ENT

post nasal pack

2008-03-30T00:21:00.002+05:30

Post nasal pack is made of gauze which is two finger breadth long and one finger breadth wide.Three threads are suspended from this pack.

Epistaxis - treatment

2008-03-30T00:11:00.002+05:30

Endoscopic cautery -

Nasal endoscopes have revolutionarised the treatment of epistaxis. Patients used to suffer with the agony of post nasal packs many times in intractable cases. Now we can examine the nasal cavity with an endoscope and pin point the area of bleeding. This area can now be cauterized by either biolar cautery or with an insulated metallic suction tube whose tip is non insulated. When connected with monopolar diathermy, the tip coagulates the bleeding area.

Epistaxis - treatment

2008-03-28T21:30:00.002+05:30

Another method of posterior nasal packing is with the foley's catheter. Introduce the foley's catheter along the floor of the nasal cavity into the nasopharynx. When the tip is visible in the oropharynx, inflate the catheter with 10-15 ml of distilled water and pull the catheter till it tightly fits the posterior choanae. Put the anterior nasal pack and clamp t yhe foley's catheter with a umbilical cord clamp after putting a gauze piece inbetween clamp and nose to prevent necrosis of columella.

Double ballooon catheters can also be used in which there is a bloon fof posterior part of nose and choanae and a separate balloon for nasal cavity. These are inflated with distilled water to give optimum pressure.

Epistaxis - treatmant

2008-03-27T00:21:00.005+05:30

Posterior nasal bleed - If the bleeding is posterior, a post nasal pack is required. Post nasal pack is made of gauze which is two finger breadth long and one finger breadth wide.Three threads are suspended from this pack.A catheter is passed from the nasal cavity into the oropharynx and taken out from the mouth. The two threads are fixed with this end and the catheter is pulled from the anterior nares thus taking the pack in the oral cavity, then oropharynx and lastly in the nasopharynx and posterior choana. In this procedure the pack is directed by the index finger of right hand. Once in the posterior choana, the nasal cavity is packed by anterior nasal packing and two threads are secured keeping a dental roll or a piece of gauze between the thread and columella to prevent columellar scarring.The third thread is taken out of the oropharynx and secured with adhesive tape on the cheek. This thread helps in taking out of the post nasal pack after 48 to 72 hours. The procedure can be repeated on the other side also if needed.

Epistaxis - treatment

2008-03-22T18:17:00.003+05:30

Anterior nasal packing - If the bleeding point on the septum is not found then one has to pack the nasal cavity. For this following packing materials can be used -

1. Ribbon gauze impregnated with BIPP (bismuth iodoform pyro phosphate) or any antibiotic ointment.The ointment acts as lubricating and moistening agent as well as an antiseptic.The ribbon gauze can be layered in the nasal cavity in two ways, either layer on layer horizontally or vertically. Most of the time this anterior packing is enough to control the bleeding by tamponading effect. This is taken out mostly after 48 hours.

2. Readymade packs like merocel can be used which are less traumatising on nasal mucosa. After placing the pack in the nasal cavity, it is made wet by putting saline on it. The pack swells and controls bleeding by pressure effect.

3. Catheters are available with an inflatable baloon which is infatted after inserting the catheter in nasal cavity.

4.Nasal packs are also available with an inner airway for the patient to breathe through it.

Epistaxis - treatment

2008-03-21T19:36:00.003+05:30

If all the general measures fail, then the patient should be taken to the operation theatre.The following procedures can be carried out as per the situation demands.

The nasal cavity of the patient should be examined using a sharp head light and a good suction. If the bleeding point is localised, it should be cauterized with a chemical agent like trichlor acetic acid or silver nitrate.

If the bleeding does not stop,the heat cautery or bipolar diathermy is used to cauterize the bleeder.

If the bleeding point can not be localised and the bleeding is not heavy, the bleeding area can be localised using a nasal endoscope (Hopkin's rod lens) and then bipolar diathermy can be used to cauterize it. If bipolar cautery is not available, then an insulated suction tip can be used that has an uninsulated tip to cauterize the area using monopolar diathermy.

Epistaxis-treatment

2008-03-19T21:09:00.002+05:30

To treat epistsaxis, first some general measures are used. The patient is asked not to panic as this will raise the blood pressure and aggravate the situation.The nose is tightly pinched. This will control epistaxis from the little's area. Pressure should be firm and be applied for at least 10 minutes while keeping the head in the neutral position and spitting out any blood which flows into the mouth. There is no benefit to pinching the bridge of the nose or to tilting the head backwards or forwards. Swallowing excess blood can irritate the stomach and cause vomiting.

Ice should be applied over the nose to promote vasoconstriction.

The use of local vasoconstrictor drops like oxymetazoline, xylometazoline or phenyepherine instilled in the nose in the form of drops or spray can help in simple bleeds. On can also use calcium alginate mesh to promote coagulation.

Epistaxis -investigations

2008-03-18T22:47:00.002+05:30

In a case of epistaxis following investigations are needed -

Haematological investigations -

i) Hb, PCV - to see the amount of haemoglobin in blood and packed cell value helpful in acessing the general condition of the patient and to see need for any blood transfusion.

ii) Platelet count - to find any platelet deficiency state.

iii) PTI (prothrombin time index) - access the coagulatory mechanism.

iv) Total and differential leucocytic count - to see for any infection

v) Perepheral blood film - to see any immature cells and deficiency states.

vi) Bleeding and clotting time

2. Radiological investigations -

i) X-ray PNS water's view - to see any sinus pathology, fractures but does not give much information.

ii) CT scan and MRI - In cases of carcinoma and angiofibroma

3. Angiography - To see the vessel which is bleeding.

epistaxis

2008-03-17T23:38:00.001+05:30

Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.

Causes of EPISTAXIS

2008-03-15T20:01:00.002+05:30

Epistaxis -

Nasal bleeding can be of two types depending upon the site of nasal bleed.Anterior bleeding mostly originates from the septum from its anteroinferior area called Little's area or Kisselbach's plexus.Posterior bleeding is from the so called artery of epistaxis i.e.sphenopalatine artery.

Causes -

1.Idiopathic - In most of the cases no cause can be identified.

2.Traumatic causes -

Nasal picking - It is the commonest cause of epistaxis in children.Nasal picking can cause injury to the Little's area causing bleeding from nose.

Nasal blows and road side traffic accidents causing facial injuries, nasal injuries and fractures cause nasal bleeding.

Iatrogenic causes like nasogastric and nasotracheal intubation.

Surgical causes like in septoplasty, submucus resection and endoscopic sinus surgery.

3.Anatomical deformities such as DNS,septal spurs or Osler-Weber-Rendu Syndrome

4.Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants.

5.Chronic granulomatous diseases like tuberculosis,lupas vulgaris , syphilis, leprosy, rhynoscleroma etc

6. Foreign bodies

7.Intranasal tumors (Nasopharyngeal carcinoma in adult, and nasopharyngeal angiofibroma in adolescent males)

8.Midline granulomas - wegener's and stauwart's granuloma

9.Nasal sprays, particularly prolonged or improper use of nasal steroids

10.Chemical inhalants like mercury and chromic acid fumes, cocaine snuff

11.Barotrauma - Atmospheric changes such as sudden movement to high altitudes.

Systemic causes -

1.Drugs - Aspirin, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others

2.Hypertension - There is relationship between hypertension and epistaxis . In adults epistaxis is more common in hypertensive patients, and patients are more likely to be acutely hypertensive during an episode of epistaxis. Hypertension, however, is rarely a direct cause of epistaxis, and therapy should be focused on controlling hemorrhage before blood pressure reduction.

3.Vascular abnormalities - like sclerosed vessels, A-V malformations, hereditary haemorrhagic telengeactasia.

4.Bleeding tendencies - thrombocytopenia, liver disease, coagulopathies.

5.Alcohol (due to vasodilation)

6.Heart failure (due to an increase in venous pressure)

7.Hematological malignancy

8.Systemic infections such as AIDS,typhoid, pneumonia, malaria, dengue fever, measles etc.

9.Pregnancy

10.Menstruation (vecarious menstruation)

Epistaxis-causes

2008-03-14T18:52:00.003+05:30

Systemic causes -

Drugs - Aspirin, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others
Hypertension - There is relationship between hypertension and epistaxis . In adults epistaxis is more common in hypertensive patients, and patients are more likely to be acutely hypertensive during an episode of epistaxis. Hypertension, however, is rarely a direct cause of epistaxis, and therapy should be focused on controlling hemorrhage before blood pressure reduction.
Vascular abnormalities - like sclerosed vessels, A-V malformations, hereditary haemorrhagic telengeactasia
Bleeding tendencies - thrombocytopenia, liver disease, coagulopathies.
Alcohol (due to vasodilation)
Heart failure (due to an increase in venous pressure)
Hematological malignancy
Systemic infections such as AIDS,typhoid, pneumonia, malaria, dengue fever, measles etc.
Pregnancy
Menstruation (vecarious menstruation)

Epistaxis

2008-03-13T23:22:00.000+05:30

Local Causes continuing -

3.Anatomical deformities, such as DNS,septal spurs or Osler-Weber-Rendu Syndrome

4.Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants.

5. Chronic granulomatous diseases like tuberculosis,lupas vulgaris , syphilis, leprosy, rhynoscleroma etc

6. Foreign bodies

7.Intranasal tumors (Nasopharyngeal carcinoma in adult, and nasopharyngeal angiofibroma in adolescent males)

8.Midline granulomas - wegeners and stauwarts granuloma

9.Nasal sprays, particularly prolonged or improper use of nasal steroids

10.Chemical inhalants like mercury and chromic acid fumes, cocaine snuff

11.Atmospheric changes such as sudden movement to high altitudes.

Epistaxis

2008-03-12T22:17:00.000+05:30

Nasal bleeding can be of two types depending upon the site of nasal bleed.Anterior bleeding mostly originates from the septum from its anteroinferior area called Little's area or Kisselbach's plexus.Posterior bleeding is from the so called artery of epistaxis i.e.sphenopalatine artery.

Causes -

Idiopathic - In most of the cases no cause can be identified.

2. Traumatic causes -

Nasal picking - It is the commonest cause of epistaxis in children.Nasal picking can cause injury to the Little's area causing bleeding from nose.
Nasal blows and road side traffic accidents causing facial injuries, nasal injuries and fractures cause nasal bleeding.
Iatrogenic causes like nasogastric and nasotracheal intubation.
Surgical causes like in septoplasty, submucus resection and endoscopic sinus surgery.

Epistaxis - Little's area

2008-03-12T00:13:00.000+05:30

Little's area or Kiesselbach's plexus is named after Wilhelm Kiesselbach (1839-1902) a German otolaryngologist.Most of the nasal bleeds especially in children arise from this area because this area is highly exposed to trauma due to nasal picking and dry air and moreover due to its rich blood supply because of anastomosis between different vessels.Anastomosis occur between the septal branches of sphenopalatine artery, greater palatine artery, superior labial artery and the anterior ethmoidal artery.Among the vessels taking part in the anastomosis, the anterior ethmoidal artery is the branch of ophthalmic artery from the internal carotid system while the other vessels are from the external carotid system. The main artery of epistaxis known as sphenopalatine artery and also the greater palatine artery are the branches of internal maxillary artery which is a terminal branch of external carotid artery. Superior labial is a branch of facial artery which is a branch of external carotid.

Epistaxis

2008-03-10T20:20:00.000+05:30

Bleeding from the nose is known as epistaxis.Nose is a very vascular organ .Nasal mucosa has a rich blood supply.It gets blood supply from branches of internal carotid artery as well external carotid artery.In children the common cause of bleeding from nose is nasal picking and in adults it is hypertension.The commonest area for nasal bleeding is Little's area or Kasselbach's plexus. Second common area is Woodruf's area which lies posterior to inferior turbinate....

Changing tracheostomy tube

2008-03-09T20:45:00.000+05:30

After performing tracheostomy, the tube should not be taken out for next 72 hours unless there is emergency like blockage of tube by thick mucus plug which can not be cleaned by doing suction.After the 72 hours tracheostome is fully formed and there are less chances of missing the tract.During this period ,it is necessary to fix the tube properly by tightly securing the tapes and additionally suturing the tube to the skin. When the tube is taken out for the first time, tracheal wound dilator should be there to keep the tracheostome open and to prevent it from collasping.Always keep another tracheostomy tube ready in cases of emergency when there is no time to clean and reinsert the tube.

Tracheostomy - post operative care

2008-03-09T00:45:00.001+05:30

After surgery following things are to be taken care of -

As the trachea is suddenly exposed to dry air of the atmosphere, there is need to do suction through the tracheostomy tube after every half an hour to clear the secretions produced due to this insult.It is advised to keep the suction catheter in for minimum period of time. The catheter is pinched while taking in and the pressure released as the catheter is taken out. Care is taken not to insert too deep so as not to touch carina and produce spasms of cough due to irritation in trachea.
Secondly the trachea has to be moistened with saline,so saline is put in the tracheostome every half an hour and a single layer of wet gauze is placed over the tracheostome.
Mucolytic agents and sodium bicarbone can be instilled to decrease viscosity and reduce crusting.
A pen,paper anb bell have to be placed near the patient for the patient to communicate as the patient is unable to speak for some time after surgery.

Tracheostomy - complications

2008-03-08T00:51:00.000+05:30

One of the immediate complication of tracheostomy is surgical emphysema.This is presence of air in subcutaneous tissue and its main cause in tracheostomy is

Tight sutures
Tight packing around tube
Wrong placement of tube in subcutaneous tissue in a false passage

The tight sutures act as ball valve. Air gets sucked into subcutaneous tissue but cannot comes out. So it gets collected under skin. If not checked, there can be pneumothorax and pneumomediastinum.

On examination ,on palpation creps can be felt under skin which can also be auscultated.

Treatment - Open the tight sutures. If extensive surgical emphysema is there oh face, neck and shoulders, then small nicks can be given to release air. If there is pnemothorax and pneumomediastinum, they are treated actively.

Tracheostomy

2008-03-05T23:23:00.000+05:30

Tracheostomy is of two types according to time when it is done

Elective tracheostomy - done electively in some surgeries as in surgery of TM joint when the patient is not able to open the mouth for intubation,before planning for laryngectomy, in long standing medical diseases like CVA for tracheobronchial toilet etc
Emergency tracheostomy - done in patients who come in respiratory distress.

In emergency tracheostomy, vertical skin incision is preferred. After incision, the larynx is fixed with one hand and the incision is deepened not bothering about isthmus of thyroid or anything in the way direct to the trachea and then after identifying it, the trachea is opened,wound dilated and the tracheostomy tube inserted. As soon as the airway is made patent most of the bleeding stops automatically. Rest of the bleeders are secured and skin wound is stitched with silk.

Tracheostomy-complications

2008-03-05T00:27:00.000+05:30

One of the most common problem is decanulation in a patient with long standing tracheostomy.This is particularly in kids. One of the causes of this is the emotional dependence on the tracheostomy tube. Other cause is the formation of granulation tissue in the trachea.As the tracheostomy tube is removed,the patient feels uncomfortable and suffers from respiratory difficulty.In such patients direct laryngoscopy should be done to look for any granulation tissue in trachea.For decanulation in such cases the size of the tube is gradually reduced and decanulation done by 72 hours or more.

Tracheostomy complications

2008-03-04T00:05:00.001+05:30

1.Obstruction of the tracheostomy tube due to -

a) any clot in the tube

b) Any mucus plug in the tube

c) impingement on the posterior tracheal wall

d) partial displacement into the mediastinum or in a false passage

2. Wound infection

3. Tracheal injury and granulation tissue formation.

4. Fatal haemorrhage due to injury to inomanate artery due to continuous irritation and injury causing a tracheo-inominate fistula leading due massive haemorrhage and death.

5. Tracheo-oesophageal fistula.

6. Scar formation and tracheal tug.

7.Difficult decanulation.

Tracheostomy Complications

2008-03-01T11:49:00.000+05:30

The immediate complications of tracheostomy are -

Haemorrhage - Bleeding can occur from anterior thyroid vein which can be easily avoided. Secondly bleeding can be from isthmus of thyroid.
Apnoea - Apnoea can occur on opening the trachea due to sudden wash out of carbon dioxide from lungs which causes loss of respiratory drive. In such cases a mixture of oxygen and carbon dioxide which is called carbogen is given for inhailation.
There can be injury to pleural apices, recurrent laryngeal nerve,oesophagus.

Tracheostomy

2008-02-29T20:01:00.000+05:30

Landmarks for tracheostomy

Cricoid cartilage - It is a circular cartilage below the thyroid cartilage and is the shape of a tyre. It is tne only cartilage in larynx and trachea which forms a complete ring and also it forms the widest ring and the most prominent one.

Suprasternal notch - Make an incision two finger breadth above supra sternal notch.

Strap muscles - these are separated vertically by blunt dissection.

Isthmus of thyroid gland - If possible retract it upwards or if not put two clamps, cut and transfix it.

Tracheal rings - palpate and confirm by aspirating with a syringe.

Tracheostomy

2008-02-28T22:33:00.000+05:30

High tracheostomy
If the opening in trachea is made between 1st and 2nd ring, it is called high tracheostomy. The main indication for a high tracheostomy is carcinoma larynx. As stoma is at a higher level and if it gets involved , it can be removed along with the larynx leaving good amount of trahea for making airway. If it is done in other cases, it can result in tracheal stenosis which is very difficult to deal with.

Tracheostomy

2008-02-27T21:04:00.000+05:30

Procedure -

Position of the patient - The patient is lying supine with a sand bag below the shoulder so as to extend the neck and make the trachea prominent but in an already respiratory compromised patient, the patient becomes more uncomfortable with this posture.

The neck is painted with povidone iodine solution and sterile sheets placed. The area is infilterated with 2% lignocaine with adrenaline solution in a diamond shape fashion. The area is palpated and landmarks identified. The incision is placed two fingers above the suprasternal notch. Most of the times a transverse incision is given in a skin crease but in emergencies a vertical incision is of great help. The subcutaneous tissue is divided and muscles exposed. Great care is taken not to leave the midline otherwise one can land in complications. The fat which comes in the way can be safely removed to get a better exposure.The strap muscles are neatly separated in the midline with blunt dissection with a small artery forceps. Now the isthmus of thyroid comes in the way. This can be lifted up with a hook or clamped with long artery forceps, cut and transfixed with ligatures.The pretracheal tissue is gently dissected and trachea exposed and identified from tracheal rings. Small amount of local anaesthetic is injected in trachea to decrease the cough reflex after aspiration of air to confirm the position of needle.Now the trachea is incised between 2nd and 3rd tracheal or 3rd and 4th tracheal rings.A small piece of cartilage can be removed to facilitate the entry of tracheostomy tube but in children this is avoided. Now the tracheostomy tube is inserted and secured. The wound is closed with silk or prolene sutures.

Tracheostomy VS Intubation

2008-02-26T18:36:00.000+05:30

Following are the advantages of intubation and disadvantages of tracheostomy-

It is easier and quicker to perform as compared to tracheostomy.
It less invasive.
No scar formation is there.
Drugs like adrenaline can be given through it.
No bleeding from the surgery site is there.
No complications like pneumothorax or delayed complications like tracheo-oesophageal fistula is ther.
Can be easily removed, no complication of difficult decanulation.

TRACHEOSTOMY VS INTUBATION

2008-02-26T00:20:00.000+05:30

Following are the benefits of tracheostomy over endotracheal intubation-

It makes the patient more comfortable and less irratable.
It reduces need for sedation.
It improves ability to maintain oral and bronchial hygiene. It helps in tracheo-bronchial toilet.
It reduces risk of glottic trauma. There can be injury to vocal cords and also intubation granuloma formation with intubation.
Tracheostomy reduces dead space and reduces work of breathing.
It can be kept for prolonged period of time.
It augments process of weaning from ventilatory support.

TRACHEOSTOMY

2008-02-24T18:16:00.000+05:30

Indications of tracheostomy

For felieving upper airway obstruction - this is done in cases of carcinoma larynx and hypopharynx when these are obstructing the airways and also after laryngectomy for maintainance of airways. Also in cases of foreign bodies and diseases compromising airways like dyptheria and retro and para pharyngeal abscesses, ludwig's angina etc
For tracheo-bronchial toilet in cases of long standing illness like CVA
For assisted ventillation
To decrease the dead space
For other surgeries like long surgeries of oro maxillary areas, and in cases where patient is not able to open mouth like TM joint ankylosis or mass obstructing in the oral cavity and pharynx
For treatment of diseases like obstructive sleep apnoea.

TRACHEOSTOMY

2008-02-23T19:49:00.000+05:30

The other tracheostomy tubes are non metallic ones.There are two types of non metallic tubes, one cuffed and other is non cuffed. The advantage of cuffed tubes is that these seal the lumen of trachea due to inflated cuffs and no aspiration of secretions in tracheo-bronchial tree is there and secondly when the patient is on positive pressure ventilation ,no leakage of air takes place. The disadvantage is that the cuff should be deflated at regular intervals otherwise chances of tracheomalacia are there. The non metallic tubes are made of inert material so less foreign body reaction and they can be easily connected to ventilator. As there is no phonation opening, patient is not able to phonate in initial stages.The tube has a radio opaque line which helps in location of the tube on x-rays.

TRACHEOSTOMY

2008-02-22T17:39:00.000+05:30

There are different types of tracheostomy tubes available in the market. Basically there are metallic and non metallic tubes. Metallic tubes have different shapes and sizes. Fuller's metallic tube has an inner tube and an outer tube. Inner tube is longer than the outer tube to prevent crusting. It has an opening on its shoulder for phonation. The outer tube is bi- phalanged.The purpose of phalanges is that the tube can be easily inserted by pinching the phalanges. The advantage of this metallic tube is that its insertion is easy. Secondly if inner tube is removed for cleaning purposes, the outer tube remains in the trachea to maintain respiration.Another advantage is phonation. The patient can learn to close the opening of tracheostomy tube with the finger and phonate as the inner tube has an opening for phonation.The disadvantage is that ventilators are difficult to connect with these tubes. Secondly these can cause pressure necrosis of trachea and the tube can itself get erroded and fall in the trachea causing a foreign body in airway.

CRICOTHYROTOMY

2008-02-21T12:10:00.000+05:30

Cricothyrotomy is a life saving procedure. If a patient is having sudden respiratory obstruction and no particular instruments or fascilities are available then this procedure is of great help even in the hands of non medical people. In this, a slit is made in between the thyroid cartilage and cricoid cartilage. Thyroid cartilage is also called Adam's apple. It is V shaped and can be easily palpated in the neck.Cricoid cartilage is a round structure below the Adam's apple and is like a small tyre. The space in between these two cartilages is cricothyroid space and is covered by cricothyroid membrane. It is this space and membrane through which we make an opening in the larynx. With a blade or in emergency with any sharp object like knife after palpating the cricothyroid membrane a slit is made and widened. When no instrument is available the tip of a pen can puncture this space and then it is made patent with the hollow of a pen.Otherwise after widening the slit, a trcheostomy tude or endotracheal tube can be inserted through it and respiration secured.

TRACHEOSTOMY

2008-02-20T22:44:00.000+05:30

Tracheostomy is a life saving procedure in which a hole is created in the trachea (wind pipe) for respiration in cases of airway obstruction and a trachestomy tube is inserted in the trachea through it which bypasses the upper respiratory tract. In case of emergency due to respiratory tract obstruction,this is the procedure which can save the life of a patient and every health worker whether he is a paramedic or a doctor should know how to perform it in case of emergency.

Another procedure which is quick, easy and used when no special instruments are available is cricothyrotomy or tracheotomy. In this a hole is made between the thyroid cartilage and cricoid cartilage.

TYMPANIC MEMBRANE

2008-02-19T16:49:00.000+05:30

Tympanic membrane commonly known as drum separates the external ear from the middle ear. It is pearly white in color and is semitranslucent. There are some landmarks on the tympanic membrane which are -

Handle of malleus which slants in posterior direction.
Cone of light which gets reflected in anteroinferior quadrant.
Umbo - the most prominent part of tympanic membrane
Anterior and postrrior malleolar folds - above these the tympanic membrane is called Pars Flaccida or sharpnell's membrane and below these is called pars tensa.
Long process of incus and incudo-stapedial joint.
Anterior process of malleus.

MYRINGOPLASTY-INDICATIONS

2008-02-16T12:44:00.000+05:30

The grafting of drum in case of perforation is necessary due to following reasons-

As the tympanic membrane has a hole in it,the chances of getting water from outside into the middle ear through the perforation are always there while bathing or swimming.This will contaminate the middle ear and cause infection in it and the ear will start discharging pus.So a route of infection persists if the perforation is not closed. The patient has to leave the sport of swimming.Also if the patient has a discharging ear, it becomes a sourse of embarasement for him in public life.

Due to perforation, the patient suffers some degree of hearing loss which depends on the site and size of perforation. If the perforation is small but is in the posteroinferior compartment opposite the round window area, itwill produce more hearing impairment.

MYRINGOPLASTY-COMPLICATIONS

2008-02-15T23:10:00.000+05:30

Ther are a few complications of myringoplasty also. If done under general anaesthesia, the complications due to anaesthesia can occur. Then there can be injury to a small nerve which supplies anterior 2/3 of tongue and carries taste sensation to brain. This nerve is chorda tympani and injury to this causes altered taste sensation. Then post operative vertigo can be there which lasts for short time. Infection can occur and this can also lead to graft rejection. Then a small residual perforation can remain after surgery.

CLOSING SMALL PERFORATION OF TYMPANIC MEMBRANE-II

2008-02-14T21:42:00.000+05:30

Another method of closure of tympanic membrane perforation is by fat graft. The edges of the perforation are made raw by removing a thin margin after giving local anaesthesia. After freshenening the margins, the fat is harvested from the ear lobule. A small incision is given on the lateral surface or under surface of lobule of ear and fat taken out of the lobule. This fat is placed in the perforation in such a manner that a part of this remains above and a part below the perforation like a dumbell. The ear canal is packed with gelfoam.

CLOSING SMALL PERFORATION OF DRUM

2008-02-13T18:22:00.000+05:30

Many a times in our clinical practice, patients come with small tympanic membrane perforation 2-3 mm in size. In these patients surgery is not required and one can close the perforation by other techniques also. If the ear is dry, one can cauterize and raw the edges of the tympanic membrane by applying Trichol acetic acid (TCA). As the outer layer of drum which is epithelium and inner layer that is mucosa meet at the edges of perforation, it is necessary to break these adhesions which is done by applying TCA with an applicator.Then this is patched with a small piece of gelfoam which can be soaked in patient's blood or any antibiotic solution.The process has to be repeated many times at regular intervals till the perforation gets healed up.

MYRINGOPLASTY-TECHNIQUES

2008-02-12T22:43:00.000+05:30

We can repair the drum by placing the graft in three different techniques. The most common used method is underlay or inlay technique in which the graft is placed under the remnants of drum. second is overlay in which graft is placed above the drum and the third is intermediate in which graft is placed in between the epithelium and mucosa of drum.

MYRINGOPLASTY-GRAFT MATERIAL

2008-02-11T23:38:00.000+05:30

Myringoplasty is the repair of damaged or perforated tympanic membrane. It has to be grafted to repair it. The commonly used graft materials are those which can be precured from the same person. The most common graft material used is temporalis fascia. This fascia covers the temporalis muscle. This fascia is chosen because of its easy approach and the fact that it is very thin but strong and resembles tympanic membrane. Secondly it can be harvested from the same post auricular incision which is used for post auricular approah for myringoplasty. Other common graft material used are vein graft, fascia lata, perichondrium and the tissue present above the temporalis fascia. cadeveric dura can also be used for this surgery.

SWELLING IN THE NECK-III (METASTATIC)

2008-02-10T17:45:00.000+05:30

Another common type of swelling in the neck in clinical practice is the lymph node swelling due to metastasis. In a patient of malignancy (commonly known as cancer) a time comes when the disease does not remain localised but spreads by lymphatics to the regional lymph node. This lymph node is called metastatic lymph node. The main charecteristic feature of this swelling is that it is painless and very hard to touch. Pain appears very late in terminal illness or when the swelling gets infected. To confirm the diagnosis, fine needle aspiration cytology (FNAC) has to be done. The areas from where neck lymph node can be involved are nose, nasopharynx, para nasal sinuses, throat and pharynx.

SWELLING IN THE NECK-II

2008-02-08T23:44:00.000+05:30

Another type of swelling in the neck can be lymphnode swelling due to tuberculosis. This is firm to touch and non tender. Sometimes tubercular lymphnode can be soft to touch and on aspiration shows pus, then this is called cold abscess. Diagnosis is generally made by FNAC and rarely on excision biopsy of lymph node. Sometimes the swelling starts discharging by itself or after incision given to drain it by somebody and can lead to a discharging sinus. Treatment is by anti tubercular therapy.

SWELLING IN NECK - I (acute inflammatory)

2008-02-07T20:59:00.000+05:30

A swelling in the neck is a very common affair in day to day practice. In children, any infection in nose, throat or even scalp can lead to a swelling in the neck. A swelling which is painful and tender to touch is usually due to acute inflammation. This can be co related by simple laboratory investigations like total leucocytic and differential leucocytic count and can be confirmed by fine needle aspiration cytology commonly known as FNAC. These swellings can be treated by simple antibiotics and anti inflammatory medicines.

ORAL ULCERS

2008-02-06T19:16:00.000+05:30

Oral ulcers are a very common problem. They are painful as well as restrict us from doing one of our favourite timepass known as eating. There can be many causes of oral ulcers but the commonest is vitamin B deficiency.The common oral ulcer known is the aphthous ulcer. In addition to vitamin B deficiency , emotional disturbances also act as a powerful causative agent. Thats why they are common in females thats too during their menstruation. The patient fells pain while swallowing. Other causes are injury to oral mucosa as in cheek bite and viral diseases like herpes etc. Oral ulcers are also seen with autoimmune disorders. To treat the patients one has to give vitamin B complex and local gels containing choline and salysalic acid.

SENSORINEURAL HEARING LOSS

2008-02-05T19:23:00.000+05:30

This type of hearing loss occurs if there is any defect in the inner ear or in the cochlear nerve. So sensorineural hearing loss has two varieties that is cochlear which is due to defect in inner ear and retrocochlear due to defect in cochlear nerve pathway. As campared to conductive hearing loss, the patient says that he can listen to the sound but not able to comprehend the sound. There are different treatment modalities. For medical treatment, we can give methylcobalamine, vasodilators and other drugs. Otherwise hearing aids can help the patient to some extent.

CONGENITAL ANOMALIES OF THE EAR

2008-02-04T19:28:00.000+05:30

Sometimes we see that either the pinna is absent or rudimentary. Absence of pinna is called anotia. If the pinna is small it is known as microtia and if it is abnormally large ,it is called macrotia.An accessory (extra) appendage or piece of tissue can also be present. The normal curves of pinna may be absent causing a bat ear.

TREATMENT OF CONDUCTIVE HEARING LOSS

2008-02-03T18:15:00.000+05:30

One of the diseases causing conductive hearing loss is ossicular chain disruption. This may be due to some accidential injury or any disease in the middle ear like cholesteatoma which errodes the ossicles mainly incus.To treat this condition, ossiculoplasty is required in which ossicular chain is reconstructed. this is done either by refashioning the remaining ossicles or with artificial prosthesis. In refashioning, the remaining part of incus is drilled and a hole is made for stapes head and a groove is made for malleus handle and thus incus is repositioned in between malleus and stapes by refashioning it. Alternatively a cartilage graft is taken and refashioned in the similar manner between malleus and stapes. Similarly handle of mlleus can be used. In artificial prosthesis TORP (total ossicular replacement prosthesis) can be used in between drum and stapes if both incus and malleus are erroded or PORP (partial ossicular replacement prosthesis) can be used if handle of malleus is preserved. These prosthesis are made from different materials like teflon, titanium,gold etc.

OSSICLES

2008-02-01T23:15:00.000+05:30

There are three small bones in the middle ear.These are malleus ,incus and stapes. Stapes is perhaps the smallest bone in the human body.These conduct sound from tympanic membrane to the inner ear.Any disease causing fixation or disruption of this chain will produce hearing loss which can be judged by tunic fork tests qualitatively and pure tone audiometry (hearing test) quantitatively. A tympanogam can differentiate between osscicular chain disruption and fixation. Both the conditions can be surgically corrected.

HEARING IMPAIRMENT (CONDUCTIVE- SECRETORY OTITIS MEDIA)

2008-01-31T18:13:00.000+05:30

The child will have decrease in hearing,irritation in the ears and earache sometimes. The main complaint comes from the teacher who reports that the child is inattentive in class or parents observe that the child listens the television at a higher level.On eamination there can be retraction of tympanic membrane or bubbles of fluid can be seen through it.The diagnosis can be made with pure tone audiometry (hearing test) and impedence audiometry (tympanogram).Treatment can be removal of the causative factor that is adenoids.Oral and nasal decongestants help. If not cured then myringotomy that is giving a small cut in the drum or myringotomy with grommet insertion can be done to cure the child. Grommets are small ventilation tubes which are inserted in the drum after giving a small incision in the drum.

If remained untreated ,this condition leads to hearing loss and deposition of chalky white patches in the drum called tympanosclerosis.

HEARING IMPAIRMENT (CONDUCTIVE)

2008-01-30T19:28:00.000+05:30

In children glue ear or secretory otitis media is a leading problem which causes conductive hearing loss.The main condition which lead to secretory otitis media is a nasopharyngeal lymphoid tissue called adenoids. This tissue either cause mechanical blockade of Eustachian tubes causing decrease in middle ear pressure levels resulting in negative middle ear pressure and thus fluid in middle ear. Secondly adenoids become a continuous source of infection resulting in eustachian tube congestion and blockade causing recurrent acute otitis media and with inadequate treatment it ends in secretory otitis media.

HEARING IMPAIRMENT (CONDUCTIVE)

2008-01-29T19:54:00.000+05:30

In conductive hearing loss, one of the commonest cause can be wax which usually gets pushed back due to self cleaning by cotton applicators available in the market by the name of buds.This wax can also swell and then gets hardened due to entry of water during bathing or swimming.The ear fells deaf and heavy and our own sound appears louder. One can instill wax solvent drops and get wax removed by an ENT specialist.

HEARING IMPAIRMENT

2008-01-28T23:04:00.000+05:30

There can be a number of causes of decreased hearing causing conductive deafness. Conductive deafness means decreased hearing due to impairment in conduction of sound from external auditory canal to inner ear. The sound enters the external auditory canal, makes the drum vibrate, then gets transmitted due to movement of three small bones namely malleus ,incus and stapes which amplifies and concentrates the sound. Stapes is the smallest bone of the human body.From stapes ,this sound wave travels to the inner ear via oval window. Anything wrong with the above mechanism causes conductive deafness.

HEARING IMPAIRMENT

2008-01-27T16:56:00.000+05:30

Decrease in hearing is a common problem. This is common with advancing age, due to misuse of medicines, noise induced or with middle ear diseases. This can be due to problem in external and middle ear, so called conductive type or problems in inner ear or cochlear nerve, also known as sensorineural type.In both the conditions the type and severity of hearing loss differs and treatment modalities also differ.

MYRINGOPLASTY:REPAIR OF DRUM

2008-01-26T01:09:00.000+05:30

When there is a hole in the ear drum this is repaired by a surgery called myringoplasty. The graft material used is temporalis fascia, vein graft or perichondrium.The graft can be placed above or below the remnants of drum.good technique can give beautiful results.

HONEYMOON RHINITIS

2008-01-23T22:46:00.000+05:30

The nasal secretions are in a way affected by our emotions. Whenever a person is excited or afraid, there is a change in his nasal secretions that can either be increase in secretions or their drying.Similarly when a person is sexually excited, his or her nose starts producing watery secretions. This commonly occurs at the time of honeymoon of newly weds. At the moments of sexual excitement of the newly weds, watery fluids starts coming out of their nose which is known as honeymoon rhinorrhea.This all depends on the activity of the sympathetic-parasympathetic nervous system.

RHINOPLASTY

2008-01-22T22:51:00.000+05:30

Rhinoplasty is the plastic surgery of the nose done to correct the external deformity of the nose. External deformities of the nose can be depressed nose ( a nose which needs to be elevated and augmented), deviated or crooked nose ( a nose which is not straight but deviated to a side), a hump on the dorsum of the nose,wide or asymmetrical openings of the nasal cavities and deformities of the tip of the nose. In the deformities of the tip of the nose, there can be wide tip, rounded tip or a parrot beak deformity. Mainly these cause a cosmetic deformities and less of functional abnormalities but if this is accompanied by deviation of the nasal septum which is a partition between the nasal cavities, this can cause difficulty in nasal breathing causing nasal obstruction.

FRACTURE OF THE NOSE

2008-01-18T16:56:00.000+05:30

Nasal bones are one of the commonest bones to get fractured because of their outward prominent position making them to become more prone to trauma due to accidents and fights. Secondly these bones are thin and easily broken. After nasal fracture, the patient usually bleeds from the nose. Swelling appears early and there can be black eye. Nose is tender to touch and on palpating the nose, a crackling sound can be heard. Bridge of nose can be depressed or deviated to one side.Patient should be given painkillers and anti-inflammatory tablets.After getting the x-ray done and after confirmation of the fracture, fracture is to be reduced if the injury is less than two days old or one has to wait till the swelling subsides. Fracture is to be reduced before ten days of injury,otherwise the bone gets fixed at the fractured position permanently and the shape of nose gets distorted. To correct this deformity, rhinoplasty (plastic surgery of nose) is needed which is a major surgery.

BOIL IN NOSE (FURUNCLE)

2008-01-17T21:30:00.000+05:30

Boil also known as furuncle of the nose is a fairly common condition.The main cause is nose picking causing infection of the the hair follicle of the nasal vestibule. This is common in dry climate where the secretions of the nose get dried up and cause irritation in the nose forcing the person to introduce finger in the nose to remove the crust. The skin over that area becomes painful and swelling starts appearing over the area which spreads very fast.The patient can have fever also.The area over the tip of nose and central part of upper lip is called dangerous area of the face as infection from this area can spread to the brain (cavernous sinus) causing fatal complications. So never press or squeeze a boil over this area or you will land yourself in grave trouble.Give plenty of hot fomentation and take appropriate antibiotics and anti inflammatory drugs. Local application of antibiotic cream is also effective. With this treatment the recovery takes place in a couple of days. This disease is not to be taken lightly and early medical help is always rewarding and advocated.

PERFORATION OF DRUM

2008-01-15T19:23:00.000+05:30

Perforation or hole of the ear drum (tympanic membrane) is a common problem. The cause of this problem can be injury from outside by inserting pins,match sticks etc during self cleaning of the ear or scratching the ear and blast injury due to slap on the ear, bomb blasts or blasts due to crackers.The patient feels heaviness of the ear and impairment in hearing. If the middle ear gets infected due to entry of water while bathing or swimming,the ear starts discharging.If the perforation is small,some times it heals by itself.If it does not heal,it can be treated by trichloracetic acid applications at regular intervals but if it is large,then the drum has to be repaired by surgery called myringoplasty. In myringoplasty, graft is placed after preparing the bed of the remnants of tympanic membrane. The graft material can be taken from temporalis fascia, perichondrium or a vein. The success rate of this operation has become high.If untreated,the patient lands in chronic ear infection due to repeated entry of water in the ear and the also suffers from hearing loss.

PAIN IN THE EAR-ACUTE SUPPURATIVE OTITIS MEDIA

2008-01-14T10:14:00.000+05:30

Acute otitis media can occur in any age group but is more common in children.Most of the kids below the age of four years suffer atleast once from severe pain in the ear especially during the night time. This is an acute condition. The child becomes irritable in initial stages and as the stage progresses, feels severe pain in the ear and starts crying. If the child is sleeping, he get up crying. This attack is common in kids having upper respiratory infections like common cold. The infection travels from the nose to the ear via a tube connecting these two called eustachian tube when the child blows his nose. In the beginning the pain increases till a time comes when the ear starts discharging if the child remains untreated. The discharge is at first blood stained but later on, it is only pus like. The child is relieved of the pain as soon as the discharge appears.The child can have fever. On examination the child looks feverish, has a running nose and irritable. In the initial stage the drum looks red (congested) but when the ear start discharging, one can see a small hole in the drum. To treat the child, the child is given pain killers and antipyretics like paracetamol, decongestants,local decongestant nasal drops and a course of antibiotics. Steam inhailation gives a soothing effect. Mostly the child is fine after the attack is cured and the small hole (perforation) of the drum heals by itself. Recurrent attacks of this disease needs special attention as the child might be suffering from enlarged adenoids which is a lymphoid tissue mass present in the nasopharynx, a space present behind the nasal cavities above the level of palate. In such cases removal of adenoids and placement of a ventilation tube in the drum becomes necessary.

FUNGUS IN THE EAR-OTOMYCOSIS

2008-01-13T16:18:00.000+05:30

Itching in the ear is a very common symptom. It can be assosiated with pain in the ear and discharge which is mainly watery in nature.This is an acute condition and its main cause is fungus in the external auditory canal and is known as otomycosis. The commonest fungus causing this is aspergillus fumagatus and niger and candida albicans. This is common in humid climates and also after swimming. Diabetics and immuno compromised persons have a more chance of getting the infection.The patient feels pain, itching and heaviness of the ear.On examination whitish or blackish cotton wool like fungus is seen in canal.Best treatment is to get suction cleaning of the ear and instillation of anti fungal drops like clotrimazole or miconazole and hot fomentation of the ear.

OTITIS EXTERNA

2008-01-12T17:18:00.000+05:30

The inflammation or swelling of external ear which means that of pinna and ear passage known as external auditory canal is called otitis externa. The most common cause of this problem is pocking of objects like pins, match stick or keys when a person feels itching in ear or self cleaning of the ear. The patient feels pain in the ear especially while eating and on touching or pressing the auricle. The patient can have discharge from the ear. There can be fever also.Ear ache is one of the severest aches of the body. Painkillers help in reducing the pain as well as swelling. Hot fomentation over the pinna really helps in reducing the discomfort. Hygroscopic agents like glycerine should be instilled in the ear which helps in reducing the swelling. One should contact an ENT specialist who can pack the ear canal with a wick impregnated with antibiotic,steroid and keratolytic ointment. Oral antibiotics,pain killers and local drops containing antibiotic and steroids along with lignocaine are to be used for a couple of days.

EAR CLEANING

2008-01-11T17:07:00.000+05:30

Most of us have the habit of cleaning our ears with readily available cotton buds or other cotton applicators. Instead of cleaning the ears, such instruments can injure the external auditory canal or push the wax deep in the passage. A common belief that wax accumulates due to dusty surroundings is incorrect. Wax is the secretion of wax secreting glands of the external auditory canal and helps to trap bacteria and dust particles. Thus wax help in protecting the ear from dust, bacteria and foreign bodies. Normally we do not have to clean the ears due to self cleaning property of the ear as a result of outward migration of the skin of the ear passage but if water enters the ear and makes the wax hard or the wax gets pushed due to using of buds then the patient feels pain, heaviness and hearing impairment. In such cases firstly the wax has to be softened with wax softeners containing turpentine oil and then one should get the services of some ENT specialist to get the wax removed by suction, dry moping or by syringing with luke warm water. In cases of perforation of the drum ,syringing with water is to avoided.

ear trauma

2008-01-10T22:26:00.000+05:30

Ear is a vital organ which is a common organ to be neglected but can pose severe threat if kept unattended.
Most of us have a tendency to poke our ears with different objects like hair pins , keys and match stick etc. This also gives a sense of pleasure but it can cause problem if this injures the ear passage called external auditory canal and especially the drum known as tympanic membrane. If it hits the canal , it can produce painful condition called otitis externa, but if it hits the ear drum this can puncture it and cause perforation of the tympanic membrane. In patients with diabetes it can cause a serious painful disease. so better avoid fiddling with your ears.

ear

2008-01-10T16:14:00.000+05:30

Ear is a vital organ which is a common organ to be neglected but can pose severe threat if kept unattended.

Most of us have a tendency to poke our ears with different objects like hair pins , keys and match stick etc. This also gives a sense of pleasure but it can cause problem if this injures the ear passage called external auditory canal and especially the drum known as tympanic membrane. If it hits the canal , it can produce painful condition called otitis externa, but if it hits the ear drum this can puncture it and cause perforation of the tympanic membrane. In patients with diabetes it can cause a serious painful disease. so better avoid fiddling with your ears.