevioussessionofBasicLifeSupport(BLS)wasfollowedup by a session on Advanced cardiac LifeSupport(ALLS).ThesameteamcomprisingDr

AlokBasuRoyandDrAtulGuptabothSeniorAnesthesiologistseducatedtheaudienceaboutthe latest ACLS recommendations issued byAmericanHeartAssociation(AHA).Thesessionwasenlivenedbysomeveryinterestingvideos.Theaudiencewholistenedwithraptattentionenjoyedtheinteractivesessionenormously.

16 November 2007: Guest lecture on Acute Coronary SyndromeA guest lecture on Acute Coronary Syndromewasorganizedonthe16thofNovember2007atIMA,EastDelhiBhawan.

Dr SP Garg, an eminent interventionalcardiologist from Detroit, USA delivered thetalk.Hecoveredall internationally recognizedissuesinmanagingAcuteCoronarySyndrome.

Dr GK Mani, a renowned cardiothoracicsurgeon and Dr SK Gupta, senior interventioncardiologist, chaired the session. Dr Mani

sharedhisvaluableexperiencesofrolesurgeryin management of Acute Coronary Syndromewhile Dr Gupta informed the audience aboutthecurrentIndianscenario.

Dr D Singhania, an eminent cardiologistassociated with Pushpanjali Healthcareconvenedtheproceedings.

About75doctorsattendedthemeeting.Delegateshadgoodinteractionswiththespeakerandthechairpersons.

Themeetingendedwithavoteofthanks.

4 December 2007: Guest Lecture on Peripheral Vascular DiseaseAguestlectureonPeripheralVascularDisease-CriticalLimbIschemiawasorganizedonthe4thofDecember,2007atDrAKNSinhaAuditorium,IMA,ConventionCentre,ITO,NewDelhi.

Dr Nishit Choksi, Chief InterventionCardiologistfromMichigan,USAdeliveredthetalk. He covered various modalities, practicedfor endovascular revascularization in CriticalLimbIschemia.

Dr(Col)KumudRai,Sr.VascularSurgeonfromMaxDevkiDeviHeart&VascularHospital,andProf Gurpreet Singh, Deptt. of Cardiothoracicradiology, AIIMS, chaired the session . Theygave their valuable comments regarding theroleofsurgeryandvariousimagingtechniquesusedforevaluatingthepatternsofCriticalLimbIschemia.

Dr Praveen Gulati an eminent radiologistassociated with Pushpanjali Healthcareconvenedtheproceedings.

More than 100 leading doctors from variousfieldsofmedicinefromacrosstheDelhiregionattended the lecture and their participationmadethesessioninteractive.

Themeetingendedwithavoteofthanks.

Dr. Nishit Choksi delivering his lecture while (L To R) Dr. Praveen Gulati, Dr. Parkash Gera, Dr. (Col) Kumud Rai and Prof. Gurpreet Singh look on

Dr. Alok Basu Roy talking to Family Physicians

(L to R) Dr. Ganesh Mani, Dr. Surinder Garg Dr. S.K. Gupta and Dr. Dhirender Singhania


Pushpanjali Health Care Events and Initiatives

Prestigious AppointmentsDr Vinay Aggarwal, Chairman & ManagingDirector,PushpanjaliHealthcarewaselectedasDean, College of General Practitoners (IMA)fortheyear2008.

Dr S. Arul Rhaj, Director,PushpanjaliMedical

Publications Pvt. Ltd has been sworn in asthe new president Commonwealth Medical Associationfortheperiod2007-2010.

3 November 2007 : friends of Pushpanjali dine togetherFollowingtheboardmeetingofCrosslayRemediesLtdonthe3rdofNovember2007,thepromotersof the400beddedmulti specialtyPushpanjaliCrosslayHospitalmetoveraninformaldinnerorganized for Directors, Investors, Consultants

and friends of Pushpanjali at Dome hall, TheAmbassador

Hotel. Dr. Vinay Aggarwal briefed the selectgathering on the progress of the project andaffirmedthecommissioningoftheHospitalbyApril2008.

4 November 2007 : Breakfast meetingA breakfast meeting was organized at theproject site of Pushpanjali Crosslay Hospitalonthemorningof4thNovember2007.Alargegathering of over 150 guests including selecthealth reporters from the print and electronicmediaandmembersofPushpanjaliHealthcarewerepresent.Asamplepatientroomwaskeptreadytoelicittheviewsandsuggestionsofthe

visitorstoensurethatthefinalproductisuserfriendly.

Speaking on the occasion Mr. Sasidhar, ChiefArchitect, assured the audience of deliveringPCHonschedulebyApril2008.

4 December 2007: North West University Medical Team VisitA high power medical team from North WestUniversity,Michigan,USAvisitedon4December2007. The team was comprising Dr. NishitChoksi, (Chief, Interventional Cardiology);Dr. Dheeraj Mittal, (Sr. Oncologist); Dr. Faber,(Sr. Oncologist); Dr. Chrisman, (RadiationOncologist); Dr. Kumar, (Gastroenterologist)andDr.GeosephChalil.Theone-dayscheduleof the team was very busy beginning with abreakfastmeetingwithPushpanjaliHealthcareDirectors at the Corporate office followed bya site visit of Pushpanjali Crosslay Hospital.

TherewasaguestlecturebyDr.NishitChoksiin the afternoon which was attended by over100medicalpractitioners.The lastactivityontheagendawasaninformaldinneronthelushgreenlawnsofHotelOberoiMaiden.

Theteamwasamazedtoseethepaceandqualityof work for Pushpanjali Crosslay Hospital. Dr.VinayAggarwalandDr.VijayAgarwalbriefedtheteamontheproject.

Dr Dey explaning the key features relatingto Oncology

Dr. Vinay Aggarwal Dr. S. Arul Rhaj

(L to R) Dr. Gaurav Aggarwal, Dr. Narottam Puri and Dr. Vinay Aggarwal

Mr. Sasidhar reaffirming commissioning of prestigious Pushpanjali Crosslay Hospitals to the guests


16 November 2007 : Health in ColorOnthespotpaintingcompetitionforschoolchildren

PushpanjaliHealthcareundertheumbrellaof“Health-in-Color”undertakes a variety of activities viz. Health Checkup Camps,RunforHealth,BabyShows,Paintingcompetitionsetc,asapartofitssocialcommitment.

An on-the-spot Painting competition for school children fromover200schoolswasorganizedonSunday18thNovember,2007onthelawnsofthefamousAkshardhamtemple.

Before the event, a press conference was organized on 15thNovember, invitingHealthReportersfromPrintandElectronicMedia.Thepressconferencewasattendedbyalargecontingentof reporters. Dr Vinay Aggarwal shared his vision of buildingthefutureofthenationbyinvestinginchildren.Hespokeofthevalueofcreativepursuits in the realizationofdreamsand thepurposeoforganizingapaintingcompetitiononvariousthemeslike Nasha Ek Abhishap, Health - Yoga & Meditation, Delhi -2010,OurHeritage,Trafficdiscipline,CareforEldersetc.

Theeventon themorningof18thwas inauguratedbySwamiAtama Swarupji, who lit the lamp followed by an invocationprayerbythedevoteesoftheAshram.

Fig 3

Mr Deepak Jolly, Dr Vinay Aggarwal, Dr PD Garg andMr Chandra, addressing the press conference

Participants having refreshments


Speakingontheoccasion,ChiefGuestMrGyanedraSrivastava,Secretary, Dept. of Social Welfare, Government of DelhiappreciatedPushpanjali’sinitiativeandcommittedunequivocalsupportofhisDepartmentforthisnoblework.

Mr Deepak Jolly, Vice President, Coca Cola India Pvt. Ltd.expressedhisgratitudetoPushpanjaliinmakinghisorganizationapartner to the event and shared thedetails of thieiworkon“Water Conservation”. Mr Mohammed Akeel, President, CocaCola(North)gaveafewtipstotheparticipatingchildrenontherole they can play in Water Conservation and the subsequentimpactitwouldhaveinimprovingthedepletedwatertable.

DrPDGarg,DirectorPushpanjaliHealthcareshared thevisionofPushpanjali“CatchthemYoung”initiativeandexpressedhissincerethankstotheparticipatingchildrenandencouragedthemtolettheirimaginationrunwildwhilepaintingonaparticulartheme.

DrAtulGupta,President,IMA-EDBblessedthechildrenfortheirparticipationandappreciatedthe“Health-in-Color”initiativeofPushpanjaliHealthcare.

MrMMKamath,DGMCanaraBankwasallpraiseforPushpanjaliinitiativeandwishedtheeventagrandsuccess.

The painting competition started at 9.30 am and continuedtill 11.30 am followed by refreshments and snacks for all thebuddingartists.

Aparallel eventofHealthLectures foraccompanyingparents,teachers and others was organized in the Auditorium ofSwaminarayanAkshardham.DrSharda Jain,DrAshokGroverand Dr Vineet Jain addressed the gathering on various healthissuesandgavesimpletofollowtipson“HowtoLiveaHealthLife”. There was a tremendous appreciation of the session bytheguests.

LeadingartistsofIndiawiththesupportofDrMadhumitaPuriconsented to select the winning entries. The winners will berecognizedinaspecial“PrizeDistributionCeremony”tobeheldonthe15thofDecember2007.

Inviewoftheveryencouragingresponseandsupportfromvariousorganizations,Pushpanjalihasdecidedtomakethiscompetition,anannualeventatamuchlargerscaleofparticipation.

15 December 2007 : Prize Distribution CeremonyOnthespotpaintingcompetitionforschoolchildren

On the afternoon of the 15th of December, 2007, a Prizedistributionceremonyof thePaintingcompetitionforchildrenheld on Sunday 18th November, 2007 at SwaminarayanAkshardham,wasorganizedatDrAKNSinhaauditorium,IMAconvention centre, New Delhi. Ten winners from over 1,200entrieswerefelicited.

The function was attended by the winners, their parents andfriendstogetherwithPushpanjaliTeammembers.

Participants in-action

Swami Atma Swarup ji lighting the lamp. Also seen in the picture Dr Hari Haran and Dr PD Garg

Dr Sharda Jain giving her tips to accompanying adults at “How to Live a Healthy Life”

Dr. Vinay Aggarwal, Dr Ajay Kumar and Dr PD Garg addressing the winners and their family members while Mr Mohit sharing his experience


DrPDGarginhiswelcomeaddressreiteratedPushpanjaliHealthcare’scommitment to promote “Healthfor All” under the banner of“Health-in-Color” and laudedthe excellent efforts made by thechildren at the competition. HeinformedtheaudiencethatasperafeedbackfromJudges(renownedartists),selectingthebestpaintingswasaverydifficulttask.

Dr Vinay Aggarwal profuselythanked Dr Ajay Kumar, ChiefGuest and President, IndianMedical Association for gracingthe occasion and being with thewinners. He appreciated theassociation of Coca Cola India,Kaleidoscope Events, IAPA,Canara Bank, Delhi Traffic Policeand IMA-East Delhi Branch fortheirsupportandannouncedthattheeventwouldhenceforthbeanannualfeaturewiththecontinuedsupportfromalltheassociates.

Dr Aggarwal also expressed hisgratitudeforthegestureofSwamiAtmaswarupji of SwaminarayanAkshardhamfornotonlyofferingthe premises for competitionbut also for blessing the eventby lighting the lamp during theinauguralfunction.

Speaking on the occasion, ChiefGuestDrAjayKumarspokeaboutkarma, samskars and sangati thatmakes men different than otherlivingbeingsandaddedthatitwasthechildrenoftheworldwhoweresymbolicofthesethreeessentials.Hecongratulatedthewinnersandappreciated the support givenby their parents and teachers ingrooming and cultivating theirbuddingtalent.

Dr Kumar praised Dr Vinay forhis pathbreaking initiatives inthe field of healthcare and socialservice.

MrParveenAggarwal,Sr.ManagerCoca Cola India announced thatall winning entries shall be usedfor Coca Cola Calendar for 2009;this announcement was cheeredbythegatheringofelatedparentsandwinners.

Then children, 5 each from eachcategory (Class V-VIII & Class IX–XII)werehonoredwithTrophiesandcashawards.

The Ceremony concluded with alunchforall.


Guidelines for Submission of Manuscripts

You are invited to contribute your articles,case reports, clinical experiences and anyotherrelevantmaterialwhichisforthebenefitof clinical community at large. The articles/contributionshouldbesent to:

The Editor in-ChiefDr. Vinay Aggarwal

&

The EditorDr Ashok Grover

PUSHPANJALIMEDICALPUBLICATIONSPVT.LTD.

A-14,15,Pushpanjali,VikasMargExtn. Delhi–110092

E-mail :[email protected]

[email protected]

Manuscriptscanbesubmittedbye-mail,butitismandatory thatphotographs (if any) shouldbesubmitted inglossypaperbypost.

Tomaintaintheuniformitythearticles,authorsshould followthe followingpattern:

All Manuscripts submitted to Medi-Focusshould not have been published in any formin any other publication, and become theproperty of the publishers. All manuscriptsmustbeaccompaniedbythefollowingwrittenstatement signed by all the authors. “Theundersigned author (s) certify (ies) that thearticle is original, is not under considerationby any other journal, and has not beenpreviouslypublished.Allcopyrightownershipof the manuscript entitled (title of article)is hereby transferred to the publishers ofMedi-focus.”

Articles will be edited for style and grammar.Technical jargon is to be kept to a minimum.Americanspellingsareused in the Journal.

Preparation of ManuscriptsFormat. The manuscript must not exceed 10-12pages typedindoublespace(including15-20 references).Number allpages in sequence,beginning with the title page. Submit a copyofallelementsarrangedas follows:

TitlePage.Thisshouldcontain the titleof themanuscript (5-6 words title) the names of allauthors,andtheiraffiliations,ashorttitle(notmore than 20 letters to be used as runninghead)andatthebottomofthepage,institutionwhere theworkhasbeencarriedout, and theaddress for all correspondence and reprints,includingFax,PhoneandE-mail.

Structured Abstract. Should be a factualcondensationoftheentireworkwithobjective,methods, results, conclusions and shouldbe in one para. The abstract should statethe purposes of the study or investigation,basic procedures (selection of study subjectsor laboratory animal; Observational andanalytical methods), main findings (givingspecific data and their statistical significance,if possible), and the principal conclusion. Itshould emphasize new and important aspectsof thestudyorobservations.

Clinical Briefs must not exceed 1000 wordswithone figureand5-8references.

Text. Authors must consider and follow theformat : Introduction, Material and Methods,Results, Discussion, and Conclusion (ifnecessary). The matter must be written ina manner which is easy to understand, andshould be restricted to the topic discussed.Donotusevertical linesorunderlining inthetext.

Acknowledgmentsshouldbeplacedasthelastelementof the textbeforereferences.

Abbreviate measurements (cm, ml).Abbreviations should be used sparingly andmustbeprecededby the full forminitially.

References. In citing other work, onlyreferences consulted in the original should beincluded.Ifitisagainstcitationbyothersthisshouldalsobestated.

Use the Sequential numbering system.Arrange the reference list in the sequence inwhich the references are first cited. In thetext, references cited should be superscriptedandshouldappearon topof the lineafter thepunctuation. Responsibility for the accuracyand completeness of references lies with theauthor.

References should not exceed 15-20 innumber.

The Journal follows the Vancouver system ofreferences. References should be numberedandlistedconsecutivelyintheorderinwhichthey are first cited in the text. Tables shouldbe identified in the text by superior Arabicnumerals.Thefulllistofreferencesattheendofthepapershouldinclude:namesandinitialsofallauthors (unlessmore than6,whenonlythe first 3 are given followed by et al); thetitleof thepaper; the journal title abbreviatedaccording to the style of Index Medicus; yearof publication; volume number; first and lastpage numbers. References of books should


give the book title, place of publication, publisher and year;those of multiple authorship should also include the chaptertitle, first and last page numbers, and names and initials ofeditors.

1. Mehta MN, Mehta JN. Serum lipids and ABO bloodgroups in cord blood of neonates. Indian J Pediatr 1984;51 :30-43.

2. Smith GDL. Chronic Ear Disease. Edinburgh; ChurchillLivingstone,1980 :78-81.

3. Malhotra KC. Medicogenetic problems of Indian tribes.In Verma IC, ed. Medical Genetics in India. Vol. 2.,Pondicherry;AuromaEnterprises,1978;51-55.

Papers accepted but not yet published should be included inthe references followed by “In press”. Those in preparation,personal communications and unpublished observationsshouldbereferred toassuch in the textonly.

For more detailed information about the Vancouversystem, authors should consult “Uniform requirements formanuscripts submitted to biomedical journals’ (Br MedJ.1982;284 :1766-70).

Legends.Adescriptivelegendmustaccompanyeachillustrationandmustdefineallabbreviationsusedtherein.

Illustrations and graphs. Submit glossy black and whitephotographs.Thecostreproductionofcolourphotographswillbe borne entirely by the author. Number all illustrations withArabicnumericals (1,2).

Tables. These must be self-explanatory. The data must beclearly organized and should supplement and not duplicatethe text. Explanatory matter should be given as footnotes.Statisticalanalysesusedmustbeappropriate.Eachtablemusthave a title and should be numbered with Arabic numericals(1,2).

Manuscript Submission Checklist

1. Threecopiesofmanuscript inhardcopy

2. Name and address of author responsible forcorrespondence.

3. StructuredAbstract (150-200words)&3-5keywords.

4. References,citedconsecutively in the text.

5. Threeglossyprints for illustrations.

6. Documentation of permission to reuse any previouslypublishedmaterial.

7. Covering letter, including statement of originality andsignifyingapprovalof finalcopybyallauthors.

8. Uponfinalacceptanceofthemanuscript,aCDdiskinMSWord should be submitted. The disk should be labeledwith the title of article, file name and version used andmustcontain the final revisedmanuscriptmaterial.

ADVERTISEMENT TARIff FrontInsideCover (Colour) Rs.12,000/-

FullPage (Colour) Rs.10,000/-

HalfPage (Colour) Rs.5,000/-

BackInsideCover (Colour) Rs.12,000/-

BackCover (Colour) Rs.15,000/-

IMPORTANT TECHNICAL DATA

PrintingProcess Offset

Frequency PublishedQuarterly

FullPage 177.8x241.3mm

MATERIAL REQUIRED

ColouronStandardNewsprint 133LineScreen4

Colourpositivewithproof

B/WonStandardNewsprint 120LineScreenPositive

RNINo.DELENG/2002/9685

ENT October 2007

Documents

Transcript of ENT October 2007