Hearing status after radical mastoidectomy without tympanoplasty

Objective: To find out the impairment of hearing associated with radical mastoidectomy by measuring the quantitative difference in the functional hearing level before and after radical mastoidectomy operation without tympanoplasty

Study Design: Cross-sectional comparative study

Place and Duration of Study: Department of Otorhinolaryngology and Head and Neck Surgery, Bahawal Victoria Hospital, Bahawalpur and PNS Shifa Hospital, Karachi, from November 2009 to January 2013

Methodology: Eighty-five patients, diagnosed clinically as chronic suppurative otitis media with extensive cholesteatoma having history of ear discharge and hearing impairment for more than 6 weeks' duration and requiring radical mastoidectomy for treatment, were included in this study. Pure tone audiogram was done before and after radical mastoidectomy. Hearing impairment was compared in each patient before and after the operation

Results: Among the 85 patients, 54 [63.5%] were males and 31 [36.5%] were females, with the age ranged between 18 to 63 years, mean age being 42.31 +/- 4.8 years. The mean increase in hearing loss after radical mastoidectomy in air conduction was 7.19 dB, bone conduction was 4.16 dB, and air-bone gap was 3.75 dB [<0.001]. The ear became dry and safe in 82 patients [96.5%] out of a total of 85, and only 3 patients required revision surgery at a second stage

Conclusion: Radical mastoidectomy has a least negligible effect on hearing status and one should not limit this technique due to the concern of aggravated hearing in patients with extensive cholesteatoma at the cost of dry and safe ears, which should be of prime importance

Application of Mouth Gag and Temporomandibular Joint Pain and Trismus in Tonsillectomy

Objective: To determine the effect of duration of application of mouth gag on Temporom and ibular [TM] joint pain and trismus after tonsillectomy. Study Design: Descriptive study. Place and Duration of Study: Department of ENT and Head and Neck Surgery, Combined Military Hospital, Nowshera, from February to July 2012. Methodology: A total of 40 patients undergoing tonsillectomy, in mouth opening prior to surgery was measured as inter incisor distance in cms. A stop watch was used to calculate the time of application of mouth gag. Mouth opening was again measured 06 hours after the surgery. Difference between the two readings was considered as trismus score and categorized as mild [1 cm], moderate [2 cm] and severe [3 cm]. Patient was asked to score pain on a visual analogue scale [0 - 9]. Score 0 was categorized as no pain; 1 - 3 as mild pain; 4 - 6 as moderate pain; 7 - 9 as severe pain. Spearman's rank correlation was used for finding correlation between time of mouth gag application and study outcome [pain and trismus]. Results: Trismus as observed by difference in inter incisor distance was mild in 11 patients; moderate in 15 patients and severe in 14 patients 06 hours after the surgery. Eleven [27.5%] had mild pain over temporom and ibular joint, 15 [37.5%] had moderate and 14 [35%] had severe pain 06 hours after the surgery. Direct relationship was observed between duration of application of mouth gag with postoperative pain and trismus. Significant strong correlation was observed between length of mouth opening to severity of pain and trismus [rs = 0.738; p < 0.001]. Conclusion: Duration of mouth gag application should be reduced to cause less TM joint pain and trismus in early postoperative period in tonsillectomy. Key Words: Boyles Davis mouth gag. Tonsillectomy. Trismus. Temporom and ibular joint pain

Diagnostic accuracy of indirect laryngoscopy and x-ray neck in the diagnosis of fish bone impaction in upper aero digestive tract

This study was aimed at finding the validity of indirect laryngoscopy [IDL] and neck X-rays in the diagnosis of fish bone impaction. Validation study. CMH Nowshera from August 2012 to February 2013. A total of 50 patients were selected by consecutive sampling presenting with history of fishbone impaction in aerodigestive tract. IDL examination and neck X-rays were performed and findings were recorded. Those with no fishbone on both the investigations were discharged from hospital with follow up after 03 days. Those with fishbone detected on either of investigations underwent removal. Fishbone easily approachable were removed under local anaesthesia with foreceps and in others endoscopy [Direct laryngoscopy or Oesophagoscopy] was performed under General Anaesthesia. Sensitivities and specificities of bath the modalities were calculated using standard 2/2 Table. ROC curve analysis was carried out and significance level p<0.05 was taken as significant. In 2Q patients no fishbone was found, 26 patients were diagnosed on IDL and in 04 patients fishbone was detected by neck X-Rays. Most common site for fishbone impaction was pharyngeal tonsil. In 22 patients fishbone was removed with foreceps and in 08 patients endoscopy was performed. Diagnostic accuracy for IDL 86% and Neck X-Rays 48% was calculated. ROC curve analysis revealed AUC for IDL 0.933 and Significance level [P] as <0.0001. ROC curve analysis for X-ray gives AUC of 0.567 and Significance level [p] 0.4132. IDL shows higher diagnostic accuracy than neck X-Rays for detection of fishbone in upper aerodigestive tract. Neck X-rays are more useful for impacted foreign bodies in oesophagus

Household teaspoon and oral liquid medication: the present scenario

To determine the parental dosing errors in administering oral liquid medication to pediatric population. Cross sectional study. Department of Pediatric Surgery Civil Hospital and Pediatric Medicine Lyari General Hospital Karachi, from February 2009 to September 2009. Parents of children admitted were enrolled in the study. They were asked to measure one teaspoonful [5 ml] of paracetamol syrup from the tray containing household spoons of different sizes. The amount filled by the parents was measured by 5 ml syringe. Accurate dose was defined as 5.0 ml while an acceptable dose was 5.0 +/- 0.5 ml [4.5 ml - 5.5 ml] according to National Formulary and USP Standards of a + or - of 10% of error dosage range for oral devices. A total of 530 parents participated in the study. The age of the participants ranged from 16 year to 55 year [mean= 28.93 +/- 6.6 year]. Only 118 [22.3%] participants measured accurate dose while 164 [30.9%] measured the acceptable dose and 366 [69.1%] participants measured inaccurate dose. Accuracy in measuring household teaspoon quantity was not associated wirh parents' age [p >.05], education [p >.05], cooking experience [p >.05] and previous drug administering experience [p>.05]. Household teaspoons were unreliable when measuring and administering liquid medication to pediatric population. Oral syringe is recommended as the best device for both measuring and delivering liquid medication

Knowledge, attitude and practice of polio prevention among people in Khyber Pakhtunkhwa

To assess the knowledge, attitude and practice of polio among people in Khyber Pakhtun Khwa and to recommand measures in order to improve the awareness of disease. Descriptive cross sectional study. This study was conducted at CMH nowshera, CMH mardan and Kohat General Hospital from March to June 2013. Persons presenting for consultation to tertiary care hospitals at medical reception rooms were approached by convenience sampling. Structured questionnaire was developed and data was collected by interviews. The findings of the study revealed that out of 296 persons participated in study 57.4% were males while 42.2% were females. They were residents of Mardan, Nowshera, Kohat and Swabi districts of Khyber Pakhtunkhwa. Persons who believed that vaccine is prohibited in religion were 13.9%, 81.1% persons knew about polio disease and 84.5% persons believed that disease could be prevented by giving vaccines to children. Persons who gave vaccine to their children were 88.9% and 66.9% also knew the schedule of the vaccine. Pressure groups which included tribal elders' stopped 19.3%people from giving vaccine to their children and for 11.1% persons the facility of giving vaccine was not available. Persons who believed that Polio can cause infertility were 11.5% and 20.9% believed that Polio Vaccine cannot prevent Polio disease. Persons who have seen patient of polio were 38.9% and 88.5% persons wanted to eradicate disease from Pakistan. The results of the study revealed that people have adequate knowledge about polio and wanted to eradicate it from pakistan by participating in vaccination activities but still there are few people who believe that polio vaccine cannot prevent disease resulting in failure to administer vaccine for their children

Bilateral loss of light reflex and accommodation following 360 peripheral retinal laser therapy

We report a case of bilateral loss of pupillary light reflex and accommodation following 360° peripheral retinal laser therapy. A 24 years old male underwent prophylactic laser barrage for peripheral retinal lattice degenerations. Soon after the procedure, he developed bilateral loss of pupillary light reflex and accommodation. The patient faced difficulty while doing near work. On instillation of 0.125% pilocarpine, both pupils demonstrated the phenomenon of denervation supersensitivity. Damage to the short ciliary nerves was the most likely mechanism responsible for this adverse outcome

comparison of safety and efficacy between sodium cromoglycate 2% and fluorometholone 0.1% in management of vernal keratoconjunctivitis

To compare the safety and efficacy of sodium cromoglycate 2% eye drops with fluorometholone 0.1% eye drops in patients with bilateral vernal keratoconjunctivitis [limbal and conjunctival palpebral or mixed]. Quasi Experimental Study This study was carried out in Department of Ophthalmology, Combined Military Hospital, Multan from 20[th] May 2009 to 20[th] June 2009. This was hospital based study conducted on 60 diagnosed cases of vernal keratoconjunctivitis attending the OPD of Eye Department Combined Military Hospital, Multan in year 2009. Cases were divided in to two groups of 30 patients each. Group 2 was treated with sodium Cromoglycate while Group 1 was given Fluoro metholone 0.1%. Ocular complaints were noted and graded. Slit lamp examination was done at the start of treatment and at the end of the treatment. After first week of treatment in group 2 [sodium cromoglycate 2%] 22 patients had mucoidal discharge with photophobia, redness and itching while in group 1 [Fluorometholone 0.1%] none of the patient had mucoidal discharge. At the end of study 24 patients had itching, redness and photophobia in group 2 but in group 1 only 16 patients had these symptoms. It was also revealed that 6 patients in group 2 had watering and mucoid discharge but none of the patient in group 1 had watering and mucoid discharge at the end of study. [p < 0.001]. Patients treated with fluorometholone 0.1% got better results than patients treated with sodium cromoglycate 2% in the management of vernal Keratoconjunctivitis

Accuracy of the retinal nerve fiber layer measurements by stratus optical coherence tomography for perimetric glaucoma

To calculate the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of measurements of the retinal nerve fiber layer using the Stratus optical coherence tomography in glaucoma subjects with visual field defects on achromatic perimetry as the gold standard. Comparative cross-sectional. Outdoor clinic of Layton Rehmatulla Benevolent Trust Hospital [LRBT], Lahore, from August 2007 to January 2008. Fifty normal subjects and 50 glaucoma patients were selected from outdoor clinic of LRBT. Retinal nerve fiber layer thickness [RNFL] of all the subjects were measured by Stratus optical coherence tomography [OCT]. Visual field defects on achromatic perimetry was used as the gold standard. The sensitivity and specificity of retinal nerve fiber layer measurement for perimetric glaucoma using the OCT were 82% and 96% respectively. The positive predictive value, negative predictive value and diagnostic accuracy were 95%, 84% and 89% respectively. There is a high sensitivity and specificity of RNFL measurements using the new Stratus OCT for the diagnosis of perimetric glaucoma

Health management information system in district health care

To study the existing Health Management Information System being practiced in Basic Health Unit and recommend measures to improve. Descriptive cross sectional study. Basic health unit. This study was conducted in Basic Health Units of Tehsil Taxilla from January to December 2008 in district Rawalpindi. Patients and Subjects were the staff working at basic health units dealing with data entry. Structured questionnaire was developed and data was collected by interview. The findings of the study revealed that although timeliness of reporting was 100% but only 70% were accurate. It was found out that 84% of the information was being analysed and 64% of the reporting facilities were getting feedback. There was no use of the information for decision making. The results of the study demonstrated that the timeliness of reporting is up to the mark but the processing of the information conveyed by the basic health unit on health management information system indicators is not being carried out at the executive district officer health office Rawalpindi. Thus not making any use of the information available for planning health activities and decision making

audit of non-idiopathic intussusception in children

Objectives: To outline the causes of non-idiopathic intussusception in children and to document the clinical characteristics of the different etiologies

Methodology: It is a retrospective review of 19 cases of proved secondary intussusception, over a span of 5 years i.e. from January 2004 to December 2008. Data was collected from private as well as from government hospitals in different centers. Patient's age ranges from three months to 12 years. Demographic data, clinical presentations, surgical management and follow up were recorded on pre designed proforma. Baseline blood investigations and radiological tests were noted. Surgery was performed in all patients due to delayed presentation and non availability of image intensifier

Results: Among 19 patients, 13 [68.42%] were boys and 6 [31.57%] were girls with male to female ratio of 2.16:1. The mean age was 2.15 years. Meckel's diverticulum was the most common cause and found in 8 [42.10%] children. Four [21.05%] had lymphoma, 2 [10.52%] had haemangiomas and 2 [10.52%] with polyps of the colon. Round worms, duplication of gut and Henoch-Schonlein's purpura were the other causes of non-idiopathic intussusceptions

Conclusion: Intussusception caused by an underlying disease or secondary to some pathological lead point is not uncommon and it is important to be vigilant for pathological lead points in children of any age

Spontaneous per urethral expulsion of gossipibyoma - a rarity

Foreign bodies left accidentally during a surgical procedure are rare. In spite of careful intra-operative precautions and gauze counts mistake still occurs. Many of these cases present with sepsis, the foreign body may erode hollow viscera with and without signs of peritonitis and discovered on laparatomy. These foreign bodies may remain silent for years. We are reporting an interesting case of an 11 years old girl who presents with gauze piece coming out of her urethra 4 years after cystolithotomy and right ureterolithotomy. Such cases of intraluminal migration and spontaneous expulsion of foreign body are rarely reported

Knotting of urethral catheters: a preventable complication

A number of complications are associated with Urethral catheterization. Feeding tube is usually used for this purpose in children. Spontaneous intravesical knotting of such urethral catheters is a known but rare complication. We are reporting two cases of intravesical knotting of feeding tube used to drain bladder in patients who underwent urethroplasty

Congenital segmental dilatation of sigmoid colon, penile agenesis and umblical cord hernia: a new association

Congenital segmental dilatation of the colon, penile agenesis and umbilical cord hernia are individually rare congenital malformations. An association between all three malformations has not been previously reported. We report a neonate with congenital segmental dilatation of the colon, penile agenesis and umbilical cord hernia all coexistent in a new born

Preliminary results of laparoscopic assisted orchidopexy for intra-abdominal testis

To analyze the outcome Laparoscopic assisted Orchidopexy for Intra-abdominal Testis. A prospective, descriptive study from July 1997 to January 2007. The study was conducted in the Departments of Pediatric Surgery at Dow Medical College / Civil Hospital Karachi and National Institute of Child Health, besides some private hospitals of Karachi. All patients with impalpable testis. Patients with intra-abdominal testis were subjected to Laparoscopic assisted single stage or 2-stage Fowler-Stephens orchidopexy. All patients were reviewed two and six months after the procedure to assess the outcome of surgery. A total of 28 patients with 35 impalpable testes were seen during the study period. Of these 13 had impalpable testes on the right and eight on the left side, whereas seven were bilateral. Laparoscopic examination revealed 29 intra-abdominal testes. Amongst these, Laparoscopic assisted Single stage Orchidopexy was performed in four testes and the first stage of Fowler-Stephen Orchidopexy in 29 testes. Second stage of the Fowler-Stephens Orchidopexy was completed in 18 testes successfully, as we did not encounter testicular atrophy in any case so far. Postoperative complications were seen in two patients. One case developed port site haematoma which was drained and the other subcutaneous emphysema which was managed conservatively. Laparoscopic assisted single and 2-stage orchidopexy is a safe and successful treatment procedure for intra-abdominal testes

To determine the efficacy and safety of caudal bupivacaine in combination with rectal diclofenac for postoperative analgesia in paediatric patients

To assess the efficacy and safety of combination of caudal bupivacaine anesthesia and diclofenac sodium suppository for postoperative analgesia in pediatric patients. Interventional study. Imam Clinic [a private hospital] North Nazimabad Karachi. from May 2004 to March 2007. All pediatric patient ASA physical one and two between the ages 6 months to 12years of either sex undergoing infra umbilical surgery received caudal block with bupivacaine 0.25% in a dose of 0.5ml/Kg and diclofenac sodium suppository 1mg/Kg rectally. Patients in whom caudal analgesia was contra indicated or failed were excluded from the study. Postoperative pain was assessed using observers' pain scale and self report of pain by child when he was greater than 2 years age. Postoperative complications were also recorded. During the study period, 99 patients undergoing different infra umbilical procedures [hernia, hypospadias repair, PPV ligation, circumcision, orchidopexy etc] received combination of caudal bupivacaine analgesia and rectally administered diclofenac sodium for post- operative analgesia. There were 94 male patients. In all patients caudal block remained successful. All patients were pain free and none of them required additional/rescue analgesia. Postoperative nausea and vomiting were reported in 3 patients. No other side effects like retention of urine, respiratory depression etc was observed postoperatively. Combination of single shot caudal block with bupivacine 0.25% in a dose of 0.5 ml/Kg and rectal diclofenac sodium for postoperative analgesia in pediatric patient is a simple, safe and effective procedure

Laparoscopic surgery in children

To assess the efficacy and safety of various laparoscopic procedures in paediatric population. An analytical case series. Various public and private sectors hospitals of Karachi, from January 2001 to December 2006. Case records of all paediatric patients who underwent laparoscopy for diagnostic or therapeutic purposes were reviewed. Age, sex, investigations, preoperative diagnosis, per operative diagnosis, procedure, duration of operation, hospital stay and intra-operative and post-operative complications where recorded. Patients with impalpable testes were excluded from the study as they are reported in another study. During the study period, 19 paediatric patients underwent laparoscopy for different surgical conditions. Age ranged from 5 to 12 years. Eight patients were males and 11 females. Six patients underwent cholecystectomy for cholelithiasis. Investigations did not reveal any cause for cholelithiasis. Appendicectomy was performed in 7 cases. Two of them had interval appendicectomy, while five were operated for acute appendicitis. Out of 5, three had acute appendicitis while two had mesenteric lymphadenitis. Adhesiolysis was performed in five patients. Adhesions in four of them were due to tuberculosis, band, recurrent appendicitis and post-operative adhesions, while in fifth patient no cause could be ascertained. One patient underwent left varicocelecotmy. None of the patients required conversion to open surgery. There was no intra-operative complication while post-operative complications were minimal. We conclude that laparoscopic surgery is feasible, effective and safe in the management of a wide range of surgical conditions in children

Modification of mathieu procedure to repair anterior hypospadias

To assess the results of one-stage repair of anterior hypospadias using modified Mathieu procedure. An interventional study. Department of Paediatric Surgery, Dow Medical College and Civil Hospital Karachi, from September 1997 to December 2003. Patients and All the patients with anterior hypospadias without or with minimal chordee were included. Patients with hypoplastic urethra or re-do surgery were excluded. Modified Mathieu repair was performed in all cases. The modifications used were interrupted inverting sutures of 5/0 polyglycolic acid for urethroplasty; neourethra covering with subcutaneous [dartos] pedicle flap, developed from the preputial or penile shaft skin and dorsal / anterior meatotomy for meatal stenosis. A total of 69 patients with anterior hypospadias were operated using modified Mathieu's repair. Only two patients [2.89%] developed urethrocutaneous fistula. Five patients developed partial devitalisation of the covering skin while one patient had complete breakdown. Modified Mathieu's procedure is an effective method, to repair the anterior hypospadias without or with minimal chordee

Abdominal masses in children: a diagnostic challenge

We report a 6 year old female child who presented with mass in right upper quadrant of abdomen. She was intensively investigated and with the suspicion of hydatid cyst liver received albendazole for many months. As mass increased further laparotomy was planned. At exploration it turned out to be a large retroperitoneal mass and dissected out easily. Biopsy report was that of benign teratoma