Laser Myringotomy Versus Ventilation Tubes In Otitis Media With Effusion.

BACKGROUND: Otitis media with effusion (OME) is a leading cause of difficulty in hearing in paediatric population. Otitis media with effusion must be detected and managed early to prevent conductive hearing loss in children. It was aimed to compare results of laser myringotomy and ventilation tube insertion, in terms of hearing improvement and recurrence of Middle ear effusion (MEE). METHODS: This randomized controlled trial was conducted from February 2012 to January 2015. Children of 4- 12 years of age with decreased hearing due to OME were included in the study. These children were investigated with pure tone audiometry (PTA) and tympanometry to confirm conductive hearing loss. Patients were put in 2 groups, group one comprised of patients treated with laser myringotomy and group 2, treated with ventilation tube insertion. The objective was to evaluate and compare results of the two procedures in terms of resolution of middle ear effusion (MEE) and improvement of hearing. The two procedures were also compared in terms of complications like otorrhea, persistence of perforation, hypertrophic scar and thinning of tympanic membrane (TM). RESULTS: Middle ear effusion cleared in 35 out of 68 ears with laser myringotomy (LM) as compared to 52 out of 62 ears with ventilation tubes (VT). The myringotomy was still patent in 21 ears treated with LM while tube was in site in 50 years with VT after 3 months. The hearing level improved with LM by 10-15 dB after first 3 months. CONCLUSIONS: The aim in Otitis media with effusion is ventilation of tympanic cavity. Laser myringotomy can be substitute to ventilation tube insertion (VT). But it remains patent for shorter time and less effective than VT. The ears with refractory or recurrent MEE should have VT insertion.

Efficacy of gastric aspiration in reducing post-tonsillectomy vomiting in children.

BACKGROUND: Nausea and vomiting are two of the most frequently experienced postoperative side effects complicating one third of the cases. The objective of this study was to determine the effectiveness of gastric decompression in reducing the incidence and complications associated with post-tonsillectomy vomiting in children. METHODS: This was a randomised control study conducted at the ENT Department, Ayub Teaching Hospital Abbottabad from January to June 2012. Patients included in this study were divided into two groups, group A undergoing gastric aspiration and group B not undergoing gastric aspiration. Gastric aspiration was done with an oro-gastric tube placed under direct visualisation while the patient was still under general anaesthesia. The incidence of vomiting, episodes of vomiting and the need for rescue anti-emetic prophylaxis were noted. RESULTS: A total of 54 patients were included in the study. Their ages ranged from 5 to 12 years with mean age 7.85 +/- 2.18 years. No statistically significant difference (p > 0.05) was noted between the two groups for the patients experiencing vomiting (33% vs 41%, p = 0.389), the mean number of episodes of vomiting (0.71 vs 0.88, p = 0.555), and patients requiring rescue anti-emetics (11% vs 15%, p = 0.500). CONCLUSION: Gastric aspiration during tonsillectomy is not useful in reducing post-tonsillectomy vomiting.

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.

Successful treatment of proximal white subungual onychomycosis with oral terbinafine therapy.

Proximal white subungual onychomycosis (PWSO) is a rare form of onychomycosis of both fingernails and toenails. It occurs when the fungus invades the stratum corneum of the proximal nailfold followed by infection of the deeper parts of the nail plate. The surface of the overlying nail is usually normal. A case of PWSO is described with complete cure by the use of oral terbinafine 250 mg/day for 3 months continuously.

Fixed drug eruption and intradermal provocation tests.

OBJECTIVE: To determine the role of Intradermal Provocation (IDP) tests in Fixed Drug Eruption (FDE). STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Dermatology Unit, Shaikh Zayed Hospital, Lahore, from August 2004 to July 2006. METHODOLOGY: The tests were performed in 96 patients in two stages. At stage I, suspected drugs were given intradermally. Changes at injection site in FDE lesions or any systemic effects were observed. In patients showing no response to IDP, Oral Provocation (OP) was performed (stage II) and its effects in FDE lesions or any systemic effect were observed. The positive response of FDE lesions after IDP and OP were compared with local changes at injection site. Control intradermal tests were repeated in normal persons with drugs and in FDE patients with distilled water on normal skin. RESULTS: At stage I, 46 positive cases had local signs of erythematous indurated nodule with or without hemorrhagic centre, urticarial weal with hemorrhagic centre and erythematous indurated nodule with central vesicle. At stage II, 41 patients had similar local signs. The changes at injection site to those of FDE lesions were compared. Z-test for proportions showed no significant difference between groups (p-value > 0.05). Control tests were negative. CONCLUSION: The drug producing erythematous indurated nodule with or without hemorrhagic centre, vesicle or urticarial weal with hemorrhagic centre at injection site was the most likely drug causing fixed eruption.

Prevalence of hepatitis B surface antigen carrier state in patients with lichen planus--report of 200 cases from Lahore, Pakistan.

BACKGROUND: To determine the prevalence of hepatitis B surface antigen carrier state in patients with lichen planus. METHODS: A quasi experimental cross sectional study was done at Department of Dermatology, Shaikh Zayed Federal Postgraduate Medical Institute, Lahore, Pakistan, from April 2003 to March 2005. Two hundred clinically diagnosed cases of LP and equal number of patients with other dermatoses not reportedly associated with hepatitis B virus (HBV) infection (control group) were collected from Skin Out Patient Department. They were screened for hepatitis B surface antigen (HBsAg) by Enzyme Linked Immunosorbent Assay (ELISA). Statistical analysis was done by using SPSS package version 11. RESULTS: Out of 200 patients of each group, three patients with LP and seven patients from control group were positive for HBsAg. The test of significance for proportions revealed that there was no significant difference (p > 0.1) between two groups. CONCLUSION: No association between HBsAg carrier state and LP was found in our study.

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.

Fixed drug eruption: topical provocation and subsequent phenomena.

OBJECTIVE: To determine the usefulness of topical provocation in detecting the incriminated drug causing fixed eruption. DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Dermatology, Shaikh Zayed FPGMI, Lahore, from November 2002 to December 2005. PATIENTS AND METHODS: Three hundred and five, clinically diagnosed cases of Fixed Drug Eruption (FDE) of either gender and of any age were subjected to topical provocation with different drugs by using concentration of 1% (n=203), 2% (n=210) and 5% (n=235) in white soft paraffin. Drug ointment of one strength was applied one at a time on normal skin of flexor surface of right or left forearm. The effects of tests on involved and uninvolved skin were observed for 48 hours. The changes in lesions like erythema, hyperpigmentation, itching, burning or appearance of new lesion were considered a positive response. In case of no change, the patients (n=5) were subjected to oral provocation test, by giving half to full therapeutic dose of the suspected drug depending upon the severity of the initial attack. A patient who exhibited see-sawing phenomenon with 5% metamizole TPT was given oral challenge with same drug. Control topical tests were repeated in equal number of normal persons with various drug ointments and in patients of FDE with white soft paraffin on normal and affected skin. RESULTS: One hundred and thirty-seven patients were males and one hundred and sixty-eight patients were females. Maximum number of patients belonged to third decade. With 1% drug preparations 12 out of 316, with 2% drug preparations 28 out of 422 and with 5% drug preparations, 312 out of 523 TPTs were positive. The comparison revealed a highly significant association (Chi-square 448.1 and p < 0.000) among various strengths of preparations and positive response. Sulphamethoxazole was found to be the most commonly incriminated cause of FDE applied in 5% concentration yielded sensitivity rate of 91% compared to 4% with lower concentrations. Positive patch test was also observed with oxytetracycline. Five patients who were given oral provocation with different drugs were found to be positive to tinidazole, dapsone, propylphenazone, belladonna and phenobarbitone. Interesting phenomena like earlier reactivation of lesion situated distal to site of application of preparation, marching, see-sawing (with oral metamizole) and lightening observed, are not yet reported in literature. CONCLUSION: Topical provocation test with 5% drug concentration applied on normal skin of patient with FDE is a possible first line investigation in finding the incriminated drug.

Itraconazole pulse therapy in the treatment of disto-lateral subungual onychomycosis.

OBJECTIVE: To assess the efficacy of itraconazole pulse therapy in disto-lateral subungual onychomycosis. DESIGN: Quasi interventional study. PLACE AND DURATION OF STUDY: The study was conducted at the Department of Dermatology, KEMC/Mayo Hospital, Lahore, during the period from 1996-1998. SUBJECTS AND METHODS: Sixty-seven patients, ages ranging from 19 to 55 years, with disto-lateral subungual onychomycosis were enrolled in the study period. Therapy was started with short pulse doses of itraconazole 200 mg twice daily for one week followed by a medicine-free interval of three weeks. Pulses were administered for two consecutive months in fingernail and three months for toenail onychomycosis. Patients were followed up to six months for fingernail onychomycosis and nine months for toenail onychomycosis. RESULTS: Out of 67 cases, there were 62 evaluable patients. Trichophyton rubrum was the most common pathogen, isolated in 42 (67.8%) followed by Candida in 11 (17.8%), T. violaceum in 5 (8%), T. interdigitale in 3 (4.8%) and Epidermophyton floccosum in one (1.6%). Fingernails were affected in 46 cases whereas 16 had toenail infection. Clinical cure in finger and toenail onychomycosis was seen in 41 (89%) and 13 (81.2%) patients, respectively while mycological cure in 43 (93.5%) and 14 (87.5%) patients, respectively with itraconazole pulse therapy. CONCLUSION: Itraconazole was found to be effective, well-tolerated and safe therapy for disto-lateral subungual onychomycosis.

Frequency of anti-HCV antibodies in patients with lichen planus.

OBJECTIVE: To determine the frequency of anti-HCV antibodies, identify risk factors associated with HCV infection and to screen asymptomatic carriers in patients with lichen planus. DESIGN: A prospective study. PLACE AND DURATION OF STUDY: This study was carried out in the out patient department of Dermatology, Shaikh Zayed Hospital, Lahore, from October, 1999 to September, 2001. SUBJECTS AND METHODS: A total of 184 clinically diagnosed cases of lichen planus (LP) were selected for the study. Blood samples of all the patients were tested for anti hepatitis C virus antibodies (anti-HCV Ab). Polymerase chain reaction for hepatitis C virus was done in patients with positive anti-HCV Ab. Transcutaneous liver biopsy was performed in 7 patients with positive HCV-RNA. The histopathological results were evaluated using validated Metavir and Knodell scoring systems. RESULTS: Out of 184 LP patients, 43 (23.4%) were anti-HCV antibodies positive. Females were predominantly affected and male to female ratio was 1:5.1. Maximum positivity for anti-HCV was observed in age group 31-40 years (39.53%) followed by 41-50 years (25.58%). Eighty-one percent patients had history of dental treatment and 63% had received multiple injections for various ailments. Forty percent patients had family history of jaundice while 26% had jaundice in the past. Ten out of 16 anti-HCV antibody positive patients, checked for HCV-RNA, had high levels of virus in blood. Transcutaneous liver biopsy done in 7 patients revealed underlying liver disease at various stages. Four patients treated with alpha-interferon and ribazole therapy for liver disease, showed marked improvement in their skin disease. CONCLUSION: A high prevalence of HCV infection was detected in patients with lichen planus. Patients with lichen planus should be screened for HCV carrier state.

Common allergens in shoe dermatitis: our experience in Lahore, Pakistan.

BACKGROUND: Shoe dermatitis is a form of contact dermatitis resulting from exposure to shoes. Different chemicals, in conjunction with a hot and humid environment within the shoe, give rise to allergic or irritant dermatitis. Allergic shoe dermatitis is commonly caused by constituents of rubber, leather, adhesives, and rarely by linings and dyes. AIM: To determine the frequency of various allergens in shoe dermatitis in our patients. METHODS: One hundred and nine patients suspected of having contact dermatitis due to shoe allergens were included. All patients were patch tested with the Shoe series and European Standard series. Patches were applied on the upper back and removed after 48 h. Results were read at 48, 72, and 120 h and interpreted according to International Contact Dermatitis Research Group (ICDRG) criteria. RESULTS: Of the 119 patients, 87 (73%) reacted positively to various allergens, 48% of whom showed polysensitivity. Glues (33.6%), particularly para-tert-butylphenol formaldehyde resin (PTBP-FR) (26.9%), were the leading cause of shoe dermatitis. Other allergens were leather chemicals (26.4%), potassium dichromate (16.18%), rubber allergens (7.6%), and dyes (7.6%). Shoe scrapings tested positive in 26.3% of patients. Other common allergens were nickel sulfate (22.7%), neomycin sulfate (10.1%), and cobalt chloride (8.4%). CONCLUSIONS: Considering the diversity of allergens, all patients presenting with shoe dermatitis should be patch tested with the Shoe series and a standard series to determine the etiologic allergens.

An unusual N-terminal deletion of the laminin alpha3a isoform leads to the chronic granulation tissue disorder laryngo-onycho-cutaneous syndrome.

Laryngo-onycho-cutaneous (LOC or Shabbir) syndrome (OMIM 245660) is an autosomal recessive epithelial disorder confined to the Punjabi Muslim population. The condition is characterized by cutaneous erosions, nail dystrophy and exuberant vascular granulation tissue in certain epithelia, especially conjunctiva and larynx. Genome-wide homozygosity mapping localized the gene to a 2 Mb region on chromosome 18q11.2 with an LOD score of 19.8 at theta=0. This region includes the laminin alpha3 gene (LAMA3), in which loss-of-expression mutations cause the lethal skin blistering disorder Herlitz junctional epidermolysis bullosa. Detailed investigation showed that this gene possesses a further 38 exons (76 exons in total) spanning 318 kb of genomic DNA, and encodes three distinct proteins, designated laminin alpha3a, alpha3b1 and alpha3b2. The causative mutation in 15 families was a frameshift mutation 151insG predicting a stop codon 7 bp downstream in an exon that is specific to laminin alpha3a. This protein is secreted only by the basal keratinocytes of stratified epithelia, implying that LOC is caused by dysfunction of keratinocyte-mesenchymal communication. Surprisingly, the 151insG mutation does not result in nonsense-mediated mRNA decay due to rescue of the transcript by an alternative translation start site 6 exons downstream. The resultant N-terminal deletion of laminin alpha3a was confirmed by immunoprecipitation of secreted proteins from LOC keratinocytes. These studies show that the laminin alpha3a N-terminal domain is a key regulator of the granulation tissue response, with important implications not only in LOC but in a range of other clinical conditions associated with abnormal wound healing.