Colistin Resistance among Human Clinical Isolates from a Tertiary Care Hospital in Nepal.

Background Colistin is increasingly being used for treatment of multidrug resistant (MDR) bacterial infections in human. The plasmid mediated mcr-1 gene was detected recently among the poultry in Nepal. Plasmid mediated colistin resistance among human isolates would severely compromise the treatment of MDR bacterial infections. Objective To find out the prevalence of colistin resistance among the gram-negative bacteria isolated from clinical specimen. Method A descriptive cross-sectional study was conducted in a tertiary care hospital in Kathmandu. Colistin resistance among all the gram negative bacilli (GNB), isolated in a year, from all clinical specimen subjected for aerobic bacterial isolation, was detected by disc diffusion and agar dilution methods. Those with a minimum inhibitory concentration (MIC) > 2 mcg/ml were subjected to polymerase chain reaction for detection of mcr-1 gene. Result A total of 1993 aerobic GNB were isolated from clinical samples received from February 2018 to January 2019. By the agar dilution screening method, 2.1% of the GNBs isolated had MIC of colistin > 2 mcg/ml. None of these possessed the mcr-1 gene. Conclusion Given the occurrence of increased MIC of colistin in the clinical isolates in our set up, nationwide active surveillance would generate data for Nepal. The study for the presence of other genes (chromosomal or plasmid mediated) responsible for the increased MIC of colistin would further guide the control measures.

Cheiro-Oral Syndrome.

Cheiro-Oral Syndrome (COS) is a very rare neurological syndrome associated with varied etiology. We report a 53-year-old man presented with left sided perioral and ipsilateral hand/fingers burning sensation for a one-month duration. On examination, he had hypesthesia over left perioral and distal palmar aspect of all five fingers. MRI revealed subacute infarct in the posterior limb of right internal capsule adjacent to and minimally involving thalamus. He was diagnosed as CheiroOral Syndrome as a result of ischemic stroke and managed.

Inducible clindamycin and methicillin resistant Staphylococcus aureus in a tertiary care hospital, Kathmandu, Nepal.

BACKGROUND: Staphylococcus aureus, an important nosocomial pathogen, is frequently associated with infections in human. The management of the infections by it especially methicillin resistant ones is often difficult because methicillin resistant S. aureus is usually resistant to multiple antibiotics. Macrolide-lincosamide streptogramin B family of antibiotics is commonly used to treat such infections as an alternative to vancomycin. METHODS: This study was conducted over the period of one and half year from November 2013-April 2015 in Microbiology laboratory of Nepal Medical College and Teaching Hospital, Kathmandu, Nepal to find the incidence of different phenotypes of MLSB resistance among S. aureus from clinical samples and their association with methicillin resistance. Two hundred seventy isolates of S. aureus were included in the study. Methicillin resistance was detected by cefoxitin disc diffusion method and inducible clindamycin resistance by erythromycin and clindamycin disc approximation test (D-test). RESULTS: Of the 270 clinical isolates of S. aureus, 25.1% (68/270) were MRSA. Erythromycin and clindamycin resistance was seen in 54.4% (147/270) and 41.8% (113/270) isolates respectively. Resistance to erythromycin and clindamycin were higher in MRSA as compared to MSSA (erythromycin-resistance: 88.2% Vs 39.1% and clindamycin-resistance: 79.4% Vs 41.8%). The overall prevalence of iMLSB and cMLSB phenotype was 11.48% (31/270) and 29.25% (79/270) respectively. Both iMLSB and cMLSB phenotypes predominated in MRSA strains. CONCLUSIONS: Detection rate of MRSA in our study shows the necessity to improve in healthcare practices and to formulate new policy for the control of MRSA infections. Clindamycin resistance in the form of iMLSB and cMLSB especially among MRSA emphasizes the need of D-test to be performed routinely in our set up while using clindamycin as an alternative choice to anti-staphylococcal antibiotics like vancomycin and linezolid in the treatment of staphylococcal infections.

Awareness and Knowledge of Oral Cancer among Medical Students in Kathmandu University School of Medical Sciences.

Background Oral cancer is a major public health problem worldwide. It has high mortality rates and chances of survival is relatively superior when detected early. Lack of knowledge and awareness about oral cancer among medical students may contribute to delay in diagnosis and treatment. Objective To assess awareness and knowledge of oral cancer among medical students. Method A cross-sectional study conducted among 286 students by Department of Otorhinolaryngology and Head & Neck surgery, Kathmandu University School of Medical sciences between July to August 2016. A questionnaire with questions on socio-demographic profile, awareness and knowledge of oral cancer was used. Independent sample t test and Pearson Chi-square tests were used for statistical analysis. Result Out of 329 students approached, 286 participated in the study yielding a response rate of 86.9%. Symptoms of oral cancer as reported were ulceration in mouth (92.3%), oral bleeding (85.0%),whitish or reddish patch (84.3%), halitosis (75.5%) and swelling in neck (74.5%), trismus (69.2%), numbness (67.1%), loosening of teeth (49.3%) and tooth sensitivity (41.6%). The perceived risk factors were smoking (97.2%), tobacco chewing (96.5%), chronic irritation (86.7%), immunodeficiency (83.9%), poor oral hygiene (88.5%), human papilloma virus infection (82.5%), dietary factors (81.1%), alcohol (79.4%), ill-fitting dentures (72.4%), hot spicy food (65.4%) and hot beverages (58.0%). Significant differences were found between pre-clinical and clinical students for knowledge of risk factors, signs and symptoms of oral cancer (p<0.001). Conclusion There is deficiency of knowledge among medical students about some aspects of oral cancer. Active involvement while examining patients and taking biopsies of malignant and premalignant lesions may help in improving students' knowledge about oral cancer.

Socio Demographic Predictors in Delayed Presentation of Head and Neck Cancer.

Background Head and neck cancer is a major public health problem worldwide. In spite of the increase in incidence, there has been paucity of research on socio demographic factors influencing head and neck cancer. Objective To study the influence of various socio demographic factors on late presentation of head and neck cancer. Method Prospective, analytical study conducted in 69 patients with Head and neck malignancies in Department of Otorhinolaryngology and Head and Neck surgery, Kathmandu University School of Medical sciences between January 2015 to January 2016. Collected data were entered and analyzed using IBM SPSS statistical software 21.0. All the socio demographic variables were compared between the early and late presentation groups of patient using Chi-square test. A 'p' value of < 0.05 was considered statistically significant. Result Forty eight were male and 21 were female. The age of patients ranged from 34 to 70 years (mean age 52.03). Twenty patients were diagnosed in stage I, 13 in stage II, 20 in stage III and 16 in stage IV. Significant association was seen between stage of head and neck cancer and duration of illness (p=0.007), educational status of patient (p=0.003) and educational status of patient's care taker (p=0.005). However, no statistical association was seen between stage at diagnosis of head and neck cancer and gender, type of family, previous consultation, systems of alternative medicine adopted before diagnosis, smoking habit, alcohol intake, tobacco chewing habit and occupation. Conclusion The results of this study suggest that educational status may influence the presentation of head and neck cancer.

Thyroid Isthmus Agenesis in a Patient with Papillary Carcinoma of Thyroid.

Thyroid gland is the largest of all endocrine glands. It is composed of two lobes. These two lobes are joined by an isthmus and this resemble the letter "H". A wide range of morphological variations and developmental anomalies of the thyroid gland like hypoplasia, ectopy, hemiagenesis, and agenesis have been reported in literature. Out of these, the incidence of agenesis of the thyroid isthmus is rare, and very few cases have been reported. In our report, 28 year old male patient was found with agenesis of thyroid isthmus with papillary carcinoma in the right lobe of thyroid. During the operation it was seen that the right and left thyroid lobes were independent from each other and isthmus was absent. We will present a case of thyroid isthmus agenesis and discuss the clinical importance and the incidence of this case.

Reflux Symptom Index and Reflux Finding Score in Diagnosis of Laryngopharyngeal Reflux.

Background Although laryngopharyngeal reflux is a common condition encountered in otolaryngological practice, its diagnosis is not very easy because of its indistinct symptoms Objective To assess the efficacy of proton pump inhibitors versus proton pump inhibitors with lifestyle modification in patients with laryngopharyngeal reflux. Method Prospective, analytical study conducted in Department of Otorhinolaryngology and Head and Neck Surgery at Dhulikhel Hospital, Kathmandu University Hospital between January 2015 to January 2016. Eighty two patients with laryngopharyngeal reflux having Reflux symptom index > 13 and Reflux finding score > 7 were included. Patients were divided into 2 groups. Group A comprised of patients treated with proton pump inhibitors alone and Group B with Proton pump inhibitors with lifestyle modification. Pre and post therapeutic reflux finding score and reflux symptom index were compared. Result The mean reflux symptom index score difference before and after treatment in group A was 16.70 and group B was 14.58. Similarly, mean reflux finding score difference before and after treatment in group A was 8.68 and group B was 9.92. Comparison of reflux finding score and reflux symptom index scores before and after treatment revealed improvement in both groups and the difference was statistically significant (p<0.001). However, comparison of pre and post therapeutic and scores between group A and B, showed no statistical significance. Conclusion The extent of symptomatic improvement correlated positively with both proton pump inhibitor therapy alone as well as with proton pump inhibitor therapy along with lifestyle modification. Although addition of lifestyle modification offered incremental benefit for treating laryngopharyngeal reflux, it was not found to be statistically significant.

Study to Compare and Evaluate Traditional vs. Endoscopic Septoplasty.

BACKGROUND: Surgery on a deviated septum has seen several modifications since its inception starting from radical septal resection to preservation of the possible septal framework. OBJECTIVE: To compare the efficacies of "Endoscope Septoplasty" over "Traditional Septoplasty" in treating pathological septum and turbinates, in terms of their outcome. METHOD: Prospective descriptive study conducted on 60 patients who presented to the Department of ENT, Kathmandu University School of Medical sciences during a period of two years. The severity of the symptoms of the patients was scored using a visual analogue scale which was compared post operatively to subjectively evaluate the efficacy of either surgery. Objective assessment was done by nasal endoscopy. P value in case of subjective and objective evaluation was done by applying Z- test. RESULT: The mean age ± SD was 29.5±1.2 .Maximum patients fell into age group of 21-30 with 31.7 % followed by 11-20 with 28.3% and then 31-40 with 25%. There were total 35 males (58.3%) and 25 females (41.7%). Among the symptoms, nasal obstruction seems to be dominating with total of 83.3%, followed by postnasal drip with 66.6% and then headache with 60%. The types of dislocation was compared, there were 66.7% cases with DNS and Spur whereas only 10 % with isolated spur. C shaped deformity was seen in 30% and S shaped in 26.6 % cases. Significance in Z test, is seen in subjective assessment post surgery for nasal obstruction, headache and rhinorrhea and for objective assessment post surgery for persistent contact with turbinates. (p value set to 0.01). CONCLUSION: Endoscopic surgery is an evolutionary step towards solving the problems related to deviated nasal septum. It is safe, effective and conservative alternative to conventional septal surgery.

Evaluation of Etiology of Epistaxis and its Management in Dhulikhel Hospital.

BACKGROUND: Epistaxis is one of the most common and most difficult emergencies presenting in 7-14% of the general population each year. Although its lifetime incidence is about 60%, only 6% require formal medical intervention but they can be serious and even life threatening. OBJECTIVE: The main objectives are to study different etiology, types, modality of treatment of epistaxis. Specific objective is also to find out if the modality of treatment is associated with age, site, amount of bleeding and etiology. METHOD: It is a prospective, cross sectional, longitudinal, analytical study done in Department of ENT, Dhulikhel hospital, Kathmandu University School of Medical Sciences (KUSMS) from Aug. 2010 to Aug. 2013. Data was collected. This study was cleared through institutional review committee of hospital. Statistical analysis was done using SPSS 16.0. RESULT: 487 patients were studied during the period. There was significant association between age group with type of treatment (p value 0.002); and with admission (p value < 0.001). Significance in the study was also shown in the correlation between site of bleeding and the type of treatment and also with alcohol intake with site of bleeding (p value < 0.001).However there was no significance between hypertension and the type of treatment methods chosen (p value > 0.01). CONCLUSION: Management of epistaxis is challenging. Most are managed by non surgical means whereas some by surgical treatment. Non surgical treatment is still useful, safe and cost effective. Type of treatment and need for hospital stay is related to age and site of bleeding.

Study of Microorganism Growth Pattern in Nasal Pack of Patients Visiting the Department of ENT, Head and Neck Surgery.

Background Nasal packs are utilized nearly by otorhinolaryngologists for controlling epistaxis and post nasal procedures. Complications have been reported due to them; therefore the use of antibiotics is a common practice among otorhinolaryngologists. Objective To detect microbiological flora associated with nasal packing and find evidence to support the benefit of systemic antibiotics with it. Method A prospective, analytical study was conducted on 51 patients presenting to the Department of ENT, KUSMS from June to September 2015 who required nasal packing. Approval of the local Institutional review committee (IRC) was taken. The mid part of the pack was collected in a sterile bottle under aseptic technique and sent to microbiology department. Specimen collection, culture, identification tests were done according to the guidelines by American Society for Microbiology. Data were collected using the individual patient records and Microsoft Office Excel 2007. Statistical analysis was performed with SPSS 16.0. Result Among the 51 cultures; 33 (64.7%) were positive. In 18 (35.3%) cultures no organism was grown. Statistical analysis did not show significance between duration of pack kept with microbial growth (p=0.051) or the type of pack kept (p=0.212) .It showed significance with foul smell of the pack to the growth (p <0.001). Conclusion Microbiological flora was associated with nasal pack. Antibiotic soaked nasal packs have lesser incidence of positive bacterial growth when compared with plain nasal packs. Nasal packs kept for less than 48 hours have lesser incidence of positive bacterial growth when compared with nasal packs kept for more than 48 hours. Therefore, administering systemic antibiotics in cases when we plan to keep the pack for longer duration is recommended.

Clinicoradiologic evaluation of Eagle's syndrome and its management.

BACKGROUND: Eagle's syndrome (Elongated styloid process) is often misdiagnosed due to its vague symptomatology. The diagnosis relies on detail history taking, palpation of styloid process in tonsillar fossa and imaging modalities. OBJECTIVE: To assess the length and medial angulation of elongated styloid process with the help of three dimensional computed tomography (3D CT) scan and to describe our clinical and surgical experience with patients suffering from Eagle's syndrome. METHOD: Prospective, analytical study conducted from August 2011 to August 2012 among 39 patients with Eagle's syndrome. Detailed history taking, clinical examination and 3D CT scan was performed. Length and medial angulation was calculated. Patients with styloid process length longer than 2.50 cm underwent surgical excision via intraoral approach. Medial angulation of styloid process on both sides was correlated with each other using rank correlation coefficient. Wilcoxon Signed Rank test was applied to test significant difference between pre-operative and postoperative symptoms scores. RESULT: Significant positive correlation was found between the medial angulation of styloid process on right side and left side (? =0.81, p<0.001). Significant difference was also observed between pre and post-operative symptoms scores (z=-5.16, p<0.001) . CONCLUSION: Possibility of Eagle's syndrome should always be considered while examining patients with vague neck pain. 3D CT reconstruction is a gold standard investigation which helps in studying the relation of styloid process with surrounding structures along with accurate measurement of its length and medial angulation.

Correlations between symptoms, nasal endoscopy computed tomography and surgical findings in patients with chronic rhinosinusitis.

BACKGROUND: Although chronic rhinosinusitis (CRS) is increasing in prevalence and incidence, its diagnosis and treatment still pose a challenge. The Task Force on rhinosinusitis (TFR) advocates the use of symptom based criteria. However, many otorhinolaryngologists depend on diagnostic nasal endoscopy and computed tomography (CT) of paranasal sinuses for diagnosis of CRS. Computed tomography has been extensively relied upon in confirming the presence of CRS, in assessing severity of disease, surgical planning and management decisions. Despite its widespread use, several studies have failed to correlate findings on CT with symptom severity. OBJECTIVE: To determine the correlations between symptoms described at presentation, radiological findings, endoscopy and extensiveness of surgery. METHODS: Longitudinal, prospective, analytical study conducted from August 2011 to August 2012 among 87 patients diagnosed as CRS according to the TFR criteria. Symptom, endoscopic, radiological and surgical scoring was done by using Lund and Mackay staging system. Pearson correlation coefficients between scores for symptoms, endoscopy, sinus CT and surgery was determined. RESULTS: When overall symptom score was correlated with radiological score and endoscopy score, it was found to be statistically significant (p= <0.01). However, no significant relationship was found between Lund and Mackay symptom and surgery score. CONCLUSION: The symptom criteria used by TFR for CRS diagnosis are not very specific for sinus disease. A detail assessment of the subjective and objective criteria (CT and endoscopy) is necessary for tailoring surgical plan but should not be relied upon for determining the extensiveness of surgical intervention.

Analysis of ear, nose and throat foreign bodies in dhulikhel hospital.

BACKGROUND: Foreign body in ear nose and throat are commonly encountered by otolaryngologists, pediatricians and primary care physicians. OBJECTIVE: The aim of this study is to analyze different types of foreign bodies and sociodemographic correlates of self inflicted foreign body insertion in ear, nose, throat. METHOD: This was a two year hospital based cross sectional descriptive study performed in the Department of ear nose and throat (ENT), Dhulikhel Hospital - Kathmandu University from June 2009 to June 2011 after verification from the Institutional Review Committee. Using a predesigned questionnaire, socio-demographic data was collected prospectively by examining clinically all patients attending with foreign body and interviewing the caregivers of pediatric patients after removal of foreign body. The data collected from 312 patients was entered and analyzed by using descriptive and analytical statistical methods using SPSS version 16.0. RESULTS: The mean age was 21.26 years with majority between 0-10 years (50.6%). Male predominance was noted (58.97%). Most patients or caregivers were illiterate (35.1%) or literacy up to primary level(21.12%).Foreign body of the ear was found to be most frequent ( 47.4%) and mostly they were non-living (96.1%). Most patients presented late (80%) and had history of prior attempted removal (67%). Pearsons chi square test between education level and duration of time was significant (p value- 0.0000). One way ANOVA test between type of foreign body and age was significant (p value- 0.001). CONCLUSION: Foreign bodies are common in adult and pediatric ear, nose and throat. They can potentially be associated with significant complications if not taken care of immediately.

Cesarean section without urethral catheterization: a randomized control trial.

BACKGROUND: Urethral catheterization is done as a routine procedure in cesarean section. It is associated with high incidence of urinary tract infections, discomfort, delayed ambulation and longer hospital stay. OBJECTIVE: To determine the feasibility and safety of cesarean section without urethral catheterization. METHODS: A prospective, randomized controlled trial was carried out from April 2008 to March 2009, in the Department of Obstetrics and Gynecology, B. P. Koirala Institute of Health Sciences. Among 150 patients who had undergone cesarean section 75 were catheterized and 75 were uncatheterized. RESULTS: First void discomfort was significantly associated with the use of indwelling catheter (OR 6.95, CI 95 %, 3.74 to 12.95; P less than 0.001).Significant number of patients with indwelling catheter had signs and symptoms of urinary tract infection (OR 6,CI 95%, 2.59 to 13. 86; P less than 0.001). Positive urinalysis for urinary tract infection was high in catheterized group (P less than 0.001). Hospital stay was shorter in patients without catheter (p less than 0.05). None of the patients had bladder injury. There were no significant differences in duration of surgery and ambulation time between two groups of patients. CONCLUSIONS: Cesarean section can be done safely without urethral catheterization with reduced morbidities.

Use of gabapentin, esmolol or their combination to attenuate haemodynamic response to laryngoscopy and intubation.

BACKGROUND: Laryngoscopy and intubation increases blood pressure and heart rate. OBJECTIVE: The study aims to investigate the effect and safety of gabapentin, esmolol or their combination on the haemodynamic response to laryngoscopy and intubation. METHODS: A total of 72 patients undergoing elective surgery were randomly allocated to one of the four groups. First study drug was administered orally as gabapentin 1200mg or placebo. Second study drug was administered intravenously as esmolol 1.5mg/ kg or normal saline. Heart rate, rate pressure product, systolic blood pressure and mean arterial pressure were recorded at baseline and at zero, one, three and five minutes after tracheal intubation. RESULTS: Baseline values were compared with the values at various time intervals within the same group. In group PE (placebo, esmolol), there was significant decrease in heart rate and rate pressure product at five minutes. In group GN (gabapentin, normal saline), there was significant decrease in systolic blood pressure and mean arterial pressure at five minutes. In group GE (gabapentin, esmolol), there was significant decrease in heart rate at zero, three and five minutes. Systolic blood pressure, mean arterial pressure and rate pressure product was significantly lower at three and five minutes. In group PN (placebo, normal saline), there was significant increase in heart rate at zero, one, three and five minutes; systolic blood pressure at zero and one minutes; mean arterial pressure at zero and one minutes and rate pressure product at zero, one and three minutes. In group GN (gabapentin, normal saline), there was significant increase in heart rate at zero, one and three minutes and rate pressure product at zero, one and three minutes. In group PE (placebo, esmolol), there was significant increase in systolic blood pressure at zero and one minutes and mean arterial pressure at zero and one minutes. However, in group GE (gabapentin, esmolol) none of the variables showed statistically significant increase at any time. Inter-group comparison was made for each time point. At zero minute, there was significant difference in heart rate between groups PN and GE, GN and PE and GN and GE Significant difference was also noted in rate pressure product between PN and GE at zero minute. At one minute there was difference in heart rate between PN and PE, PN and GE, GN and PE and between GN and GE. Significant difference was observed in rate pressure product between PN and PE amd between PN and GE at one minute. No significant side effects of the study drugs were observed. CONCLUSIONS: Combination of gabapentin and esmolol in this study design is safe and better attenuates both the pressor and tachycardic response to laryngoscopy and intubation, than either agent alone.

Impalement injury to the heart.

Cardiac impalement injury is rare and one of the most severe penetrating chest injuries, often fatal. The management of penetrating cardiac injuries is a challenging one. The success in management of impaling cardiac trauma requires stabilization of the impaling object, expeditious transfer to a facility for open heart surgery, rapid imaging, access to blood and blood products and a ready surgical team. We report a case of impalement injury to the heart by a stick, transfixing the right ventricle and its successful treatment.

Prevalence of noise induced hearing loss among traffic police personnel of Kathmandu Metropolitan City.

BACKGROUND: Noise induced hearing loss (NIHL) is a major preventable occupational health hazard. OBJECTIVE: To measure permanent threshold shift in traffic police personnel due to noise exposure and to examine whether it was associated with duration of noise exposure, years of work and risk factors. METHODS: Cross sectional, descriptive study conducted at Dhulikhel hospital, Kathmandu University Hospital in 110 responding traffic police personnel. Detailed history and clinical examination of ear, impedence audiometry and pure tone audiometry was performed. RESULTS: Mean age group was 29.82 years; 82(74.5%) were males and 28 (25.5%) were females. Mean duration of service is 11.86 years. Twenty six (23.6%) had tinnitus and 39(35.5%) had blocked sensation in ear. Sixty five (59.1%) worked between 10- 19 years. Alcohol and smoking shows positive impact on NIHL (p value =0.00). Odds ratio with 95% confidence interval were 4.481 (1.925-10.432) and 6.578 (2.306- 18.764) respectively. Among 73(66.4%) noise induced hearing loss positive cases, bilateral involvement was seen in 45 (40.9%) and unilateral in 28(25.4 %) cases. Among unilateral cases most were left sided. Hearing threshold at 4 kHz increased according to age and duration of service. CONCLUSION: Traffic police personnel are in constant risk of noise induced hearing loss. Screening for hearing loss is recommended for people exposed to noise.

Comparison of clinical presentation between Chronic Otitis Media Mucosal with Squamous.

BACKGROUND: Chronic otitis media is a chronic inflammatory disease of the middle ear cleft which is manifested as deafness and ear discharge. It is a common condition affecting 0.5 - 30% of any community worldwide, and most common in developing countries. The prevalence mainly depends on age, low socio-economic status, overcrowding and limited medical facilities. OBJECTIVE: To compare the clinical presentation between chronic otitis media mucosal with squamous types. METHODS: A prospective, longitudinal and analytical study performed among 200 patients who have features of chronic otitis media and were attended to in the ear, nose and throat outpatient department of Dhulikhel Hospital - Kathmandu University Hospital, Dhulikhel, Nepal from January 2010 to January 2011. Patients who had already undergone surgery and came back to the hospital, with inadequate information were excluded from the study. RESULTS: The results showed that, out of 200 cases, 120 (60%) were chronic otitis media- mucosal and 80 (40%) were chronic otitis media - squamous. Patients less than 30 years were affected in both groups. The male to female ratio in chronic otitis media mucosal was 1.14:1, whereas in chronic otitis media squamous, it was 1.96:1. Similarly in etiological factors, oil and water exposure (76%) was the most common cause in chronic otitis media mucosal, whereas in chronic otitis media squamous, oil and water exposure (62.5%) and recurrent upper respiratory tract infection (62.5%) were the most common causes. Of all the clinical features, ear discharge was the leading feature in both chronic otitis media mucosal (98%) and squamous (100%) cases. The complications were mainly seen in the chronic otitis media squamous and the most common complication was mastoid abscess (5%). CONCLUSIONS: The frequency of chronic otitis media is higher in the younger age group and those lacking in health education. As a result, it is important to disseminate the health education regarding the ear disease which will help in decreasing the frequency of the disease in developing countries like ours.

Unexplained apnoea and loss of consciousness during sub arachnoid block for caesarean section.

Sub arachnoid block (SAB) is often perceived safe by many anesthesiologists and other faculties but is also not completely safe choice especially in pregnant females, as the incidence of complications and local anaesthetic agent toxicity is high in these groups of patients. Here we present four such cases out of the seventeen patients over a period of six months, who developed apnea and transient loss of consciousness after spinal anesthesia for lower segment caesarean section. Typically all these patients after spinal anesthesia developed difficulty in breathing, became apnoea and had loss of consciousness for about a minute or two. The apnea was relieved with bag and mask ventilation following which the patient regained consciousness and start breathing normally. The rest of the procedure was uneventful. We presented these cases with aim of sharing similar experiences, and to aware about the possibility of such events as these events do occur frequently but case reports and literatures are unavailable.

Hookworm causing melaena and severe anaemia in early infancy.

Hookworm infestation is usually acquired by transcutaneous penetration of larvae whilst walking barefoot on contaminated soil. We present a small infant who presented with melaena and severe anaemia requiring multiple blood transfusions where the cause of gastro-intestinal bleeding was found to be massive hookworm infestation.