Role of Pre-Operative High-Resolution Computed Tomography for Surgical Planning in Patients Undergoing Cochlear Implantation - An Observational Study.

Background: Currently preoperative magnetic resonance imaging (MRI) brain and High-Resolution Computed Tomography (HRCT) scanning of temporal bones form part of routine Cochlear implantation (CI) assessment. Pre- operative imaging demonstrates anatomic details or anomalies if any, that prove essential in pre-surgical evaluation of patients. These form a road map for the surgeon to anticipate any difficulty during surgery, to aid in decision making to implant the most appropriate ear, plan surgical technique, or select electrode arrays. Methods: A descriptive observational pilot study was conducted at tertiary care hospital involving 51 paediatric patients worked-up for CI. Patients after detailed clinical evaluation and MRI Brain, a tentative surgical plan was formulated by a candidacy CI screening committee. Patients selected for surgery underwent HRCT temporal bones and surgical plan was modified after analysing the same. Percentage of cases in which surgical plan changed (in terms of laterality of surgery) after correlating with HRCT findings were determined and data analysed. Results: A total of 51 patients worked up for CI were included in the study. In 37.3% cases, there were unfavourable MRI findings. HRCT scan was used to aid the surgical road map in these patients, which based on MRI findings would have had suboptimal outcome. Conclusion: With this understanding, we recommend that, MRI with precise interpretation would be sufficient to furnish all necessary information in preoperative assessment of CI patients, and a HRCT temporal bones maybe indicated only in difficult cases or those with unfavourable MRI findings, may aid predict surgical events.

Evaluation of surgical skill among otology residents during cadaveric temporal bone dissection using an objective assessment tool.

Background: The acquisition and refinement of technical skills by the surgical residents are central to surgical teaching; hence, there is increasing interest in the objective assessment of surgical competence. In the field of otology, as of now, there are limited studies for the assessment of surgical competence, also, various subjective methods are being used to assess this vital aspect of training. This study aimed to validate and use an objective assessment tool for the valuation of surgical skills in a tertiary care teaching institute in the Indian subcontinent. Methods: Surgical competence of the residents in temporal bone dissection was assessed on a Likert scale by using a grading scale developed by Wan et al., after obtaining necessary permissions. Results: Junior residents in ENT who had completed one year of residency in otolaryngology were asked to perform temporal bone surgery (cortical mastoidectomy) and were marked according to the proforma by two senior experienced otologists. The Cronbach's alpha value was .86 which is an indicator of good technical validity. Conclusions: In our study, we have validated a grading scoring scale used by Wan et al. to objectively assess the ability of an otology resident to perform temporal bone surgery. It is recommended for use in Indian scenario due to its good technical validity. The use of a Likert scale to individually rate each competency makes the evaluation precise and simple.

Evaluation of the Viability of Auditory Steady State Response Testing for Detection of Pseudohypacusis in Serving Personnel of the Indian Armed Forces.

The most popular objective physiologic test for detecting hearing loss that is in use today is the ABR, however it is not frequency specific. The frequency specific tool available for evaluation of hearing is ASSR. The study is aimed to assess the ability of ASSR to estimate hearing thresholds and identify the ideal modulation frequency in hearing impaired personnel. All subjects and controls were subjected to PTA to determine presence/absence of hearing loss, and the nature and configuration of the hearing loss if any. The subjects were then subjected to ASSR testing to objectively ascertain hearing thresholds. The PTA thresholds obtained and the hearing thresholds obtained by ASSR were correlated in this study. The study was carried out in 100 subjects under the age of 50 years (50 with normal hearing & 50 with impaired hearing by PTA) after obtaining informed consent. Moderate correlation was found between PTA and ASSR thresholds only in certain frequencies while in other frequencies the correlation though present, was low. This study concluded that ASSR system could be used to estimate hearing thresholds only approximately as no significant linear correlations were found between PTA thresholds and ASSR at the tested frequencies.

Identifying entrustable professional activities for post-graduation in ENT: What should an ENT specialist be able to do?

BACKGROUND: Though regulatory bodies of medical education in India mandate post graduate medical education to be competency based, the implementation of the same has not kept pace. The present study aims to develop and propose a set of entrustable professional activities for a masters degree in the discipline of ENT. It also attempts to present it in the form of a portfolio. METHODS: Experts in the subject went through a series of activities including brainstorming, discussions and internal peer review to shortlist and enumerate EPAs. RESULTS: 335 EPAs were identified and are presented. They were further classified as per need and expected expertise. CONCLUSION: The EPAs may serve as a guideline to medical colleges/institutions aiming to adopt competency based medical education in the post graduate curriculum in the subject of ENT.

Use of Otoacoustic Emissions (OAE) to detect sub-clinical inner ear damage in divers of the Indian Navy.

BACKGROUND: Professional Divers are at a high risk of Sensorineural Hearing Impairment. Divers may sustain sub-clinical hearing loss that is not identified on pure tone audiometry (PTA). Otoacoustic Emissions (OAE) reflect the functional status of the Outer Hair Cells. OAE testing constitutes the only non-invasive means of objective cochlear investigation and may be a more sensitive measure than PTA in identifying sub-clinical hearing loss. METHODS: This cross-sectional study was performed to determine utility of Otoacoustic Emissions testing in detecting sub-clinical Inner Ear damage in divers of Indian Navy. Transient Evoked Otoacoustic Emissions (TEOAE) levels were measured in 50 audiologically asymptomatic ship divers of Indian Navy and compared with control group comprising of 50 normal hearing individuals. RESULTS: No statistically significant differences were observed between the study and control group. Also no correlation was observed between diving years and TEOAE levels. There was no correlation greater than -0.49 between diving years and TEOAE SNR. CONCLUSIONS: We concluded that TEOAE levels are not a sensitive tool in identifying ships divers without any history of noise exposure at risk for developing hearing loss.

High resolution multi detector computed tomography of temporal bone: our experience in a tertiary care service hospital.

High resolution multi detector computed tomography (HRMDCT) is an excellent tool for evaluation of a variety of congenital and acquired conditions affecting the temporal bones. We describe our experience of HRMDCT of temporal bones of 145 patients in a tertiary care and teaching hospital of Armed Forces Medical Services of India over a period of three and half years. Hearing loss was the most frequent indication for HRMDCT and congenital bilateral profound sensorineural hearing loss for evaluation prior to possible cochlear implant formed the single largest group (62, 42%) among all indications for HRMDCT of temporal bones. Major vestibule-cochlear and semicircular canal anomalies were noted in 11 such cases. Seven patients of microtia were studied and all had positive CT scan findings. All patients of vertigo had normal HRCT study. Extent of temporal bone injuries and inflammatory conditions were clearly delineated in all cases. Thinner collimations allowing image reconstructions in planes of anatomical interest with near isotropic resolution has been a major advantage of HRMDCT of temporal bones.

Lateral temporal bone resection for malignancy of external auditory meatus: our approach.

OBJECTIVE: Surgical management of tumors of the external ear remains controversial with regard to the extent of resection and the efficacy of piecemeal resection compared to standard en bloc resection. The objective was to study the results of lateral temporal bone resection with soft tissue resection used at our centre in managing a series of such cases. SETTING: Tertiary referral centre PATIENTS: A retrospective study was carried out on seven cases of temporal bone malignancies treated at our center, with lateral temporal bone resection by the otologic microsurgical technique and superficial parotidectomy, with adjuvant radiotherapy where indicated. The mode of presentation, clinical and pathological staging, extent of surgical resection, reconstructive methods used and adjuvant therapy given were evaluated. The disease free survival on follow-up was noted. RESULTS: Disease free survival achieved was comparable with other published series, with acceptable morbidity patterns. CONCLUSION: Lateral temporal bone resection using otologic microsurgical technique with soft tissue resection is an effective way of achieving control of temporal bone malignancies.

Management of the node negative early carcinoma tongue.

OBJECTIVE: To determine the role of thickness of the primary lesion in early Squamous Cell Carcinoma (SCC) of the oral tongue for decision-making regarding the management of possible occult cervical node metastases. SETTING: Tertiary referral centre PATIENTS: Patients who were treated by the authors for early (T1, T2) primary lesions in the oral tongue in two malignancy treatment centres of the Armed Forces Medical Services were included in this prospective study. Where the primary lesion was less than 04 mm in depth, the neck was not addressed electively. Those who developed nodal disease in the neck on follow up were subjected to comprehensive neck dissection. In those patients where the tumour thickness was more than 04 mm, the neck was addressed with at least a supra-omohyoid neck dissection. Postoperative radiotherapy was given as per standard indications. The patients were followed up as per standard protocol. RESULTS: Disease free survival rate achieved was 86% and this compares well with survival rates achieved by other workers. CONCLUSION: Treatment of neck nodes in early (T1,T2) SCC of the oral tongue can be expectant in cases where tumour thickness is less than 04 mm, but where it is more than 04 mm elective treatment of the neck is recommended.

Ultrasonography: Its role in nodular thyroid disease.

OBJECTIVE: The objective was to correlate the number, size and extent of the nodules as determined during the preoperative clinical examination of the thyroid gland, USG, intra-operative examination and histopathology. Also, FNAC (with or without USG guidance) and USG findings suggestive of malignancy were correlated with the final histopathology. SETTING: Tertiary referral centre PATIENTS: A retrospective chart review was done for 106 patients who underwent surgery for benign or malignant nodular thyroid disease in our center, between Jan 2004-Dec 2006. RESULTS: USG has 7 times higher predictive value than clinical examination in detecting number of nodules and determining size of nodules. USG guided FNAC has a sensitivity of 85.71% and specificity of 90.0% in detecting malignancy in nodular thyroid disease. However for predicting malignancy in thryoid nodules, this study shows that USG has a sensitivity of 20.0% and specificity of 97.67%. CONCLUSION: In patients with nodular thyroid disease, USG can accurately determine the number and the size of the nodules. It is extremely useful in guiding FNAC; However its role in predicting malignancy is doubtful. We therefore recommend that USG guided FNAC be carried out as a routine in the evaluation of thyroid nodules.

Cochlear implantation in multi-handicapped patients: the merf experience.

Hearing loss is the most common form of sensory impairment in humans. When hearing impairment is present from birth or is acquired in early childhood, it can be devastating for normal development. Early childhood deafness also has implications for cognitive, emotional and social development. In the majority of cases of early childhood hearing impairment, deafness is an isolated disorder. However, in a substantial number of cases, early childhood hearing impairment is not isolated, but forms part of a genetic syndrome with associated handicaps, or is acquired through pre-, perior postnatal causes, possibly with associated deficits. This means that more demands are made on the child's family, the teachers and medical professionals to help these children cope with their rehabilitation, needs and demands. The presence of an additional handicap can pose special problems with regard to surgery, anesthesia or rehabilitation. Cochlear implantation is effective and aids in the effective rehabilitation of other additional handicaps. However, careful patient selection is required and thorough parental counseling regarding expectations must be given. In our Cochlear Implant Clinic a large proportion of implantees are in the paediatric age group. Of these, a few have had multiple disabilities in addition to their deafness. This paper attempts to share our experience in this extremely challenging and specialized field.

Surgical management of trismus due to Oral Submucous Fibrosis - Lysis of fibrotic bands with the KTP-532 Laser.

Oral Submucous Fibrosis is an insidious, chronic disease affecting the oral cavity, sometimes the pharynx and rarely the tongue. 15 patients with Oral Submucous Fibrosis presenting with severe trismus were treated with lysis of the fibrotic bands with a KTP-532 Laser and adjunctive treatment with excellent results over a 12 month follow-up period.