Type-I Tympanoplasty By Underlay Technique - Factors Affecting Outcome.

BACKGROUND: Type-I Tympanoplasty is an operation which is widely done to close a persistent tympanic membrane perforation after clearing the disease from the middle ear. It is very safe and effective procedure. The success rate varies in different setups and there are some confounding factors which affect the result of Type-I tympanoplasty like the size, type and location of perforation. By conducting this study, we aimed to calculate the success rate of Type-I Tympanoplasty in Ayub Teaching Hospital and assess which confounding factors affect the success rate. METHODS: This case series study was conducted at Ayub teaching hospital from 1st January 2014 to 31st December 2015. All the patients who presented with dry ears, no nasal disease and persistent tympanic membrane perforations during this period were operated upon and overall success rate was calculated. In addition, the relationship between the site of perforation, size of perforation and the type of perforation and the success rate of Type-I Tympanoplasty was also calculated. RESULTS: One hundred and thirteen patients were included in this study. Out of these 91 (80.5%) showed complete healing after surgery. Anterior perforations were found to fail the procedure in 41.7% of the cases, while central perforation failed in only 5.4% of the cases. In cases of marginal perforations healing was significantly decreased, i.e., only 47.1% while it was 94.9% in cases where annulus was not involved. Larger perforations also showed poor surgical outcome. 100% of the small perforation healed completely while only 58.3% of the large perforations showed successful result after surgery. When p-value was calculated all of these findings were more than 95% significant. CONCLUSIONS: There is a significant association between the healing of tympanic membrane after Type-I Tympanoplasty and site, size and type of perforation. Anterior perforations, marginal perforation and large perforations reduce the chances of successful outcome of Type-I Tympanoplasty.

Recurrent Laryngeal Nerve Injury In Total Versus Subtotal Thyroidectomy.

BACKGROUND: Both Total and Subtotal Thyroidectomy are correct treatment options for symptomatic Euthyroid Multinodular Goitre. The choice depends upon surgeon's preference due to consideration of disadvantages like permanent hypothyroidism in Total Thyroidectomy and high chances of recurrence in Subtotal Thyroidectomy. Many surgeons believe that there is a higher incidence of Recurrent Laryngeal nerve injury in Total Thyroidectomy which affects their choice of surgery. This study aimed to compare the incidence of recurrent laryngeal nerve injury in total versus subtotal thyroidectomy. METHODS: This non randomized controlled trial was carried out at Department of Surgery and ENT of Ayub Teaching Hospital Abbottabad, and Combined Military Hospital Rawalpindi from 1st September 2013 to 30th August 2014. During the period of study, patients presenting in surgical outpatient department with euthyroid multinodular goitre having pressure symptoms requiring thyroidectomy were divided into two groups by convenience sampling with 87 patients in group 1 and 90 patients in group 2. Group-1 was subjected to total thyroidectomy and Group -2 underwent subtotal thyroidectomy. All the patients had preoperative Indirect Laryngoscopy examination and it was repeated postoperatively to check for injury to the recurrent laryngeal nerve. RESULTS: A total of 177 patients were included in the study. Out of these, 87 patients underwent total thyroidectomy (Group-1). Two of these patients developed recurrent laryngeal nerve injury (2.3%). In group-2 subjected to subtotal thyroidectomy, three of the patients developed recurrent laryngeal nerve injury (3.3%). The p-value was 0.678. The overall risk of injury to this nerve in both surgeries combined was 2.8%. CONCLUSIONS: There is no significant difference in the risk of recurrent laryngeal nerve damage in patients undergoing total versus subtotal thyroidectomy.

Complications of nose and paranasal sinus disease.

BACKGROUND: Diseases of nose and paranasal sinuses can complicate to involve the orbit and other surrounding structures because of their close proximity. These diseases are usually infective or can be neoplastic in origin. METHOD: All the patients presenting in ENT or Eye Departments of Ayub Teaching Hospital during the one year study period who had complicated nose or paranasal sinus disease were included in the study. A detailed history and examination followed by CT scanning and laboratory investigations to assess the type and extent of the disease, was carried out. RESULTS: Infections were the most common cause of complicated sinus disease 11 (75%). The rest of the 4 (25%) cases were tumours. 12 (80%) of the cases presented with proptosis. In I of these 12 cases. there was complete blindness. In 2 (13%) of the cases there was only orbital cellulitis. Two of these patients had facial swelling and 2 had nasal obstruction and presented as snoring. Two patients presented with history of weight loss and these patients had malignant tumour of the paranasal sinuses. One patient presented with early signs of meningitis. In 1 case subperiosteal scalp abscess (Pott's puffy tumour) was the only complication noted. CONCLUSION: Nose and paranasal sinus diseases can complicate to involve mostly the orbit, but sometimes brain, meninges and skull bones can also get involved.

Correlation of operative findings with pre-operative clinical signs and analysis of x-rays in patients with airway foreign bodies.

BACKGROUND: Foreign body aspiration is one of the commonly encountered emergencies in ENT and still it remains a significant cause of mortality and morbidity. However with the development of modern endoscopic techniques and controlled anaesthesia, most foreign bodies can be removed safely with a bronchoscope. METHODS: This study was carried out at Department of ENT, Head and Neck Surgery, Ayub Medical College, Abbottabad from 1st Jan 2003 to 30th June 2005. Total 81 patients were registered in the study. Two patients, in whom the foreign body could not be removed, were excluded from the study. RESULTS: The most consistent finding was decreased air entry on chest auscultation on the side of impacted foreign body which was present in 72 (91.1%) patients. The second most consistent finding was audible wheeze on the side of impacted foreign body found in 42 (53.2%) patients. The most common finding on Chest X-ray was emphysema found in 19 (61.3%) patient, followed by atelactasis in 9 (28%) patients while 3 (9.7%) patients had normal Chest x-ray. CONCLUSION: The pre-operative clinical signs in patient with aspirated foreign body give an idea about the site of foreign body in an airway. Although chest x-ray gives an idea about the pathological changes in respiratory tract it has little impact in the management of a patient with aspirated foreign body.

Analysis of tracheobronchial foreign bodies with respect to sex, age, type and presentation.

BACKGROUND: Foreign body inhalation is one of the life threatening emergencies. It may happen at any age, however, most of these accidents occur in children especially below the age of five. METHODS: This prospective study was done at Department of Otolaryngology, Head and Neck Surgery, Ayub Teaching Hospital, Abbottabad, from 1 January 2003 to 30 June 2005. A total of Eighty one patients, referred from the casualty and Paediatric unit with suspicion of tracheobronchial foreign body were included in the study. RESULTS: Eighty one were studied. Fifty (61.7%) were male and thirty one (38.3%) were female. Sixty three (77.8%) were below five years, thirteen (16%) were between five and fifteen years and five (6.2%) were above fifteen years. Sixty seven patients (82.7%), presented mainly with chocking, while fifty nine patients (72.8%) had stridor and forty five patients (55.6%) had cough at initial presentation. Seventy two (88.9%) patients had decreased air entry and forty two (51.9%) had wheeze on auscultation, whereas cyanosis was noticed in five (6.2%) patients. Peanut was the commonest foreign body, retrieved in forty five patients (55.6%). Other foreign bodies were whistle (18.5%), maize seed (13.6%), bean seed (6.2 %), nuts (2.5%), sewing needle with thread, dice and denture (1.2%) each. CONCLUSIONS: Foreign body inhalation is more common in male patients, mostly below five years of age. Chocking is the commonest symptom and decreased air entry on auscultation is the typical examination finding. Peanut has been found to be the commonest type of foreign body.

Evaluation of safety of bipolar diathermy tonsillectomy.

BACKGROUND: Tonsillectomy is a common operation in both children as well as adults, performed by a variety of techniques that have evolved over the years to ensure the safety of the procedure. Cold dissection and electrodissection are the two mostly used techniques. Bipolar diathermy tonsillectomy was evaluated for its safety and postoperative morbidity. METHODS: This study was conducted over a period of two years, in the Department of Ear, Nose Throat and Head & Neck Surgery at Ayub Teaching Hospital, Abbottabad, Pakistan. Two hundred and forty-six were enrolled; however, 238 patients completed the full evaluation as the technique had to be modified in 8 patients. All the procedures were performed by the first author thereby ensuring the same expertise level. Operating time, intraoperative blood loss, postoperative algesia, feeding status and time taken getting back to school/work and episodes of secondary bleeding were recorded. RESULTS: Time taken by the procedure ranged from 10 to 20 minutes. Intraoperative blood loss ranged between 2 to 5 ml. Postoperative pain averaged around 3-5 on a 1-10 point scale in 75% of patients. 80% of patients were back to normal diet by day 3 postoperative. Nine (3.6%) patients had a secondary haemorrhage that was managed conservatively and did not need surgical intervention. CONCLUSION: Bipolar diathermy tonsillectomy is an effective and safe technique, especially in children population. Adequate experience with the technique is mandatory to achieve the desired goals.

Evaluation of efficacy of management protocol in allergic rhinitis.

BACKGROUND: Allergic rhinitis represents a global health issue affecting between 10% to 25% of the world population, with increasing prevalence, resulting in a significant impact on quality of life, multiple comorbidities and the considerable socio-economic burden. Majority of the patients are younger than 30 years and it may be inherited. Symptoms typically occur as a result of exposure to dust, dander or certain seasonal pollen. Lack of standardized management protocol is one of the major factors responsible for poor control of this condition. This study was designed to evaluate the patients suffering with allergic rhinitis and manage them with a protocol based on the pathogenesis of the condition. METHOD: This prospective study was conducted in the Department of Ear, Nose & Throat and Head & Neck Surgery, Ayub Teaching Hospital, Abbottabad, over a period of two years (2005 - 2006), to assess the efficacy of a standard protocol of treatment developed and followed in the department. 1167 patients, clinically diagnosed as suffering with allergic rhinitis, were evaluated and managed. Age ranged from 08 months to 64 years. All the patients were prescribed medical treatment, divided into initial phase of 10 days to two weeks duration followed by a maintenance phase, and a regular follow-up schedule was maintained upto two years. RESULTS: 634 (54.32%) patients were male and 533 (45.67%) were female. Age ranged from 08 months to 64 years, 85% being between 05 and 45 years. 91% of patients had symptom duration of 06 months to 03 years. 96% of the patients were getting treated on as required basis, whereas 98% had no educational sessions with the treating doctor, especially regarding preventive measures. Typical presentation in most of the patients was nasal obstruction, runny & itchy nose, post nasal drip and bouts of sneezing. 90.57% patients reported improvement in symptoms. 53.21% patients had a relapse of symptoms at some stage during the study period. 37.53% patients had surgery done for associated pathologies, mostly a DNS. Compliance regarding medication was more than 90% in the initial phase of treatment that dropped to 50% in the maintenance phase. 93% of the patients tolerated the treatment well. CONCLUSION: Allergic rhinitis is a growing problem worldwide. Optimal treatment protocol is still lacking especially in the developing countries. Patient's education on avoidance of allergens must be stressed. Associated problems that may need surgical treatment. Regular follow-up must be ensured to monitor the progress of treatment as well as to identify patients who might be candidates for immunotherapy. Newer modalities of treatment need to be further explored. A team approach is mandatory in the presence of symptoms related to lower respiratory tract.

Significance and cost effectiveness of pre-operative routine laboratory investigations in young healthy patients undergoing elective ear, nose & throat surgery.

BACKGROUND: Pre-operative preparation is an important component of surgical workup. Adequate clinical assessment to determine fitness for anaesthesia and surgery and to outrule possibilities of existing disease or risk factors against the procedure would suffice in elective surgery on healthy young patients. Still routine investigations are carried out following a protocol, that does not offer added benefit and is not cost effective. METHOD: We evaluated one hundred and fifty young healthy patients planned for elective surgery, to compare adequate clinical assessment with results of routine investigations in such patients, in terms of significance and cost effectiveness. RESULTS: Significant co-relation was demonstrated between clinical assessment and routine investigations. Only 03 abnormal results were reported following 600 laboratory investigations on 150 patients. CONCLUSION: Thorough clinical assessment is mandatory for successful outcome of surgery. There is significant co-relation with routine investigations in elective Ear, Nose & Throat (ENT) surgery. Investigations should be restricted to where indicated by clinical assessment. Such policy will significantly reduce the costs and workload, thereby improving quality of health care system.

Foreign body inhalation--site of impaction and efficacy of rigid bronchoscopy.

BACKGROUND: Foreign body inhalation is a relatively commonly encountered emergency in otolaryngology. Foreign body can get lodged at any site from the supraglottis to the terminal bronchioles. Rigid bronchoscopy is one of the well established methods of removing inhaled foreign body with fewer complications. METHODS: This prospective study was conducted in the Department of ENT, Head & Neck Surgery, Ayub Teaching Hospital, Abbottabad, from January 2003 to June 2005. The total number of patients was eighty one. Patients in whom a foreign body was retrieved, were included in the study. RESULTS: Foreign body was found in the right main bronchus in sixty patients (74.1%), left main bronchus in seventeen patients (21%), terminal bronchioles in two patients (2.5%) and one patient (1.2%) each in trachea and laryngeal inlet. Foreign body was successfully removed in seventy-nine patients (97.5%). Nineteen patients (23.5%) had postoperative airway edema, one (1.2%) had trauma to the false cord and laceration of the posterior pharyngeal wall. CONCLUSION: It was concluded that the right main bronchus is the most common site of impaction of inhaled foreign body. Rigid bronchoscopy is very effective procedure for inhaled foreign body removal with fewer complications.

Management outcome of secretory otitis media.

BACKGROUND: Secretory otitis media is a common otological manifestation, that most of the time is left undiagnosed on account of unawarenes s and negligence in seeking early medical attention for trivial ailments. Untreated, it might end up in serious consequences in the form of poor speech and intellectual development and permanent anatomical disabilities within middle ear cleft. The objectives of the study were to determine most affected age group, the common etiological factors. to access the efficacy of medical and surgical treatment and finally to find out the coumplication associated with the surgical procedures. METHODS: This study was conducted in the ENT, Head and Neck Surgery department of the Ayub Teaching Hospital, Abbottabad from January 2001 to December 2003. Only the diagnosed cases of SOM were included in the study. After detailed history, clinical examination, routine investigations and special investigations such as pure tone audiogram and tympanometry were carried out to confirm the diagnosis of SOM . All patients were initially treated by medical therapy. In cases of failure, underwent myringotomy with or without ventilation tube insertion and where indication present adenotonsillectomy and antial lavage was done. Follow up of cases was carried out from 18-24 months. RESULTS: It included 87 patients, 58 were males (66.6%) and 29 females (33.3%). Majority of the patients were between 5-8 years (62%). The most common aetiological factor was rhinosinusitis (36.7%) followed by hypertrophic adenoids (34.5%). All patients were initially given medical treatment. Out of 87 patients,30 patients (34.4%) improved and 57 patients (65.5%) had no response and underwent surgery. Surgical procedures included myringotomy with and without ventilation tube insertion., adenotonsillectomy and antral lavage. CONCLUSION: lt is concluded from this study that conservative treatment has a definite role and should be tried before any surgical step is taken however surgery is the treatment of choice in more resistant cases.

Lemierre's syndrome: a forgotten complication of oropharyngeal infection.

BACKGROUND: Lemierre's syndrome (postanginal sepsis) usually complicates an oropharyngeal infection as septicemia, septic thrombophlebitis of the internal jugular vein, and metastatic lesions, most frequently in the lungs. Fusobacterium necrophorum is the usual etiologic agent. Lemierre's syndrome is not widely known by clinicians. This study aims at creating awareness amongst the clinicians of existence of this potentially fatal but curable clinical entity. METHODS: All the patients admitted in the ENT department of Ayub Teaching Hospital, during the period of January 2000 to December 2002, for the treatment of acute oropharyngeal infection, were critically assessed by consultants, for features of Lemierre's syndrome, and investigated further, accordingly. RESULTS: 156 patients were admitted with acute oropharyngeal infection. Two patients (1.28%) had features suggestive of Lemierre's syndrome. A male and a female, 25 and 28 years old respectively, had a history of a preceding sore throat for a variable duration followed by complications. Attempts were made to make the diagnosis of Lemierre's syndrome and they were treated appropriately, as per recommendations, to a successful outcome. CONCLUSIONS: Widespread use of antibiotics for pharyngeal infections has significantly reduced the incidence. Rare and a forgotten complication, Lemierre's syndrome is potentially fatal. Early diagnosis and prolonged treatment with appropriate antibiotics are usually curative. A high degree of clinical suspicion is necessary for diagnosis. Modern day clinician should be aware of this potentially life threatening clinical entity that may complicate a trivial oropharyngeal infection.

A critical analysis of the management protocols for idiopathic sudden sensori-neural hearing loss.

BACKGROUND: Sudden sensori-neural hearing loss (SSNHL) is a clinical dilemma with great diversity in presentation and poorly understood pathogenesis and hence no definitive treatment protocol as yet. Both sexes are affected, middle age to elderly being the commonest age group. A variety of causes have been implicated as responsible for this condition, but most of the times it is difficult to isolate one, and hence most of the times a battery of investigations proves to be a clinical exercise. A number of treatment protocols have been suggested and used over the years, based on presumed etiological theories, claiming varying degrees of success. METHODS: Relevant literature available on the net regarding the management and the efficacy of various treatment regimens for ISSNHL was critically analyzed by the authors (who are professorial staff of a medical college and consultants of a teaching hospital) to develop a consensus and recommendations on the most appropriate protocol. RESULTS: It was asserted that various treatment regimens have not proved beyond doubt to be superior to one another or spontaneous recovery rates. CONCLUSION: SSNHL is a medical emergency that entails thorough investigations to search for a possible cause and institution of appropriate therapy. Failing identifying a cause, i.e. idiopathic group, combination therapy with steroids and antiviral drugs could prove beneficial provided treatment is instituted early. A number of placebo controlled trials consuming various modalities are needed to determine an optimal treatment of ISSNHL. Psychological and psychiatric assistance has a certain role and so has the rehabilitation in the management of these patients.

Frequency of post-tonsillectomy haemorrhage following tonsillectomy with bipolar diathermy--an experience at Ayub Teaching Hospital, Abbottabad.

BACKGROUND: Tonsillectomy remains one of the most common surgical procedures performed in the world. Various techniques have evolved over the years. One of the most significant complications is postoperative hemorrhage. There is a general perception of increased frequency of PTH with the clectro-cautery technique. A prospective study was designed to determine the frequency of post-tonsillectomy haemorrhage (PTH) following tonsillectomy with bipolar diathermy at ENT department. Ayub Medical College & Teaching Hospital, Abbottabad. METHOD: 246 patients of varying ages and both sexes were operated by the same consultant using bipolar diathermy, during the period of April'2001 to March'2003. All the patients had antibiotic prophylaxis and analgesia on regular basis. Patients were hospitalized for 24-48 hours and were reviewed after one week. RESULTS: 9 (3.6%) patients presented with PTH. These presented between day 3 and 11.4(1.6%) presented with active bleeding, 3(1.2%) presented with clot in the tonsillar fossa and 2(0.8%) had a history of bleeding per-orally at home but did not have evidence of bleeding on arrival. All the patients were hospitalized and treated with a broad spectrum intravenous antibiotic, parenteral analgesia and intravenous fluids. None of the patients needed surgical intervention. CONCLUSION: Tonsillectomy with bipolar diathermy doesn't carry risk of PTH different from other standard techniques. It has the added benefit of minimal per-operative bleeding which bears significance in paediatric population. However adequate training in its use is mandatory to avoid thermal damage to the tissues.