Looking after local nasal and sinus mucosa in health, disease and after surgery.

The paper emphasises the need for looking after of nasal and sinus mucosa in health, disease and after nasal surgery. It is a systematic arrangement of steps required to restore nasal mucosa to healthy state. These steps have been arranged to co relate them to diseases and symptoms for symptomatic and curative treatment. It can rationalise the need for surgery in cases non responsive to maximum medical treatment. It can improve postoperative surgical results after functional endoscopic sinus surgery (FESS) and other endoscopic assisted procedures.

Hearing impairment in the aged.

Ageing affects all parts of the ear. The effect on the inner ear and its central connections is the most important cause of presbyacusis and contributes maximally to communication difficulties faced by the aged. A number of studies have been conducted on prevalence of presbyacusis. A prevalence of 3.7 to 3.3 per cent was found in the general populations surveyed in rural and urban areas respectively. There is hardly any systematic arrangement available for rehabilitation and fitting of hearing aid as an organized facility. Further research is needed to develop better quality hearing aids which will fully satisfy the needs of the aged.

PHONOSURGERY AND OTHER VOICE IMPROVEMENT TECHNIQUES.

This paper records our experience in dealing with 432 patients where phonosurgery was done. The cadaver study of the larynx confirms the basic principles on which the techniques are based. Our experience with Type 1 thyroplasty is that it gives better results than Teflon paste injection. Use of the microscope during laryngeal surgery has given us greater precision in dealing with mucosal and submucosal pathology. The results of surgery are excellent but require to be followed up with vocal rest, hygiene and rehabilitation to prevent recurrence and get good long-term results of voice improvement.

Inquiry-driven strategies for innovation in medical education: experiences in India.

Four medical institutes, viz, AIIMS, New Delhi; CMC, Vellore; JIPMER, Pondicherry and IMS-BHU, Varanasi formed a consortium to introduce reforms in undergraduate medical education. A detailed inquiry was conducted by administering questionnaires to the faculty, recent graduates and patients to identify the deficiencies in the present system. Morbidity patterns prevalent in the community at primary, secondary and tertiary care levels were determined. These were matched with the actual curricula being followed and the assessment patterns. The main findings were: inadequate emphasis on practical skills (including communication), insufficient coverage of common diseases; and neglect of behavioral, social and ethical aspects in the curriculum. Based on these findings certain corrective programmes are being introduced. The content areas in the curriculum have been classified in to 'must know', 'good to know' and 'need not know'. A list of essential skills have been identified. Steps are on to ensure that these skills are acquired by the graduates. A modular approach to the teaching was suggested and modules on some of these topics are under preparation.

Need-based undergraduate medical curriculum.

There is a growing concern over the quality of medical education for undergraduates in India. This paper is an attempt to define a need-based curriculum and outline the initiatives taken by the Medical Council of India (M.C.I.) in developing a need-based curriculum. The steps include: clear delineation of goals and objectives of education; adoption of innovative teaching and learning methodology, adjustments in the course structure, updating of course content, rationalizing assessment strategy, and emphasis on structured and skill oriented internship. For effective implementation of these measures, strategies such as establishment of Medical Education Unites (MEUs), visible funding of education, more recognition to teaching and impetus to staff development activities have been suggested.

Articulatory ability of hearing-impaired children belonging to the different 'Kostic groups'.

Hearing-impaired children in the age range of 3-6 years, registered at the Rehabilitation Unit of Audiology and Speech Pathology, Department of ENT, A.I.I.M.S., New Delhi as the 'control group' of the project 'SAFA for the hearing-impaired', were studied for their articulatory ability. The findings are discussed in the frame work of Kostic classification of the hearing-impaired which takes into consideration the degree of hearing impairment as well as the age of onset of loss.

Hearing loss after head injury.

Sixty head injury patients were evaluated for hearing loss; ten underwent ABER testing. Forty percent of the cases had hearing loss of different degrees. The audiometric pattern was variable in the different types of injuries, although the incidence of conductive deafness was quite low (5%). In most of the cases of sensorineural hearing loss, the end organ was implicated. Recruitment was demonstrated in the ABERs, as well as in the retrocochlear lesions, by studying the IPLs present.

A simple, effective method of treating vertigo patients.

Medical treatment of vertigo even today is far from satisfactory. A controlled clinical trial of treating vertigo patients by 1% ephedrine hydrochloride nasal douche has been conducted in 84 patients; 74.3% patients were either completely or partially relieved of their dizziness. The therapy was well accepted by patients and side effects were minimal.

Nasopharyngeal angiofibroma: (a nine-year experience).

In a nine-year period 50 nasopharyngeal angiofibromas, of whom 13 had recurrent tumour, were treated surgically at the All India Institute of Medical Sciences, New Delhi. A new staging system according to the regions involved was used; 31 patients in whom the tumour was limited to the nasopharynx (Stage I) and those with superior spread into the ethmoid or sphenoid sinuses (Stage IIA) had their tumours removed by a transpalatal route, alone or in combination with other approaches. Tumours with lateral extensions into the pterygopalatine or infratemporal fossae or the cheek (Stage IIB), and those with simultaneous superior and lateral spread (Stage III) underwent a transmaxillary excision (19 cases). In two of the three cases with intracranial extension (Stage IV), the tumour was removed successfully from below. There was no mortality. The usefulness of the transmaxillary approach, especially in recurrent cases, is emphasized. No adjuvant modalities were employed in this series and blood loss was acceptable.

Revision stapes surgery.

The records of 120 patients who had undergone revision stapedectomy were analyzed to determine: (i) the causes of failure; (ii) how to prevent failure by taking precautions during primary surgery; (iii) hearing results; and (iv) possible identifying factors which might pinpoint those patients with a high risk of sensorineural deafness. A review of these cases demonstrates that the results of revision stapedectomy are different from those of primary stapedectomy. The commonest cause of failure was prosthetic dislocation (30.8 per cent), followed by fibrous adhesions (18.3 per cent) and otosclerotic regrowth (14.1 per cent). First revision operations resulted in post-operative bone-air gaps of 15 dB. or less in 46.5 per cent of cases, much better than 25 per cent for second revisions. Primary stapedectomy resulted in successful closure of the air-bone gap to 15 dB. or less in 89.5 per cent of cases. The sensorineural loss occurred in 11.3 per cent or first revisions and in 16.6 per cent of second revisions, as compared to 1.3 per cent after primary surgery. 'Dead ears' were encountered in 2.2 per cent of first revisions, as compared to nil in the primary group.

Diffuse meningeal melanosis (an unusual presentation).

An unusual presentation of diffuse meningeal melanosis with involvement of the temporal bones, the spheno-ethmoidal complex, the pharynx and the viscera is reported.

Auditory brain-stem evoked responses in cerebellopontile angle tumors.

Large acoustic or nonacoustic cerebellopontile angle tumors cause severe to total hearing loss on the same side. Such a tumor can also cause hearing loss on the opposite side by pressure effect on the brain stem. This was observed in 23 patients with large tumors that were surgically treated. Their computed tomographic scans and surgical findings supported the auditory brain-stem evoked potential changes noted in this study. Early removal of such a tumor is essential to prevent any possible hearing loss on the opposite side that may be produced by the tumor.

Congenital mid-line sinus of the dorsum of the nose. Two case reports with a literature survey.

Two cases of congenital mid-line sinus of the nose are presented. The etiology of the condition with emphasis on its embryology and treatment are discussed. A reversed 'u' incision in each nostril gives a wider exposure and is more acceptable cosmetically.

Nasal septal deviation: effective intervention and long term follow-up.

Nasal septal deviation (DNS) occurs more frequently during childhood although it occurs at any age due to trauma. Recently, it has been increasingly recognized that nasal septal deviation is seen also at birth and a number of explanations for this occurrence is forwarded. Awareness of such occurrence and its recognition at birth both by pediatricians and obstetricians is essential for early interventional management of this condition in close collaboration with the otorhinolaryngologists. Closed surgical intervention of this defect carried out early after it was detected at birth benefitted the afflicted in terms of nasal airway improvement and its maintenance resulting in normalization of its anatomy and physiology in long term follow-up. Septal deviation detected at birth if left alone without interventional procedure continues to persist. It is furthermore accompanied by statistically valied symptoms like upper respiratory infections, cough, earache, ear discharge, fever, mouth breathing and at times feeding difficulty during infancy and childhood. Long term follow-up of children who underwent closed surgical correction of DNS at birth, revealed no untoward effects such as nasofacial disproportion or retardation of facial growth. Early interventional management of DNS detected at birth therefore appears to be a safe procedure. It can even be performed by neonatologists or an obstetrician. Such an intervention procedure early in life can prevent septoplasty surgery at a latter date besides preventing a number of nasal airway-related conditions.