Monopolar cautery versus cold steel dissection for tonsillectomy in children. a randomized clinical trial

Objective: To compare monopolar cautery with cold steel dissection for tonsillectomy in pediatric age group

Study Design: A randomized clinical trial

Place and Duration of Study: Ear, nose and throat [ENT] department Combined Military Hospital Gujranwala, from Jan 2013 to Jan 2015

Material and Methods: A total of 220 consecutive pediatric patients undergoing tonsillectomy for recurrent or chronic tonsillitis between Jan 2013 to Jan 2015. Both groups were compared with regards to surgery time, intraoperative bleeding, post operative pain and complications

Results: A total of 20 patients were excluded from the study for various reasons while the data of the rest of the patients has been presented. Mean age of the study group was 8.82 years. A total of 58% of the patients were male. Average time of surgery for monopolar cautery was 29.33 [SD 2.77] min as compared to 18.53 min [SD 2.94] for dissection method which was significant [p<0.005]. Average blood loss for monopolar surgery was 11.66 ml and 29.04ml for dissection method [p<0.005]. Average pain scores were less for dissection method at 2nd post op day 3.59 vs. 5.51. Rates of primary and secondary hemorrhage were less for monopolar method although they were not statistically significant

Conclusion: Monopolar cautery though causes decreased intraoperative blood loss however requires longer anesthesia and causes significant post operative pain to the patient

Nasal packing with ventilated nasal packs; a comparison with traditional vaseline nasal pack

Objective: To compare the benefits of ventilated nasal packing with traditional vaseline guaze nasal packing

Study Design: Randomized controlled trial

Place and Duration of Study: This study was conducted at CMH Multan, from Jun 2014 to Dec 2014

Material and Methods: In this study, sample size of 80 patients was calculated using WHO calculator. Patients were divided in two groups using lottery method endotracheal tube and piece of surgical glove filled with ribbon guaze was utilized for fabricated ventilated nasal pack and compared with traditional nasal packs. Nasal obstruction and sleep disturbance were studied at eight hours and twenty-four hours following surgery using visual analog scale

Results: Mean nasal obstruction with ventilated nasal pack was 45.62 +/- 6.17 and with Vaseline nasal pack was 77.67 +/- 4.85 which was statistically significant [p=0.001] in both the groups. Mean sleep disturbance in both the groups was 46.32 +/- 5.23 and 68.75 +/- 2.70 respectively which was statistically significant [p=0.001] in both the groups

Conclusion: Patients with ventilated nasal packs were found to have better tolerance to nasal packs due to less nasal obstruction and sleep disturbance

Clinical comparative study of efficacy of Epley manoeuvre and Semont manoeuvre in benign paroxysmal positional vertigo

To compare the efficacy of Epley manoeuvre and Semont manoeuvre in the management of benign paroxysmal positional vertigo. Randomized controlled trials. ENT Department Combined Military Hospital [CMH] Kharian and Gilgit from March 2005 to February 2010. Hundred cases of benign paroxysmal positional vertigo [BPPV] were selected on Dix-Hallpike test by non probability convenient sampling technique and randomly divided into two groups of 50 cases each. Patients in group-1 were treated by Epley manoeuvre and patients in group-2 were treated by Semont manoeuvre. The patients were examined on first day, 3[rd]30 day, 7[th] day and after 01 month and clinical results were observed. In group-l, 68% cases showed immediate resolution of symptoms, 74% cases on 3[rd] day, 80% cases on 7[th] day and total 82% cases recovered completely after one month. In group-2, 62% cases showed immediate resolution of symptoms, 68% cases on 3[rd] day, 74% cases on 7[th] day and total 78% cases showed complete recovery after 1 month. There was insignificant difference between the two groups regarding recovery at different follow ups. It was concluded that Epley and Semont manoeuvres are equally effective in the management of BPPV

Tympanic membrane disintegration by otomycosis

To report ear drum disintegration in cases of otomycosis. Case series study. E.N.T and Head and Neck Surgery Department PNS Shifa Hospital Karachi and E N T Department of Combined Military Hospital, Quetta Cantt from August 2009 to October 2010. 242 patients with clinical diagnosis of otomycosis were registered over a period of 15 months. On registration ear was meticulously cleaned under microscope removing fungal debris to establish the integrity of eardrum. In the same sitting cream with combination of triamcinolone acetonide, neomycin sulphate, gramicidin, nystatin was applied all around within external auditory meatus [EAM] on effected walls and same drops were advised locally thrice daily for 3 to 5 days. Every patient was advised to report back immediately on occurrence of irritation, earache, ear discharge, blockage of ear and pain. Out of 242patients [140 males and 102 females] 110 [45.45%] were cured after single visit as outpatient adopting a regimen of single application of antifungal cream and thrice daily antifungal ear drops for 5 days after proper cleaning of fungal debris from EAM. 73 [30.16%] cases were cured of otomycosis after two sittings of same regimen. 59 [24%] patients neglected the otomycosis for days to weeks till the time pain became unbearable. In 18 [7.43%] patients ear drum was perforated by otomycosis and all these patients had neglected the disease. Neglected Qtomyeosis has all the potentials to create a defect in ear drum causing chronic disability .Meticulous cleaning and local antifungal therapy still remains the gold standards for curing otomycQsis

Effect of preoperative dexamethasone on postoperative pain, emesis and haemorrhage in tonsillectomy by dissection method

To compare the effect of single preoperative intravenous dose of dexamethasone on postoperative morbidity that is pain, episodes of emesis, and hemorrhage in patients undergoing tonsillectomy by dissection method with those who do not receive dexamethasone. Randomized control type. ENT Department Combined Military Hospital Rawalpindi, from Feb 2006 to Feb 2007. After getting informed consent a total of 60 patients who fulfilled the probability sampling. Group A received 0.25 mg/kg body weight [maximum 20 mg] of dexamethasone intravenously 10 minutes before start of operation while group B [control group] did not receive any steroid. Pain control had significant difference in both groups with better control rates in group A. Similarly, emesis control was significantly better in group A. There was no significant difference in secondary haemorrhage in the two groups. Single dose of dexamethasone given preoperatively significantly reduces the postoperative morbidity that is pain, episodes of emesis with no effect on secondary hemorrhage in patients undergoind tonsillectomy by dissection method

Pressure splintage by coat buttons versus simple pressure dressing in management of hematoma pinna

To compare pressure splintage by coat buttons versus simple pressure dressing in management of haematoma pinna in terms of re-accumulation, perichondritis and cosmetic deformity. Randomized clinical trial. Department of ENT, Combined Military Hospital, Rawalpindi from October 2007 to February 2009. Sixty patients of haematoma pinna, of less than one month duration, were selected and randomly allocated to the button splintage and the pressure dressing groups. There was significantly less re-accumulation of haematoma in patients in whom pressure splintage was performed by coat buttons [3.33%] as compared to simple pressure dressing [26.66%]. There was no difference in perichondritis [3.33%] in both the groups, while difference in cosmetic deformity [16.66%] in button group and [33.33%] in dressing group was not statistically significant. pressure splintage by coat buttons is more effective than simple pressure dressing in preventing re-accumulation of haematoma pinna

Horner's syndrome as a co-presentation of tuberculous retropharyngeal abscess

Tuberculosis is a disease known to affect any part of the body and to present in many interesting forms. A case of tuberculous retropharyngeal abscess is described here presenting with odynophagia and Horner's syndrome. Horner's syndrome as a presenting feature of tuberculous retropharyngeal abscess has never been reported in Pakistan

Comparison of locally made phonating device versus oesophageal speech in postlaryngectomy speech rehabilitation

To compare the effectiveness of locally made phonating device with oesophageal speech as a communication method in a laryngectomized patient. Randomized Controlled Trial. Combined Military hospital Lahore from January 2004 to July 2007. Twenty five patients who had undergone total laryngectomy were divided in two groups by random sampling. 13 patients were placed in experimental group and provided with a locally made phonating device El [Electro-larynx, 'BM Talk'] and speech training with this device started between 20th to 30th post-operative day. The results were compared to a Control Group consisting of 12 laryngectomized patients who were provided instruction and training on oesophageal speech for communication. Speech assessment was made at the end of 2nd, 4th and 6th month post-operatively in both the groups. Assessment parameters were defined according to the patient's ability to communicate ten predetermined sentences of Urdu and Punjabi to a team of three speech assessors on each speech assessment day. Speech communication score was fixed at 100 if all the spoken sentences were fully understood by all the three assessors irrespective of character of speech, while it was 0 if none of the sentence spoken could be understood by any of the three assessors. In between the two were different percentages of speech communication scores depending on the number of sentences understood by the speech assessors. The character of voice was assessed by Visual Analogue Score where variation between robotic and normal speech character were divided into ten grades from 1 to 10. At the end of six months, speech communication score was 76.62 with SD 17.29 for EL [Electro-Larynx]; while for control group [oesophageal speech] it was 34.17 with standard deviation of 8.63. Those score was compared by using t test and was highly significant i.e. <0.001 in favor of EL. The character of voice was closer to normal in case of oesophageal speech compared to EL where it was closer to robotic. Locally made EL [Electro-larynx] 'BM Talk' is a useful device for speech rehabilitation in laryngectomised patient. It has added advantage of local availability and cost effectiveness. The character of voice may be robotic and monotonous, nevertheless full sentence can be communicated with relative ease to the listener, which is more important factor in our setup

comparison of oral and topical steroid therapy for recurrent apthous stomatitis

This study was carried out to compare the efficacy of oral and topical Steroids in the treatment of Recurrent Apthous Stomatitis [RAS]. It was a quasi-experimental interventional study conducted on 60 patients of Recurrent Oral Ulcers seen in ENT Department of the Combined Military Hospital, Peshawar and Quetta, and was carried out in these hospitals from 01 August 2008 to 31 May 2010. Sixty patients, age ranging from 20 to 40 years; both genders were selected for the study purpose. The patients were included on the basis, having experienced oral ulcers at least thrice during the last one year severe enough to cause significant discomfort leading to absence from work place and remained afebrile during the ailment. Patients suffering from Hypertension, Bronchial Asthma, Glaucoma or Acid Peptic Disease were excluded. People taking medicines of any kind were not included in the study. Children, lactating mothers and pregnant females were excluded. Patients fulfilling the criteria were divided into two groups. Group I were given tablet Prednisolone [45mg] in daily divided doses for three days. Group II were prescribed topical application of Steroid[Triamcinolone acetonide] for the same duration. The day on which the treatment was started was counted as Day 1, the patients were re-examined on Day 2, 4 and 7. 91% of the patients of group I were symptom free on Day 4. Rest of the patients though not fully recovered were able to resume normal pattern of life. Only 47% of the patients of group II had comparable outcome on Day 4.On Day 7 all the patients of group I were normal while 18% of group II had some residual symptoms. Short term therapy of oral steroids brings an early and significant improvement in clinical picture of patients with RAS

Frequency of chronic suppurative otitis media in the junior ranks of Pakistan Army

The purpose of this study were to find out the frequency of chronic suppurative otitis media [CSOM] in the junior ranks of army, and to find out the number of such patients serving in low medical category due to CSOM. It was a simple multi-centre descriptive study. This study was conducted in ENT department of Combined Military Hospital Lahore from March 2003 to August 2003. Feedback was also taken from CMH Abbottabad and HIT Hospital Wah during this period. A total of 5000 junior ranks were examined for CSOM. Out of these 56 [1.12%] were suffering from inactive mucosal disease. Seventy nine [1.58%] had active mucosal disease. Attico antral disease was present in 33 [0.66%] subjects and out of these 8 [0.16%] subjects had undergone mastoid exploration in the past. Ninety [1.8%] cases were serving in low medical category due to CSOM. The frequency of CSOM is significantly high in the army [03.36%], considering that all inductions are made after initial medical examination. By observing few precautions the frequency may be reduced, thus decreasing the financial drain on national exchequer

Laterality of pleomorphic adenoma of parotid gland

Although pleomorphic adenoma is the commonest benign tumor of both major and minor salivary glands, yet it bears certain peculiar characters like invariable growth rate, short spells of spurts of growth, long quiescent periods, invasion of surrounding tissues by its capsular projections, recurrence, notorious for implantation and classic origin from the tail of parotid gland. Since the nerve of facial expression [facial nerve] falls within the domain of otolaryngologists but its course along with its variable branches through the parotid gland has always remained an area of common interest between general and ENT surgeons. With the more and more involvement of E.N.T. surgeons in head and neck oncology, the cancer of salivary glands looks to be being taken over by them in recent decades. FNAC inspite of its accuracy is loosing its superiority over modern ultrasonography. This is an observational study. This study was carried out in Combined Military Hospital Lahore from Feb 2005 to Feb 2008. A total of 28 patients with unilateral mass of parotid gland, all with FNAC [Fine needle aspiration cytology] positive for pleomorphic adenoma were included in the study without any discrimination of age, sex or size of tumor. Each patient underwent CT scan and surgical modality of treatment was selected for every patient with post-operative histopathology study to confirm or otherwise of FNAC diagnosis. Female male ratio was 3:4, mean age in males was 44, in females was 37. Histopathology-disproved FNAC in 7.14%. Ratio between involvement of superficial lobe and both lobes was 13:1. Post-operative transient facial nerve paresis was seen in 12 out of 28 patients and there was surprising laterality of right parotid involvement, ratio between right and left parotid being 11:3. Smallest tumor at presentation was 3x3 centimeter and largest was 14x10 centimeter in size. Markedly more incidence of pleomorphic adenoma on right side of face is observed. It has not been reported previously. Zero percent facial nerve severance in 28 parotidectomies reflects vigilance and surgical skill of today's otorhinolaryngologists

Post SMR intranasal packing - do we really need it?

Sub mucous resection [SMR] for the deflected nasal septum [DNS] is the commonest nasal surgery all over the world. The unpleasant part of the whole event is postoperative nasal packing for 24 to 48 hours. Handsome numbers of patients delay the operation just to avoid the horrible experience of nasal packs by close friends or relatives. Many a times there is no bleeding at all on termination of operation but we still do nasal packing for the sake of doing it perhaps a fear of reactionary or primary bleed on the back of our mind. A variety of packing materials are being used most of which are not evidence based. This study was conducted at combined military hospital, Lahore over a period of one and half year from June 2006 to December 2007. A total of 72 patients were included in the study having moderate to marked deflection of nasal septum. All patients underwent classical SMR operation under local anesthesia. Only 04 patients were given nasal packs on termination of opearation. All patients were closely monitored for in 02 to 03 hours post operatively. All patients were seen on 2[nd], 5[th] and 15[th] day. 65 [90.27%] patients had no problem. 02 [2.7%] patients reported back with 24 in hours with septal haematoma. The operation was terminated in 01 [1.3%] patient just at the time of incision

Branchial fistula: a rare presentation

Remains of cervical sinus of His may persist as a branchial cyst. A branchial sinus is formed when 2nd branchial arch fails to meet the 5th pharyngeal arch. Peak age for presentation of cysts is in the third decade and that of the congenital sinuses and fistulae is at birth. Rarely a branchial sinus is found to have an internal opening as well, thus forming a true branchial fistula. We present a case of true branchial fistula with external opening on the lateral side of neck and internal opening near the lower pole of tonsil

Efficacy of epley maneuver in BPPV

Benign paroxysmal positional vertigo [BPPV] is one of the most common causes of vertigo. The diagnosis is confirmed by observing a classical response during the Dix-Halipike maneuver. The cause of BPPV is usually idiopathic. There are two popular hypotheses described regarding the pathogenesis i.e. cupulolithiasis and canalithiasis. The clinical course of BPPV is spontaneous recovery in weeks or months. Treatments for BPPV have ranged from no intervention to surgical treatment. The new treatment, "Canal it h-repositioning procedure [CRP]" which was introduced by Epley in 1992 produces a very high rate of success. This treatment has caused interest and has been modified and studied worldwide in recent years. To determine the efficacy of Epley maneuver in BPPV. We recruited 100 patients with a history of positional vertigo and unilateral positional nystagmus on physical examination [Dix-Halipike maneuver]. Patients were randomized to either the Epley [n=50] or a prochlorperazine [n=50]. Measured outcomes included resolution of vertigo and positional nystagmus at follow-up examination. RESULTS: The mean duration of follow-up was 14 days for both groups. In Epley's group resolution of symptoms was reported by 36[72%] of the patients after first visit on single maneuver treatment and by 46 [92%] patients on second visit on repeating maneuver, while 4 patients had minimal symptomatic improvement and were offer other treatment options. While in prochlorperazine group, 11 [22%] patients reported improvement in symptoms on first visit and 17[34%] on second visit and 19 [38%] had improved by 14th day. The Epley's maneuver is safe, economical and effective treatment of benign paroxysmal positional vertigo and this procedure can be performed by general internists on outpatients with this disorder

Stridor in afebrile children

To enlist the causes of stridor in afebrile children under twelve years of age. Design: Descriptive study. Carried out in ENT Dept CMH Rwp from Sep 2001 to Feb 2003. Fifty children presenting for the first time with symptoms of stridor were selected according to the inclusion criteria by non-probability purposive sampling. Every patient was evaluated by detailed history, thorough physical examination and investigations including radiographic studies, laryngoscopy and bronchoscopy. Data was recorded on the performa attached as Annex 'A'. Of the 50 patients, there were 29 males and 21 females. The mean age at presentation was 3.8 years. About forty-eight diagnostic observations were made during the initial endoscopic procedure on these 50 children. Acquired lesions [76%] outnumbered the congenital lesions [24%]. Of the congenital type, laryngomalacia [42%] was the commonest cause followed by vocal cord paralysis [17%], laryngocele [17%], laryngeal web [8%], tracheomalacia [8%] and tracheal stenosis [8%]. The most important acquired lesion was foreign body in the Aerodigestive tract [55.26%], followed by respiratory papilomatosis [21.05%], traumatic [13.16%] and subglottic stenosis [10.13%] Because of chronic and presistent upper airway obstruction, tracheostomy was electively performed in 02 cases in this series. There was no complication associated with complete endoscopic examination Foreign body in the tracheobronchial tree is the most frequent cause of stridor in afebrile children followed by congenital conditions and recurrent respiratory papillomatosis

Modified Epley's maneuver for treatment of benign positional vertigo: an experience with over 100 cases

Treatment for Benign positional vertigo has traditionally been pharmacological. However, physical methods of treatments are gradually replacing the former. Particle repositioning maneuver as described by Epley, has gained wide acceptance over the last decade. We present our experience with more than 100 cases treated with modified Epley's maneuver [no sedation given, nor mastoid vibrator applied]. The study was conducted at CMH Rawalpindi from Jun-2002 to May-2003. All patients with features typical of benign positional vertigo, confirmed by positive Dix-Hallpike test, were included. The patients were followed-up for 3 months. The success rate in our series was around 66%. We conclude that modified Epley's maneuver is indeed an effective method for treatment of BPV, but success rate is less than generally reported