Volume 114 u Number 12 u Kolkata u December 2016
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Vol 114 No. 12
Dr S S Agarwal
Dr K K Aggarwal
Dr Debasish Mukherjee
Dr Santanu Sen
National President, IMA
Honorary Secretary General, IMA
Honorary Editor, JIMA
Honorary Secretary, JIMA
Volume 114 u Number 12 u Kolkata u December 2016
CONTENTS Editorial : u Cardiac disease and pregnancy — Debasish Mukherjee, Subesha Basu Roy .......................7 Originals and Papers : u A study of bone marrow examination in cases of pancytopenia — Manjula Manchale K, Praveen B Biradar.......................................................................8 u Tubercular manifestations in head and neck region — our experience — Dwaipayan Mukherjee, Chiranjib Das, Pritam Chatterjee ............................................11 u Understanding and treatment of serious ENT complications in patients with diabetes mellitus — a study — Swagata Khanna, Mahamaya Prasad Singh, Sunil K C.................................................15 u Comparative study between temporalis fascia and tragal cartilage with perichondrium as graft in type 1 tympanoplasty — Atish Haldar, Soumik Saha.........................................19 Practitioners’ Series : u Ocular trauma : basic primary management — Gunjan Prakash, Nisha Chauhan, Achin Rawat, Ashwini Gangadher, Arpita Gupta, S K Satsangi.............................................23 Current Topic : u Professionalism in medicine — the present scenario — Lukram Sidartha, Lukram Amarjit Singh .........................................................................28 Case Notes : u Repair of bilateral lumbar hernia using prolene hernia system — John Mathew Manipadam, Ebby Asirvathamm, Edwin Stephen, Sunil Agarwal...............30 u Term Pregnancy in women with tetralogy of fallot — case report — Anil F Jasani, Vineet V Mishra, Rohina S Aggarwal, Anju D Yadav, Snigdha A Khurana, Kunur N Shah.......................................................................................32 u Congenital fetal heart block — a rare isolated presentation of asymptomatic maternal SLE — D V Kurdukar, Akanksha Sood, Rekha G Daver..........................................33 u Medicolegal autopsy in a post embalming donated dead body — a case report — Biplab Shee, Saurabh Chattopadhyay, Vikas Gurbani, Vivek Kumar..............................35 22
Vol 114 No. 12
Vol 114 No. 12
Office bearers for the year 2017-18 National President Elect 2016-17 Dr. K K Aggarwal National President Elect 2017-18 Dr. Ravi Wankhedkar National Vice Presidents Elect 2016-17 Dr. Roy Abhram Kallivayalil, Dr. K. Prakasam Dr. Mahendra Choudhary, Dr. Parmanand Prasad Pal Four National Vice Presidents Elect 2017-18 Dr. Rajendra Airan, Dr. Bhupendra M. Shah Dr. Paramjit Bakshi, Dr. Ashok Aggarwal Dean-IMA CGP 2016-17 Dr V C Shanmuganandan Dean-IMA CGP 2017-18 Dr. Akhilesh Verma Chairman-IMA AMS 2016-17 Dr. Joseph Mani Chairman-IMA AMS 2017-18 Dr. Madhuchanda Kar Director-IMA Dr. AKN Sinha Institute 2016-17 Dr. Sarbari Dutta Director-IMA Dr. AKN Sinha Institute 2017-18 Dr. Rajan Sharma Hony. Editor-JIMA 2016-17 Dr. Dilip Kumar Dutta Hony. Editor-JIMA 2017-18 Dr. Samarendra KumarBasu Hony. Secretary General, IMA HQs. 2016-18 Dr. R N Tandon Hony. Finance Secretary, IMA HQs. 2016-18 Dr. Vinod Kumar Monga Hony. Joint Secretaries, IMA HQs. stationed at Delhi 2016-18 Dr. Vinod Khetarpal, Dr. Anil Goyal, Dr. Ashwini Kumar Dalmiya Hony. Joint Secretary, IMA HQs. stationed at Calcutta 2016-18 Dr. Santosh Kumar Mandal Hony. Joint Finance Secretary, IMA HQs. stationed at Delhi 2016-2018 Dr. Manjul Mehta Delhi
Hony. Joint. Finance Secretary, IMA HQs. stationed at Calcutta 2016-2018 Dr. Santanu Sen Hony. Asstt. Secretaries, IMA HQs. stationed at Delhi 20162018 Dr. Dinesh Sahai, Dr. Amrit Pal Singh Hony. Secretary, IMA CGP HQs. 2016-2018 Dr. R. Gunasekaran Hony. Joint Secretaries, IMA CGP HQs. 2016-2018 Dr. B. Sridhar, Dr. N Muthurajan Governing Council Members, IMA CGP HQs. from among C.C. Members 2016-2018 Dr. Ajay Goverdhan, Dr. Ramendra Nath Sarkar Vice Chairman, IMA AMS HQs. 2016-2018 Dr M S Hari Babu Hony. Secretary, IMA AMS HQs. 2016-2018 Dr. Sadanand Rao Vulese Executive Editor (Annals), IMA AMS HQs. 2016-18 Dr. S. Lakotia Hony. Executive Secretary, IMA AKNSI 2016-2018 Dr. Raman Kumar Verma Hony. Joint Secretaries, IMA AKNSI 2016-2018 Dr. Sanjiv Ranjan KumarSingh, Dr. Ram Rekha Hony. Associate Editors, JIMA 2016-2018 Dr. Amitabha Bhattacharya, Dr. Dipanjan Bandyopadhyay Hony. Secretary, JIMA 2016-2018 Dr. Kakoli (Mandal) Sen Hony. Asstt. Secretary, JIMA 2016-2018 Dr. Gopal Das Hony. Editor, Your Health for the year2016-2018 Dr. Ashok Kumar Chatterjee Hony. Associate Editors, Your Health 2016-2018 Dr. Swapan Nag, Dr. Sarmishtha Bandyopadhyay Hony. Secretary, Your Health 2016-2018 Dr. Meenakshi Gangopadhyay Hony. Editor, Apka Swasthya for the year2016-18 Dr. Vivek Kumar Hony. Secretary, Apka Swasthya 2016-2018 Dr. Sanjay Kumar Rai
Vol 114 No. 12
Editorial Cardiac disease and pregnancy
erious maternal cardiac disease complicating pregnancy is relatively uncommon, however it can have a significant adverse effect on maternal and fetal Dr Subesha Basu Roy Dr Debasish Mukherjee outcomes, despite modern cardiac care. The MBBS, MS MBBS, DLO, MS Guest Editor Honorary Editor, JIMA overall incidence of serious heart disease 1,2 complicating pregnancy is approximately 1% with a decrease in maternal death as a result of the classic causes of hemorrhage, hypertension and infection, 1-3 the relative importance of cardiac disease increased . During the last few decades the etiology of heart disease 1,2,4 changed from primarily rheumatic to predominately congenital . Despite the potential for significant maternal morbidity in most patients with cardiac disease, a satisfactory outcome can be expected with careful, antenatal, intrapartum and postpartum management1,2,4,5. Serious complications during pregnancy and the postpartum period include congestive heart failure, arrhythmias and stroke. Women with heart conditions who desire or anticipate pregnancy should have “preconceptional Counseling”. The first step in the preconceptional counseling session is to obtain a through history, perform a physical examination and have available information from recent electrocardiograms and echocardiograms. Maternal mortality generally varies directly with functional classification at pregnancy onset, however this relationship may change as pregnancy progresses. Contemporary literature quantifying the risk of maternal mortality is limited for a number of reasons. Most congenital lesions are diagnosed early, allowing appropriate surgical repair. The significant decrease in the incidence of rheumatic heart disease limits the number of patient with acquired lesions who are seen for the first time because of the physiologic stresses of pregnancy: Patients who are at greatest risk for cardiac decompensation are offered sterilization or termination. In most instances management involves a team approach, including an obstetrician, cardiologist, anesthesiologist and other specialist as needed Cardiovascular changes likely to be poorly tolerated by an individual women are identified and a plan is formulated to minimize these. Within this frame work both prognosis and management are influenced by the nature and severity of the specific lesion, in addition to the functional classification. 1 2 3 4 5
Sugrue D, Blake S, MacDonald D — Pregnancy complicated by maternal heart disease at the National Maternity Hospital, Dublin, Irelard 19691978. An Obstet Gynecol 1981; 139: 1-6. Mc Faul PB, Dornan JC, Lamkih — Boyled Pregnancy complicated by maternal heart disease : A review of 519 women. BJOG 1988; 95: 861-7. Hogbery U, Innala E, Sandstrom A — Maternal Mortality in Sweden, 1980-1988. Obstet Gynecol 1994; 84: 240-4. Siv S, Sermer M, Colman J — Prospective multicenter study of pregnancy out come in women with heart disease. Circulation 2001; 104: 515-21. Siv S, Sermer M, Harrison D — Risk and predictors for pregnancy – related complications in women with heart disease, Circulations 1997; 96: 2789-94.
Disclaimer The information and opinions presented in the Journal reflect the views of the authors and not of the Journal or its Editorial Board or the Publisher. Publication does not constitute endorsement by the journal. JIMA assumes no responsibility for the authenticity or reliability of any product, equipment, gadget or any claim by medical establishments/institutions/manufacturers or any training programme in the form of advertisements appearing in JIMA and also does not endorse or give any guarantee to such products or training programme or promote any such thing or claims made so after. — Hony Editor 6
Originals and Papers
A STUDY OF BONE MARROW EXAMINATION IN CASES OF PANCYTOPENIA — MANCHALE K AND BIRADAR
A study of bone marrow examination in cases of pancytopenia 1
Manjula Manchale K , Praveen B Biradar
Bone marrow examination (aspiration and biopsy) carried out in 30 cases having pancytopenia, had megaloblastic anemia as the commonest cause (46.6%) of pancytopenia. Other common conditions presenting as pancytopenia were micro-normoblastic erythroid hyperplasia(16.6%), aplastic anaemia (13.3%). Uncommon causes of pancytopenia were Acute leukemias, myelodysplastic syndrome (MDS), myelofibrosis (MF) and multiple myeloma (MM). [J Indian Med Assoc 2016; 114: 8-10]
Key words : Pancytopenia, bone marrow aspiration and biopsy.
ancytopenia may be a manifestation of a wide variety of disorders, which primarily or secondarily affect the bone marrow . This may be due to ineffective erythropoiesis, decreased cell production, increased peripheral utilization and increased destruction without an adequately matching compensatory increase in the cell production. The cause of pancytopenia may be thus lie in the bone marrow, periphery or both, Various factors encompassing geographic distribution and genetic disturbances may cause variation in the incidence of disorders causing pancytopenia . Prognosis in pancytopenia depends upon the underlying pathology and determines the management. We present 30 cases of pancytopenia along with clinical and haematological features.
Thirty cases of pancytopenia was reported. Age ranged from 18-82yrs with M : F ratio being 2:1(20/10). Maximum number of cases were found in age group of 2050yrs(70%). Criteria for diagnosis of pancytopenia were: H b < 1 0 g m% , To tal leu co cy te co u n t ( TLC ) <3500cells/cumm and platelet count < 1,00,000/cumm . The commonest presenting complaint was fever in 20(66.6%) cases followed by fatigue in 12(40%) patients. Bleeding manifestation and bone pain in 2(6.66%) cases each were seen (Table 1) Pallor was present in all the patients. Majority of patients 15(50%) had hepatosplenomegaly. Peak range of Hb: 5-8gm% Peak range of TLC: 3000-3900 cells/cumm Peak range of platelet count: 50,000-1.3l cells/cumm Absolute Reticulocytosis was seen in one case. Peripheral blood findings of all the cases were noted (Table 2). The commonest cause of pancytopenia was megaloblastic anemia which was seen in 14(46.6%) cases, followed by iron deficiency anemia(16.6%), aplastic anemia(13.3%). The other causes of pancytopenia were acute leukemia(6.6%), myelofibrosis(10%), myelodysplastic syndrome(3.3%) and multiple myeloma (3.3%). Bone marrow aspiration and biopsy was done in all cases. Further analysis was done based on cellularity of bone marrow. (I) Hypocellular marrow : (A) Aplastic anemia — Peripheral smear of all the 4 cases showed pancytopenia with relative lymphocytosis. It was the only case which showed reduced cellularity of marrow and marked reduction in erythroid, myeloid and megakaryocytic series with predominance of lymphocytes and plasma cells.
MATERIAL AND METHODS
The present study was carried out over a period of 1 year (2003-2004) at JSS Medical College, Mysore. Total 50 cases of various haematological disorders were randomly selected for bone marrow aspiration and biopsy study. Thirty of these cases had pancytopenia on peripheral smear examination. Bone marrow aspiration and biopsy was performed using Jamshidi trephine biopsy needle from posterior superior iliac crest. Leishman stain was done for aspiration smears. H&E and other special stains like Prussian Blue, MPO, PAS, Reticulin were done wherever necessary. Various clinico-hematological parameters were noted. 1
MD, DNB, Assistant Professor, Department of Pathology, Mandya Institute of Medical Sciences, Mandya, Karnataka 571401 2 MD, Consultant Pathologist, Manipal Northside Hospital, Bengaluru, Karnataka 560003 8
Mean age of the patients was 20yrs and M: F=3:1. Table 1 — Clinical spectrum of various disorders Trephine biopsy showed reduced cellularity with No of Fever Hepato- Petechiae Lympha- Bone fat cells occupying more than 75% of marrow. Diagnosis cases Splenodenopain Scattered rests of erythropoietic cells seen in megaly pathy paratrabecular region, with relative increase in Megaloblastic anemia 14 12 11 01 number of lymphocytes and plasma cells. Micro-normoblastic (II) Hypercellular marrow : erythroid hyperplasia 05 03 02 04 02 01 (A) Iron deficiency Anemia — Bone marrow Aplastic anemia 03 was hypercellular in all the cases and showed Myelofibrosis Acute leukemias 02 02 01 01 01 micronormoblastic erythroid hyperplasia. The MDS 01 01 01 01 01 micronormoblasts were small with ragged Multiple myeloma 30 20 15 02 01 02 cytoplasmic borders. Prussian blue stain done Total was negative for iron stores. Table 2 — Peripheral blood findings of various disorders (B)Megaloblast No of Aniso- Tear Poly- nRBC RouleNeutro- Imma- Relative Absolute ic anemia — 12 Diagnosis cases cytosis drop chroaux phils with ture lymphoc- Reticuloc a s e s h a d cells masia formation 5 lobes cells ytosis Cytosis hyperceullar 12 04 08 02 14 01 marrow and had Megaloblastic anemia 14 dry tap in 2 cases. Micro-normoblastic erythroid hyperplasia 05 04 04 04 M e g a l o b l a s t s Aplastic anemia 04 01 04 03 02 03 03 having sieve-like Myelofibrosis Acute leukemias 02 01 01 02 02 chromatin were MDS 01 01 01 01 01 seen with bizarre Multiple myeloma 01 01 01 01 mitoses and giant metamyelocytes. karyocytes had abnormal nuclear-cytoplasmic ratios, Bone marrow biopsy showed hypercellular marrow with abnormal chromatin clumping with hyperchromatic reduction in fat cells and increased in erythroid cells with nuclei. Increased fibrosis was seen. Reticulin stain was large nuclei having fine chromatin pattern. However, done for grading of fibrosis. All were in cellular phase. megaloblasts were more characteristic in aspiration than (F) Multiple myeloma — A 60yr old patient presented in biopsy. with bone pain, backache and loss of weight. Aspiration (C)Acute Leukemia — Marrow was hypercellular in was done to rule out secondaries. Marrow was one case and was inaspirable( dry tap) in the other. Marrow hypercellular with 80-90% of plasma cells infiltrating the of Acute Myeloid Leukemia showed 28% blasts having marrow. Binucleate and trinucleate cells were also seen. size 3-4times larger than RBC and large nuclei with fine Biopsy was hypercellular with interstitial (well chromatin, 3-4 nucleoli and moderate amount of pale differentiated) and diffuse (poorly differentiated) pattern cytoplasm having granules and Auer rods. MPO- positive. of arrangement of cells which gives prognostic Acute lymphoid leukemia was diagnosed on biopsy. information. Patient had multiple lytic lesions, Marrow was hypercellular with lymphoblasts having hypercalcemia, presence of Bence Jones protein in urine scant basophilic cytoplasm, hyperchromatic nucleus and raised albumin, ESR and b2 microglobulin all of having one or two nucleoli. PAS – positive, MPO – which was complementary to marrow findings for a final negative. diagnosis. (D) MDS — A single case had hypercellular marrow DISCUSSION with M:E ratio being 1:1. Dyserytropoietic features Pancytopenia develops due to decrease in included multinuclearity, asynchrony of maturation hematopoietic cell production as a result of destruction of between nucleus and cytoplasm, cytoplasmic the marrow tissue by toxins, replacement by abnormal vacuolations, nuclear budding, karyorrhexis and mitotic tissue or suppression of normal growth and differentiation. figures. A diagnosis of refractory anemia was made as the There is limited number of studies on the frequency of patient had not responded to any treatment for the past six pancytopenia. Limited data has been reported from the months. No evidence of abnormal localization of Indian sub-continent. immature precursors (ALIP) seen in biopsy. In the present study, commonest cause of pancytopenia (E) Myelofibrosis — Marrow aspirate was dry tap in all was megaloblastic anemia (46.6%). A study by Retief the 3 cases. Biopsy showed moderate cellularity with decrease in erythroid and myeloid series of cells. Mega
Originals and Papers
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
F P revealed that bone marrow failure was the commonest cause of pancytopenia and severe infections (9.7%) was the second common cause . In one study, pancytopenia was seen in 52.7% of aplastic anemia and 10.5% of MDS patients . Verma N and Dash S found aplastic anemia in 40.6% and megaloblastic anemia in 23.26% of patients . Megaloblastic anemia(68%) was the commonest cause of pancytopenia followed by aplastic anemia (7.7%) in a study by Tilak N and Jain R . This increased incidence of megaloblastic anemia correlates with the high prevalence of nutritional anemias in Indian population as well as in developing countries. The second most common cause of pancytopenia in the present study was aplastic anemia(13.3%). All were idiopathic. No history of exposure to radiation/drugs was obtained. The incidence of aplastic anemia in west is much higher than that studied by us. Micronormoblastic erythroid hyperplasia with peripheral pancytopenia was seen in 16.6% of our cases. Iron stores were decreased. Iron deficiency anemia presenting as pancytopenia is uncertain. Patients responded well to iron therapy. No case of drug induced pancytopenia with bone marrow depression was encountered in the study. Leukemias can present with pancytopenia . Bone marrow aspiration helps in diagnosis and biopsy becomes mandatory in cases of dry tap. Aspiration and biopsy helped to arrive at diagnosis of AML and ALL in our study. Pancytopenia is known to occur in MDS. It is the least common finding in MDS as compared to mono and bicytopenia . In a study of 31 patients of MDS by Kini J, bicytopenia was the commonest finding and pancytopenia was common in the subtypes RAEB and RAEB-t. Patients with multiple myeloma can develop pancytopenia due to replacement of bone marrow by immunoproliferative cells . Tilak V and Jain R reported one case of pancytopenia due to multiple myeloma in their study. In the present study, patient had multiple lytic lesions, hypercalcemia, increased Bence Jones proteins and infiltration of marrow by plasma cells. Pancytopenia due to myelofibrosis occurs due to various etiological factors . Myelofibrosis causes hypersplenism leading to pancytopenia . Pancytopenia is a common finding in advanced AIDS. Fibrosis of marrow is seen in 20-50% making aspiration difficult . In the present study, patient was HIV negative. Aspirate was a dry tap and biopsy showed increased fibrosis. Variation in the frequency of disorders causing pancytopenia, has been ascribed to differences in methodology, stringency of diagnostic criteria, geographic area, period of observation, genetic differences and varying exposure to cytotoxic agents. 5
Pancytopenia is relatively a common entity. Hence, appropriate physical examination and peripheral blood findings is relevant in planning investigations in pancytopenic patients. Bone marrow aspiration and biopsy is a must in cases of pancytopenia to arrive at the diagnosis and patient management. Most common causes of pancytopenia are megaloblastic anemia, aplastic anemia, erythroid hyperplasia. However, uncommon and rare causes such as multiple myeloma, myelofibrosis, should be kept in mind during complete work up. A comprehensive clinical and haematological study of patients with pancytopenia will usually help in the identification of underlying cause. REFERENCES 1 Williams WJ, Bentkr E, Erskv AJ — Haematology – 3rd edition, Singapore, Mc Graw Hill Book company 1986; 16184. 2 International agranulocytosis and aplastic anemia study. Incidence of Aplastic anemia, relevance of diagnostic criteria. Blood 1987; 70: 1718-21. 3 Wintrobe MM(ed) — Clinical Hematology. Eighth edition, Philadelphia: Lea and Febiger 1981; 699-915. 4 Keiser M, Ost A — Diagnosis in patients with severe pancytopenia suspected of having aplastic anemia. Eur J Haematol 1990; 45: 11-4. 5 Retief FP, Heyns AD — Pancytopenia and aplastic anemia: a retrospective study. S Afr Med J 1976; 50: 1318-22. 6 Verma N, Dash S — Reappraisal of underlying pathology in adult patients presenting with pancytopenia. Trop Geog Med 1992; 44: 322-7. 7 Tilak N, Jain R — Pancytopenia – A clinical haematological analysis of 77 cases. Indian J Pathol Microbial 1999; 42: 399-404. 8 Mckenzie SB — Text book of Hematology. Baltimore: Williams and Wilkins, 1996, 2nd edition. 9 Kini J, Khandilkar UN, Dayal JP — A study of the haematologic spectrum of myelodysplastic syndrome. Indian J Pathol Microbiol 2001; 44: 9-12. 10 Linch CD, Goldstone HA, Mason YD — Malignant lymphomas, Post-graduate Haematology. Hoffbrand, Lewis, Tuddenham, Oxford: Butterworth-Heinemann, 4th edition, 1999, 479-504. 11 Young NS — ‘Aplastic anaemia, myelodysplasia and related bone marrow failure syndromes’, Harrison’s ‘Principles of Internal Medicine’. Braunwald, Fauci et al, New York: Mc Graw – Hill, 15th edition, 2001, 660-5. 12 Firkin, Chesterman et al. De Gruchy’s Clinical Hematology in clinical practice’. Oxford University press, 5 edition, 1989. 13 Costello C — The haematological manifestations of HIV disease, Post-graduate Hematology. Hoffbrand, Lewis, Tuddenham, Oxford: Butterworth- Heinemann, 4th edition, 1999: 309-22. th
Tubercular manifestations in head and neck region — our experience Dwaipayan Mukherjee1, Chiranjib Das2, Pritam Chatterjee3 Tuberculosis still remains a challenging clinical entity in the developing countries. The commonest organ affected is the lung but tuberculosis of other regions of the body is also encountered in day to day practice.Tuberculosis of the head and neck region poses a significant clinical and diagnostic challenge.The present study was conducted to assess the incidence and evaluate various diagnostic modalities for tuberculosis affecting head and neck region. This prospective study comprises of 92 patients who presented with different tubercular manifestations in head and neck region in the department of Otorhinolaryngology and Head and neck surgery in a teaching hospital of West Bengal, over 3 years from July 2012 to June 2015. The most common localization of tuberculosis in the head and neck region was cervical lymph nodes (82.61%) followed by larynx (5.43%), scrofuloderma andoral cavity (3.26% each), cervical spine and salivary gland (2.17% each), and ear (1.09%). Tubercular lesions in the head and neck region present with diverse clinical features. The absence of typical symptoms of tuberculosis makes their diagnosis difficult. Clinical suspicion should arise when symptoms are not responding to regular antibiotic therapy. [J Indian Med Assoc 2016; 114: 11-4 & 18]
Key words : Tuberculosis, Extra-pulmonary, Head and neck region, Incidence, Cervical lymphadenitis, Laryngeal TB.
MATERIALS AND METHODS
uberculosis (TB) is still one of the commonest chronic granulomatous diseases, especially in the developing world. World Health Organisation (WHO) statistics have revealed an annual incidence of 100 cases detected per 1,00,000 population in Europe and North America. The incidence is much higher in the Asian countries, almost 300 cases per 1,00,000 population . The commonest organs affected are the lungs but tuberculosis of other regions of the body is also encountered in day to day practice . Though the incidence of pulmonary TB is declining, proportion of extra-pulmonary TB is on the rise . Studies regarding otorhinolaryngological manifestations of TB are sparse. Non-availability of diagnostic facilities in many parts of developing world renders true incidence of extra-pulmonary tuberculosis unexplored . The present study was conducted to assess the incidence and evaluate various diagnostic modalities for tuberculosis affecting head and neck region in patients attending the outpatient department in a teaching hospital of West Bengal.
This was a prospective study conducted in the department of Otorhinolaryngology and Head and neck surgery in a teaching hospital of West Bengal. This study comprises of 92 patients who presented with different tubercular manifestations in head and neck region over 3 years from July 2012 to June 2015. Patients with cytologically or histopathologically proven TB of head and neck region were included in the study.Patients who did not complete investigations, who did not complete anti-tubercular therapy and who did not turn up in followup were excluded. A detailed history and thorough clinical examination including fibre-optic laryngoscopy was carried out. In addition to routine blood tests HIV screening was done in all patients. Chest X-ray and sputum for acid fast bacilli (AFB) were done to rule out co-existing pulmonary TB. Fine needle aspiration cytology (FNAC) was the main diagnostic tool in patients presenting with neck swelling. Neck swellings and oral lesionswhich were inconclusive on FNAC were subjected to biopsy. Direct laryngoscopy and biopsy was done in patients with abnormal findings on laryngeal endoscopy. Pus from abscess, discharging sinus and ear was stained with Ziehl-Neelsen (ZN) stain. X-ray soft tissue neck, cervical spine, mastoids,
Department of ENT, KPC Medical College & Hospital, Kolkata 700032 1 MS (ENT) Associate Professor 2 MS (ENT) RMO cum Clinical tutor, Bankura Sammilani Medical College & Hospital, Bankura 722102 3 MS (ENT) Senior Resident, Bankura Sammilani Medical College & Hospital, Bankura 722102 11
TUBERCULAR MANIFESTATIONS IN HEAD AND NECK REGION — OUR EXPERIENCE — MUKHERJEE ET AL
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
CT scan and USG of the affected sites were done in relevant cases. After confirming the diagnosis, all patients were treated with anti-tubercular drugs. Surgical management was reserved for selected refractory cases in the form of excision of lymph nodes or sinus tracts. All patients were followed up for 6 months post treatment.
Table 1 — Distribution of patients according to age Age (in years) Number < 20 21-30 31-40 41-50 51-60 61-70
This study includes 92 cases with tuberculosis of the head and neck region. 69 patients (75%) were males and 23 (25%) were females. The age group of the patients ranged from 8 to 69 years. 4 patients (4.35%) were in the age group of 20 years and below, 17 patients (18.48%) were in the age group of 21-30 years, 23 patients (25%) were in the age group of 31-40 years, 25 patients (27.17%) were in the age group of 41-50 years, 14 patients (15.22%) were in the age group of 51-60 years and 9 patients (9.78%) were in the age group of 61-70 years (Table 1). The most common localization of tuberculosis in the head andneck region was cervical lymph nodes (82.61%) followed by larynx (5.43%),scrofuloderma andoral cavity (Fig 3) (3.26% each), cervical spineand salivary gland (Fig 4) (2.17% each), and ear (Fig 5) (1.09%) (Table 2). Of the 92 patients, 66 patients (71.74%) presented with neck swelling, 5 patients (5.43%) presented with change in voice, 7 patients (7.61%) presented with difficulty in swallowing and 15patients (16.30%) presented with different skin lesions like non-healing ulcer, sinus and scrofuloderma (Table 3). Only 16.30% patients had constitutional symptoms like fever, night sweats and weight loss. Of 76 patients with tubercular cervical lymphadenopathy, 35 patients presented with single l y m p h a d e n o p a t h y, 1 9 p a t i e n t s w i t h m a t t e d lymphadenopathy, 9 patients with abscess, 7 patients with non-healing ulcer (Fig 6) and 6patients with sinus (Fig 7) (Fig 1). Among 5 patients with laryngeal tuberculosis, true vocal cord was involved in 4 cases (Fig 8), false cord,aryepiglottic fold (AE fold) and epiglottis in 2 cases each, posterior commissure in 1 case (Fig 1). Presence of caseation necrosis (Fig 9) or AFB (Fig 10) in FNAC or biopsy was considered as diagnostic of TB.3.95% of tubercular lymphadenitis, 60% of laryngeal TB, 33.33% of scrofuloderma, 50% each of TB spine and salivary gland, 66.67% of TB of oral cavity, 100% of aural TB had associated pulmonary tuberculosis (Table 4). None had coexisting HIV infection.
4 17 23 25 14 9
Percentage 4.35% 18.48% 25% 27.17% 15.22% 9.78%
Table 2 — Distribution of patients according to site of involvement Site
Number Percentage (%)
Lymph node Larynx Scrofuloderma Cervical spine Oral cavity Salivary gland Ear
76 5 3 2 3 2 1
82.61% 5.43% 3.26% 2.17% 3.26% 2.17% 1.09%
s i s 3 . C e r v i c a l Table 3 — Distribution of patients according to presenting symptoms lymph nodes are most commonly Symptom Number Percentage a f f e c t e d f o l l o w e d b y Neck swelling 66 71.74% 5 5.43% laryngeal tuber- Change in voice 15 16.30% c u l o s i s , d e e p Skin lesions Difficulty in swallowing 7 7.61% n e c k s p a c e Constitutional symptoms 15 16.30% abscess and tubercular otitis Distribution of patients according m e d i a 4 . L o w Table 4 — to co-existing pulmonary TB standards of l i v i n g , p o o r Site Co-existing Percentage TB pulmonary sanitation and h y g i e n e , Lymph node 3/76 3.95% consumption of Larynx 3/5 60% unboiled milk Scrofuloderma 1/3 33.33% 1/2 50% c o n t r i b u t e Cervical spine Salivary gland 1/2 50% towards the high Oral cavity 2/3 66.67% i n c i d e n c e o f Ear 1/1 100% tuberculosis in 1 our country . Most common extra-pulmonary manifestation is cervical lymphadenopathy4. It was also the commonest site in our study and accounting for 82.61% of the cases. In our study we had found that tubercular lymphadenitis was more common in male patients (M=55, F=21) in contrast to KAkbar Khan et al where they observed that tubercular lymphadenitis was more common in female 1 . It may present as isolated node, matted nodes, fluctuant mass or draining sinus. Surgical intervention is done when a node remains enlarged after
Pulmonary tuberculosis is the most common type of tuberculosis accounting for approximately 80% of the tuberculosis cases. Tuberculosis of head and neck region comprises about 10% of all extra-pulmonary tuberculo
laryngitis classically involves posterior commissure of glottis. Disease progresses to involve entire laryngeal framework - the vocal folds, vocal cords, epiglottis, aryepiglottic folds, arytenoids, and the subglottis6. In our study the true vocal cords were the commonest affected site (4 Fig 7 — Tubercular cervical sinus out of 5). The macroscopic finding was generalized oedema with irregular edges resembling mostly nonspecific inflammatory conditions. The posterior commissure involvement was found in only 1 out of 5 Fig 2 — Distribution of patients according to site of larynx involved (20%) cases. Typical laryngoscopic features are turban shaped epiglottis and mouse nibbled appearance of vocal cords6. Deep neck space abscess was the second most common presentation according to Kamath Pandurang et al8. But in our study larynx was the second common site in the neck to be affected by tuberculosis. Our observation matched with Choudhury et al9. We had only 2 cases of deep neck space abscess presenting with retropharyngeal abscess. Patients with chronic retropharyngeal abscesses presented with neck pain and dysphagia. Radiography of cervical Fig 4 — Tuberculosis of submandibular Fig 3 — Tubercular oral ulcer spine revealed widening of retropharyngeal salivary gland space with osteolyticchanges in the cervical spine. anti-tubercular therapy. Abscesses, whenever detected, Amongst these cases, pulmonary tuberculosis was were aspirated with wide-bore needle. Incision and confirmed in 1 (50%) case. Such abscesses pose drainage should be avoided because this commonly results diagnostic difficulties, especially in the absence of any in a draining sinus. Tubercular sinus can be repaired at the history or evidence of tuberculosis elsewhere in the body. end of therapy by excising the fistula along with a cuff of Re-accumulation of pus, failure to respond to standard affected tissue enmass .Primary TB in larynx is a very rare antibiotic regime, bone erosion, sterile culture report may entity.It usually presents secondary to pulmonary TB . suggest a tubercular aetiology with additional clue if there Laryngeal tuberculosis was common in male patients is lymphocytosis, raised ESR or a positive Mantoux test. (M=4, F=1) in our study which is well corroborated with Y AFBs are rarely present in the pus drained from neck space vette et al . Sixty per cent of the patients of laryngeal abscesses. Histopathological examination of granulation tuberculosis in our series had associated sputum-positive tissue from the abscess wall is more helpful in pulmonary tuberculosis. The same result was obtained by the diagnosis Y vetteet al. Hoarseness is most common symptom o f s p e c i f i c followed by odynophagia, dysphagia, cough and otalgia. g r a n u l o m a 1 0 . TB Open drainage through cervical incision for the retropharyngeal abscess is not n o r m a l l y necessary; but the involvement of the other deep neck 5
Fig 1 — Distribution of patients according to nature of involved lymph node
Fig 5 — Tubercular otitis media with post-aural fistula
Fig 6 — Tubercular non-healing ulcer
Fig 8 — Fibre-optic laryngoscopic image of tubercular laryngitis
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
Originals and Papers Understanding and treatment of serious ENT complications in patients with diabetes mellitus — a study Swagata Khanna1, Mahamaya Prasad Singh2, Sunil K C2
Fig 9 — High power magnification (40x) view of Haematoxylin and Eosin stained slide of tubercular sinus showing Caseation necrosis (N) and Langerhans giant cell (L)
space compartments is an indication for the external drainage . In our study, both the cases of retropharyngeal abscess underwent intra-oral drainage. Three of our patients presented with tubercular oral ulcer. With respect to the route of infection of the bacilli in the oral cavity, it is generally regarded that pulmonary bacilli are transmitted to secondary lesions via lymphatic or haematogenous routes. For primary oral lesions the mycobacterium may directly inoculate oral mucosa following minor injury as a result of trauma, inflammatory conditions, or tooth extraction . In our series, 2 out of 3 patients with tubercular oral ulcer had co-existent pulmonary TB. Clinical features of oral TB are chronic ulceration and painless regional lymphadenopathy. Histopathological examination may be required to distinguish these lesions from those of carcinoma . Mycobacterial infections of salivary glands are very rare. In our study, 1 patientpresented with complaints of painless swelling in the submandibular region, which was diagnosed as tubercular sialadenitis by FNAC. Another patient presented with tubercular parotitis with fistula. As a rule, surgery should be avoided in cases of swellings suspicious for tuberculosis, but because of its atypical presentation surgery could not be avoided in most of the cases . Aural tuberculosis is a very rare disease entity. Mechanism of aural infection is nasopharyngeal spread througheustachian tube or haematogenous spread. Symptoms are chronic serous/seromucinous/blood stained painless otorrhea despite adequate conventional antibiotic therapy, otalgia and profound hearing loss. Otoscopic findings are polyps in external auditory canal, multiple perforation of tympanic membrane (considered hallmark of the disease), eroded handle of malleus, pale middle ear mucosa, abundant pale granulations in middle ear and mastoid. Pre-auricular lymphadenopathy with post-auricular fistula is pathognomonic 11
Fig 10 — Oil immersion view (100x) of ZN stained slide of tubercular sinus showing AFB
for tuberculosis otitis media . We had only 1 patient with tubercular otits media. He had unilateral profuse seromucinous ear discharge, post-aural fistula and mixed deafness of long duration. Polyp and abundant pale granulation tissue was noticed. He also had underlying pulmonary tuberculosis.Nasal tuberculosis present as three entities: Nodular form (Lupus vulgaris), Ulcerative form, Sinus Granuloma.Lupus vulgaris is the most common form. It presents as painless, solitary, soft, tiny, reddish brown gelatinous plaque known as apple jelly nodules.Ulcerative form involves cartilaginous part of nasal septum which may progress to septal perforation. The nasopharynx and oropharynx are the two main sites of pharyngeal involvement. Most of them are primary infection. Tuberculosis has also become common in patients with HIV. According to Antoni et al, laryngeal tuberculosis is more common in immunocompromised patients but in our study there was no coexisting HIV infection among the tuberculous patients . 15
Conclusion : Tuberculosis of the ENT region though not very frequent, still remains an important clinical entity, which should be kept in mind especially in developing countries. Tubercular lesions in the head and neck region present with diverse clinical features. The absence of typical symptoms of tuberculosis makes their diagnosis difficult. Cervical lymph node involvement remains one of the commonest manifestations. Clinical suspicion should arise when symptoms are not responding to regular antibiotic therapy. Painful dysphagia in patients presenting with hoarseness should raise the suspicion of laryngeal tuberculosis. Anti-tubercular drugs form the mainstay of treatment. Surgery is reserved for cases which progress to complications and as part of diagnostic confirmation. (Continued on page 18)
Diabetes mellitus is a chronic metabolic disorder causing considerable morbidity and mortality and can influence the course of diseases. Various ENT diseases when associated with diabetes mellitus, increases the severity of infectious complications and poses a therapeutic challenge. The present study was undertaken to understand the various serious ENT complications and the challenges in their management in patients with diabetes mellitus. The present study was carried out over a period of two years in patients with diabetes mellitus who were admitted in ENT department of GMCH. Various investigations and otological functions were carried out in 62 cases of diabetes mellitus patients with various ENT diseases. In all, 62 cases were studied, where, the most common presentation was found to be Furunculosis with facial cellulitis in 30 patients (48.3%) followed by vestibulitis with nasal cellulitis in 12 patients (19.3%). 16 patients (25.8%) were found to have various complications like cavernous sinus thrombosis. One patient (1.6%) of Necrotizing fasciitis succumbed to death due to septicemia. On culture and sensitivity, the most common organism was found to be Staphylococcus followed by Klebsiella and Pseudomonas species. Incidentally, 11 patients (40.7%) were found to have pure sensory neural hearing loss. From our study, it has been seen that patients with diabetes mellitus are more prone to flaring up of infectious conditions. Adequate control of diabetes and early appropriate management is essential to prevent life threatening complications. [J Indian Med Assoc 2016; 114: 15-8]
Key words : Diabetes mellitus, Cellulitis, Cavernous sinus thrombosis.
iabetes mellitus has been known to mankind since age old times. Sushruta as early as in the 6 century BC has identified diabetes and classified it as “Medhumeha” which literally translates to ‘sweet urine disease’ .
In our study, we aim to understand the various serious ENT complications and the challenges in their management in patients with diabetes mellitus.
MATERIALS AND METHODS
The study was conducted in the Department of ENT and Head & Neck surgery, Gauhati Medical College & Hospital, Guwahati; from 1st June 2009 to 31st May 2011. Sixty two patients with diabetes mellitus were admitted in department of ENT during this period and various investigations and otological functions were carried out. The criteria for selection of patients were as follows: (a) Previously diagnosed patients receiving diabetic treatment (b) Newly diagnosed patients based on blood sugar levels (both fasting and post-prandial) Patients attending ENT out-patient department with minor ENT manifestations with diabetes mellitus, who were managed as an out-patient basis were not included in the study. In all admitted cases, a detailed clinical history as well as systemic and ENT examination was done. In patients with history of diabetes mellitus, duration of dia-
Diabetes mellitus is a chronic metabolic disorder causing considerable morbidity and mortality and can influence the course of diseases. The disorder has been known to be associated with increased incidence or severity of infectious complications , so do in various ENT diseases. People with diabetes mellitus experience worse outcome with infection than someone without the disease because of depressed immune system. 2-4
Due to anatomical proximity, infections from the head and neck region can progress to cause intra-cranial complications like meningitis, cavernous sinus thrombophlebitis etc and the chances raise many-fold if associated with diabetes mellitus and can lead to serious life threatening events. Department of ENT, Gauhati Medical College and Hospital, GMCH Road, Bhangagarh, Guwahati 781032 1 DLO, MS, FICS, Professor 2 MBBS, MS ENT, Postgraduate trainee 15
UNDERSTANDING AND TREATMENT OF SERIOUS ENT COMPLICATIONS IN PATIENTS — KHANNA ET AL
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
betes, type of treatment and regularity of the treatment were recorded. Various laboratory investigations like routine blood examination, culture and sensitivity of pus, blood sugar levels (both fasting and post-prandial) were estimated which aided in their management. Various ENT manifestations in these patients were documented and managed accordingly.
Table 2 — Complication Profile No. of cases
Cavernous sinus thrombosis Deep neck infections Necrotizing fasciitis Non healing ulcer Total
8 4 3 1 16
Table 4 — Hearing assessment (Pure tone audiometry) Percentage (%) 12.9 6.4 4.8 1.6 25.8
Table 1 — Distribution of Disease ENT Manifestations Males Females Total Percentage (%) Furunculosis with facial cellulitis 18 12 30 48.3 Vestibulitis with nasal cellulitis 8 4 12 19.3 Neck abscess 5 4 9 14.5 *CSOM 4 3 7 11.2 Malignant Otitis Externa 2 1 3 4.8 Ulcer over nose 1 0 1 1.6 *CSOM – Chronic Suppurative Otitis Media
As shown in Table 1, amongst the cases, the most common presentation was found to be Furunculosis with facial cellulitis in 30 patients (48.3%) followed by vestibulitis with nasal cellulitis in 12 patients (19.3%). 9 patients (14.5%) of Neck abscess were noted, 7 patients (11.2%) of Chronic suppurative otitis media were seen, 3 patients (4.8%) of Malignant otitis externa were noted and 1 patient (1.6%) with ulcer over the dorsum of the nose was seen (Figs 1 & 2) (Table 2). Among the 62 patients, 16 patients (25.8%) were found to have complications. As shown in table no.2, 8 cases
Fig 1 — Facial cellulitis following furunculosis of Left upper lip
Fig 2 — Facial cellulitis following nasal vestibulitis
(12.9%) were seen to have Cavernous sinus thrombosis (CST), 4 (6.4%) and 3(4.8%) cases were complicated with Deep neck infection and Necrotizing fasciitis respectively. One patient (1.6%) of necrotizing fasciitis succumbed to death due to septicemia. One patient (1.6%) was found to have non-healing ulcer over the dorsum of the nose (Fig 3 & Table 3). Among the 62 patients, 27 patients underwent culture and sensitivity of pus. As shown in table 3, out of 14 patients with cellulitis, 6 showed staphylococcal infection while 4 patients reported Klebsiella and 2 patients Fig 3 — Cavernous sinus thrombosis following nasal vestibulitis Pseudomonas species. There was no growth on culture in two of the pa tients. Of the 9
Table 3 — Culture & Sensitivity Report
Furnculosis with facial cellulitis Vestibulitis with nasal cellulitis Neck abscess Malignant otitis externa Ulcer over nose Total
Kleb. Pseudo. Fungal No Sp. Growth
3 1 27
0 0 10
0 0 5
1 0 4
0 1 1
2 0 7
neck abscesses, 4 patients showed Staphylococcal, 1 patient each of Klebsiella and Pseudomonas while 3 patients showed no growth. Of the 3 otitis externa patients, 1 patient showed Pseudomonas infection while 2 patients did not yield any growth on culture. 1 patient of nonhealing ulcer over dorsum of nose showed Candidial infection on culture (Table 4). Of all the 62 admitted patients, 27 patients complained of hearing difficulty. All underwent pure tone audiometry in which 11 patients (40.7%) were found to have pure sensory neural hearing loss, conductive hearing loss was
progressive and dangerous condition that requires immediate initiation of intensive treatment . In these patients’ radiological investigations like CT scan and MRI was done which aided in our diagnosis. Expert opinion from Neurologist and Neurosurgeons was sought and the patients were treated with triple regimen of Injection Ceftazidime (1g iv BD), injection Vancomycin (1g in 100ml NS BD), infusion Metronidazole (100ml iv TDS) for a period of 3-4 weeks followed by broad spectrum oral antibiotic therapy for another 4 weeks. All the patients responded to the treatment well without any post disease sequelae. Neck abscess was observed in 9 patients in the present study. 4 patients developed deep neck infections and 3 patients developed necrotizing fasciitis. Patients with neck abscesses associated with diabetes mellitus are more susceptible to deep neck infections and necrotizing fasciitis . Few of the patients underwent incision and drainage of the abscess and the pus was sent for culture and sensitivity. In these patients, exploration and radical debridement was done. All the patients were treated with broad spectrum antibiotics and regular antiseptic dressing with povidone iodine solution was done. Expert opinion from plastic surgeons was sought for skin grafting. Of the 3 patients of necrotizing fasciitis, one patient succumbed to death owing to septicemia and uncontrolled diabetes. In our study, of the 27 patients who underwent culture and sensitivity of the pus, 10 patients (37.0%) showed Staphylococcal growth and is the most common organism causing infection followed by Klebsiella found in 5 patients (18.5%). Pseudomonas was seen in 4 patients (14.8%) while 7 patients (25.9%) showed no growth on culture. One patient was observed to have non-healing ulcer over the dorsum of the nose despite proper diabetic care and antibiotic therapy. On culture and sensitivity, Candidial growth was seen. The patient required a prolonged duration of management with anti-fungal therapy. We have observed that 11 patients i.e., 40.7% showed pure sensory neural hearing loss. A study with large number of cases is required to establish any correlation between diabetes mellitus and hearing loss. All these patients were properly investigated and treated with appropriate antibiotics. Uncontrolled diabetic patients were properly monitored and in these cases expert opinion from endocrinologist was sought. Due to limited availability of literature, further larger studies are warranted so as to derive a definite correlation between diabetes mellitus and its implication on ENT diseases. 7
Type of Deafness Pure sensory neural Hearing loss Conductive Hearing loss Mixed Hearing loss Normal Hearing Total
In all, 62 cases were studied in which 38 cases (61.2%) were male patients and 24 cases (38.7%) were female patients. The age range for these patients was between 35 to 70 years of age (Table 1).
No of Patients
11 4 5 7 27
40.7 14.8 18.5 25.9
found in 4 patients (14.8%), 5 patients showed mixed hearing loss (18.5%) and 7 (25.9%) patients were found to have normal hearing. DISCUSSION
The increased incidence of diabetes mellitus in developing countries has led to the flaring up of infectious conditions which are more common in these countries. The infections of the head and neck region are the most common manifestations of ENT diseases associated with diabetes mellitus. Cellulitis is a serious infection that spreads under the skin, affecting soft tissues such as the skin itself and the fat underneath it. Bacteria are the most common culprits but very occasionally a fungus is responsible. Bacterial infection within a cervical lymph node may progress to cause local cellulitis and abscess. Otitis media is defined as “an inflammation of the middle ear without reference to etiology or pathogenesis” . Chronic suppurative otitis media (CSOM) is the result of an initial episode of acute otitis media and is characterized by a persistent discharge from the middle ear through a tympanic membrane perforation. Otitis Externa / swimmer’s ear is an infection of the skin covering the outer ear and the ear canal. Acute otitis externa is commonly a bacterial infection caused by streptococcus, staphylococcus or pseudomonas. Skin is said to be the first defense mechanism of the body. A discontinuity or a break in the skin when associated with infection produces erythema and induration in the surrounding tissue leading to progression of diseases process. In our study, cellulitis (both facial and nasal) affected 42 patients (67.7%) and was the most common ENT complication associated with diabetes mellitus. Furunculosis of the nasal vestibule and the upper lip and the resultant facial cellulitis led to the spread of infection from the dangerous area of the face to give rise to intracranial complications. We observed that 5 patients developed cavernous sinus thrombosis (CST) following cellulitis. CST is a formation of a blood clot within the cavernous sinus, the cavity at the base of the brain. Although CST has become rare, it remains a potentially life-threatening complication of an infection that may originate within the face, orbit, paranasal sinuses, or temporal bone . CST as a complication is a rapidly 5
Patients with diabetes mellitus are more susceptible to head and neck infections. We should pay more attention
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while dealing with these conditions because they tend to have complications more frequently and have to face longer hospitalization for recovery. Diabetic patients in hospitals do not necessarily have a higher mortality rate due to infections because of the advent of good antibiotics but certainly increases the morbidity. Adequate diabetic control along with appropriate supportive management and awareness of the disease is the main stay of treatment to prevent life threatening complications. REFERENCES 1 Dwivedy, Girish, Shridhar — Sushruta – the clinician – teacher par excellence. History of Medicine 2007. 2 Mowal AG, Baum J — Chemotaxis of polymorphonuclear leucocytes from patients with diabetes mellitus. N Engl J Med 1971; 284: 621-7. 3 Miller ME, Daker L — Leukocyte functions in Juvenile diabetes mellitus: Humoral and cellular aspects. J Pediatr 1972; 81: 979-82.
4 Hill HR, Sauls HS, Dettloff JL, Quie PG — Impaired leukotactic responsiveness in patients with juvenile diabetes mellitus. Clin Immunol Immunopath 1974; 2: 395-403. 5 Bluestone CD, Gates GA, Klein JO, Lim DJ, Mogi G, Ogra PL et al — Panel reports: Definitions, terminology and classification of otitis media. Ann Otol Rhinol Laryngol 2002; 111: 8-18. 6 Schuknecht B, Simmen D, Yu¨ksel C, Valavanis A — Tributary Venosinus Occlusion and Septic Cavernous Sinus Thrombosis: CT and MR Findings. Am J Neuroradiol 1998; 19: 617-26. 7 Migirov L, Eyal A, Kronenberg J — Treatment of Cavernous Sinus Thrombosis. IMAJ 2002; 4: 468-9. 8 Huan TT, Tseng FY, Liu TC, Hsu CJ, Chen YS — Deep neck infections in diabetic patients: comparison of clinical picture and outcomes with non-diabetic patients. Otolaryngol Head Neck Surg 2005; 132: 943-7 9 Afifi RY, El-Hindawi AA — Acute necrotizing fasciitis in Egyptian patients: a case series. Int J Surg 2008; 6: 7-14.
(Continued from page 14) REFERENCES 1 Akbar Khan K, Nazir Ahmed Khan, Mohammed Maqbool — Otorhinolaryngological manifestation of tuberculosis. JK Science 2002; 4: 115-8. 2 Nalini B, Vinayak S — Tuberculosis in ear, nose, and throat practice: its presentation and diagnosis. Am J Otolaryngol 2006; 27: 39-45. 3 World Health organization, Global tuberculosis control, Geneva, Switzerland, WHO Report 2010, WHO/CDS/TB/2010.275. 4 Sharma SK, Mohan A — Extrapulmonary tuberculosis. Indian J Med Res 2004; 120: 316-53. 5 Kanlikama M, Mumbuc, Bayazit Y, Sirikci A — Management strategy of mycobacterial cervical lymphadenitis. J laryngol otol 2000; 114: 274-8. 6 Kakar PK, Singh IKK, Lahiri AK — Laryngesl tuberculosis. Ind J Otolaryngol 1971; 23: 70. 7 Y vette, E Smulders, Bert-Jan De Bondt, Martin Lacko — Laryngeal tuberculosis presenting as a supraglottic carcinoma: a case report and review of literature. Journal of Medical Case Report 2009; 3: 9288. 8 Kamath Pandurang, Vijendra S Shenoy, KiranBhojwani, Arathi Alva — Vishnu Prasad and SoujanyaGandla. Tuberculosis in the head and neck in India: down but not yet dead. J Mycobac Dis 4: 148. 9 Choudhury N, Bruch G, Kothari P, Rao G, Simo R — 4 years’ experience of head and neck tuberculosis in a south London hospital. J R Soc Med 2005; 98: 267-9. 10 Choudhury S, Guha R, Verma AK, Banerjee SN — Tuberculous Infection in Neck- Still a Health Problem”. Journal of Evidence based Medicine and Healthcare 2014; 1: 1338-46. 11 Pandurang K, Shenoy VS, Bhojwani K, Alva A, Prasad V — Tuberculosis in the Head and Neck in India: Down but not yet Dead. J Mycobac Dis 2014; 4: 148. doi:10.4172/21611068.1000148 12 Manolidis S, Frenkiel S, Yoskovitch A, Black M — Mycobacterial infections of the head and neck. Otolaryngol Head Neck Surg 1993; 109: 427-33. 13 Mignogna MD, Muzio LL, Favia G, Ruoppo E, SammartinoG, Zarrelli C — Oral tuberculosis: a clinical evaluation of 42 cases. Oral Dis 2000; 6: 25-30. 14 Lau SK, Wei WI, Hsu C, Engzell UC — Efficacy of fine needle aspiration cytology in the diagnosis of tuberculous cervical lymphadenopathy. J LaryngolOtol 1990; 104: 24-7.
15 Yaniv E — Tuberculous otitis media. A clinical record. Laryngoscape 1987: 97: 1303-06. 16 Bruzgielewicz A, Rzepakewska A, Osuch-Wojckewicz E, Niemczyk K, Chmielewski R — Tuberculosis of the head and neck- epidemiological and clinical presentation. Arch Med Sci 2014; 10: 1160-6.
Originals and Papers Comparative study between temporalis fascia and tragal cartilage with perichondrium as graft in type 1 tympanoplasty 1
Atish Haldar , Soumik Saha
Type 1 tymplanoplasty, one of the commonest operation done by an ENT surgeon. Different materials used as graft in this operation. Among those temporalis fascia, tragal cartilage with perichondrium, tragal perichondrium are the most common. The aim of the study is to compare the results of tympanoplasty between two groups of patients 21 each, one using temporalis fascia as graft material and the other using tragal cartilage with perichondrium. It is prospective study. The study group consisted of 42 patients between the ages of 10-49 years. Patients having dry safe central perforations and pure conductive hearing loss was included. Success was defined as ear drum closure with no residual perforations. Hearing improvement was defined as air-bone gap < 10 dB in pure tone audiometry. The study showed that both temporalis fascia and tragal cartilage with perichondrium gave the better results with regard to successful drum closure and hearing improvement. [J Indian Med Assoc 2016; 114: 19-22]
Key words : Type 1 Tymplanoplasty, Temporalis Fascia, Tragal cartilage with Perichondrium.
ympanic membrane perforation mostly associated with the low socioeconomic conditions, occurs due to chronic suppurative otitis media and trauma commonly. For some people this is a minor inconvenience but for others it can be extremely troublesome due to repeated infection and a source of social embarrassments. Failure to heal this perforation results middle ear exposure to the external allergens and infections. Also due to absence of the vibratory area of tympanic membrane, the hearing capacity of the patient is less, requiring surgical intervention in the form of tympanoplasty to restore the vibrating area of the tympanic membrane, to increase hearing and to protect the middle ear and round window from external allergen and infection. The aim of tympanoplasty is to reconstruct the tympanic membrane and the sound conducting mechanism. Since the introduction of tympanoplasty, in the fifties, by Zoellner and Wullstein , numerous graft materials have been used for the closure of the defective membrane: ski n, fascia lata, temporalis fascia, vein, cartilage, perichondrium, duramater . To date, temporalis fascia, remains the most commonly employed material for tympanic membrane reconstruction with a success rate of 93-97% in primary tympanoplasties . To combat with the tympanoplasty various autogenous and 1
heterogenous graft materials are used by the ENT surgeons. The most common autogenous graft materials are temporalis fascia, tragal perichondrium, tragal cartilage with perichondrium, due to its anatomic proximity, translucency and easy availability. But each of these materials has a different failure rate leading to great disappointment on the part of ENT surgeons. One of the most common cause of failure is the graft rejection. The aim of the study is to present the experience in underlay tympanoplasty while comparing tragal cartilage with perichondrium with temporalis fascia as the ideal graft material with regards to graft uptake and hearing Improvement (post operative A-B gap < 10 dB ) is satisfactory. MATERIALS AND MEHODS
The study of the prospective one was conducted in the department of Otorhinolaryngology and head and neck surgery, in a tertiary care centre over two yrs. The study group consisted of 42 patients: 20 Males (47.6%) and 22 Females (52.4%) between the age of 10-49 years. Patients with dry (for at least 6 weeks) central perforations and pure conductive hearing loss were included in our study. Patients with obvious ossicular disfunction, cholesteatoma flakes, external ear pathology, requiring mastoid explorations or ossiculoplasty were excluded from our study. Patients were randomly allotted in two groups of 21 each.
Department of ENT, Malda Medical College, Englishbazar 732101 1 DLO, MS (ENT), Assistant Professor 2 MS (ENT), Senior Resident, Department of ENT, Calcutta National Medical Colllege, Kolkata 700014 19
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One group underwent tympanoplasty with temporalis fascia and the tragal cartilage. Success was defined as eardrum closure with no residual perforations. Hearing improvement was defined as air-bone gap less than 10dB. Pre operatively all the patients underwent a through clinical examination of nose throat with special reference to the ear. All the findings were confirmed with operating microscope after examination with otoscope. Everyone underwent routine haematological tests including blood sugar, radiological tests including chest x- ray and lateral oblique view of mastoids, preoperative audiological tests including tuning fork tests, pure tone audiometry and impedence audiometry. After premedicating with 10 mg diazepam, atropine, pethidine and promethazine patients were operated under local anaesthesia using 2% lignocaine with 1: 200000 of adrenaline. Young and non cooperative patients were operated under general anaesthesia. Every patient was operated using endaural route. For tragal cartilage an incision was made 2 mm medial to the tragal crest line, and cartilage with perichondrium was removed by cutting through skin, areolar tissue. Temporalis fascia harvested through separate incision. The edge and undersurface of each perforation freshened, Rosen incision was made to enter the middle ear. After checking ossicular integrity some pieces of gelfoam putted in middle ear. Every graft placed over the gelfoam below the handle of malleus. External ear packed with antibiotic socked gelfoam to stabilize the graft. Each patient was advised to take antibiotics for 10 days, and nasal decongestant for three weeks and analgesic for one week. Every patient was advised not to sneeze or cough forcefully, not to strain. On seventh post operative day dressing and suture removal were done. To facilitate the desolution of gelfoam and to promote healing, antibiotic ear drops were started after two weeks following removal of gelfoam on three weeks. Patients were called for follow up every week upto one month and then monthly for six months. After three months pure tone audiometry was done after assessing the status of the neotympanum. The same was also done after six months to see if there were any changes in the audiogram or not.
COMPARATIVE STUDY BETWEEN TEMPORALIS FASCIA AND TRAGAL CARTILAGE — HALDAR AND SAHA Table 1 — Showing Male and Female ratio in different types of grafts used Sexcode
Female Count % within Graft used Male Count % within Graft used
GRAFT Used Total Temporalis Cartilage with fascia perichondrium 12 8 20 57.1% 38.1% 47.61% 9 13 22 42.9% 61.9% 52.39%
Pre operative patients number
Postoperative patients number
<10 dB 0 10- 19dB 20- 29dB 30- 39 dB 40-49 dB
17 0 7 8 6
2 1 1 0
Tragal cartilage with perichondrium
10 - 19 years 20 - 29 years 30 - 39 years 40 - 49 years
5 7 5 4
3 4 8 6
graft in 1960. The superior qualities of fascia, its ready availability in the operative field, and its ideal handling qualities made it the standard for drum grafting, and, temporalis fascia remaining the most commonly employed material for tympanic membrane reconstruction with a success rate of 93-97% in primary tympanoplasties . In 1963 Salen & Jancen used cartilages as graft material. In 1957 first medial grafting done by Shea using a vein graft Underlay myringoplasty due to its relative simplicity, requiring placement of the graft under the annulus and the manubrium without the need for deepithelialisation. On the other hand, there is the risk of graft collapse, middle-ear volume reduction and adhesion of the graft to the promontory, especially when the malleus is rotated medially . In this study we have compared the results of temporalis fascia, tragal cartilage with perichondrium grafts because they are accessible near the operative site, available in adequate amount, have excellent contour, can be thinned down and possess excellent survival capacity. As mesodermal in origin, so they are free from the possibility of post operative cholesteatoma fulfilling all the criteria of excellent graft tissue. All the patients distributed randomly and were between the age group of 10 years to 49 years. 13
Table 2 — Distribution of age groups on the basis of two different types of grafts
Table 3 — The incidence of successful Drum closure in different types of grafts used Drum closure Successful closure Residual perforations
Temporalis Fascia Group
Tragal cartilage with perichondrium
Fig 2 — Pre and postoperative audiometric assessment of temporalis fascia graft tympanoplasty
and barotrauma. Tympanoplasty is the main surgical treatment for tubotympanic disease. It is defined as any operation involving reconstruction of the tympanic membrane and/ or the ossicular chain. The ideal tympanoplasty restores sound protection for the round window by constructing a closed, air containing middle ear against the round window membrane. This also restore sound transfer for the oval window with stapes footplate via either an intact or a reconstructed ossicular chain. To accomplish the two physiologic principles of tympanoplasty, sound protection for the round window must first be provided by means of a tissue graft to repair the tympanic membrane defect, and the middle ear must contain air to protect the window.
In the study conducted by Gibb using temporalis fascia as graft material by underlay technique the percentage of graft take rate was 87.5% . Strahan achieved graft uptake success rate of 87% by underlay method 15
Results : We had included 42 patients in our study.Out of them, 21 had tympanoplasty with temporalis fascia and the other 21 had tympanoplasty with tragal cartilage with perichondrium. The following aspects of the study were analysed. DISCUSSION
Otitis media is a general term used to describe any inflammatory disease of the mucous membrane lining the middle ear cleft and is caused by multiple interrelated factors including infections, Eustachian tube dysfunction,
Table 4 — Pre and postoperative audiometric assessment of temporalis fascia graft tympanoplasty
Mishra el al performed 100 underlay tympanoplasties with superiorly based circumferential flaps using temporalis fascia graft for dry subtotal perforation. They underwent this study during the period August 2001February 2004. Further study could be used on Temporalis Fascia graft to close subtotal perforations and could achieve good results both in terms of drum healing (97%) . 17
We got a success rate of about 90.5%i in temporalis fascia group, drum closure was19 out of 21 patients.
Fig 3 — Pre and postoperative audiometric assessment of tragal cartilage with perichondrium graft tympanoplasty
Pre operative patients number
Postoperative patients number
<10 dB 10- 19dB 20- 29dB 30- 39 dB 40- 49 dB > 50 dB
0 0 5 7 8 1
12 4 2 2 1 0
Over the years different grafting materials have been introduced right from pig’s bladder membrane by Benzer in 1640 to canal wall skin by Willium House and Sheehy . In 1952 the procedure was publicized and popularized by Wullstein using split-thickness skin grafts. Hermann & Storrs 1st performed the use of temporalis fascia as a 7
Fig 1 — The incidence of successful Drum closure in different types of grafts used
According to Spielmann et al 2006 , a cartilage and perichondrial graft can either be harvested from the tragus. A piece of cartilage larger than required is obtained and the perichondrium is attached to one side. The cartilage is trimmed to the required size, leaving the perichondrium untouched. The graft is introduced as an underlay with a fringe of perichondrium spread over the bone of the external auditory meatus to stabilize it. By this technique they got Data on 51 patients with posterior retraction pockets are presented. Forty-two (82 per cent) patients had no aural discharge one year following surgery and the tympanic membrane was not retracted in 43 (84 %) . 18
Table 5 — Pre and postoperative audiometric assessment of tragal cartilage with perichondrium graft tympanoplasty
From the study of Xiao-wei et al, 2010 . Patients aged from 13 to 67 years were followed up in average for 24 months (10–36 months). Seventy-four ears (72.61%) were used the tragal perichondrium/cartilage as graft material. 19
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
Graft take was successful in all patients. Successful closure occurred in 92% of the ears. In our study we got four failure cases out of 21 patients. We achieved about 81% success rate where we used tragal cartilage with perichondrium as grafting material. If we compare temporalis fascia with tragal cartilage with perichondrium,where tragal perichondrium and cartilages were used the success rate a little bit lower In respect to percentage 19% drum were not closed, so we got only 81% success and as stated above temporalis fascia got a success rate of about 90.5%. The hearing improvement by temporalis fascia graft in underlay tympanoplasty by Strahan, 1971 was 82% . Mishra el al reported by temporalis fascia closure of (A-B) gap achieved in 95% of patients. They showed closure of A-B gap to 10-30dB . Dabholkar et al, 2007, achieved 76% hearing restoration by temporalis fascia . Our results were quite similar in respect of hearing improvement. When we used temporalis fascia as graft material about 81% patients achieved the desired level of air bone gap below 10 dB post operatively. Two patients had air bone gap postoperatively between 10-20 dB. Other two patients had air bone gap above 20 dB. Page et al compared preoperative and postoperative audiograms of 175 patients who underwent tympanoplasty by perichondrium & cartilage graft. In their cases postoperative audiograms were better in 49% of cases, identical in 16% and worse in 11% . Anand et al, 2002, done butterfly inlay tympanoplasty using tragal perichondrium and cartilages and got hearing improvement of 5-10 db was found in 4 patients, 4-15 db in 6, 16-20 db in 4, 21-25 db in 3 and 26-30 db in1 patient. 2 patients did not improve at all . From the study of Xiao-wei et al we got the audiometric results were based on the 102 patients. The preoperative PTA-ABG was (41.66±10.22) dB in the tympanoplasty group (n=76), or (46.94±9.26) dB in the tympanomastoidectomy (n=26), and the postoperative PTA-ABG was (26.86±8.92) dB or (23.60±10.33) dB . When we used tragal cartilage with perichondrium as graft material the hearing improvement was not good enough. From the above table we got that only 12 patients post operatively achieved the A-B gap <10 dB. If we compare all the graft material we used we got that the desired level of air bone gap achieved in temporalis fascia graft was 81%, and in tragal perichondrium & cartilage graft was only 57.1%. From the above comparison we found that reports of different otologists regarding hearing gain in tympanoplasty vary widely. In all cases where graft take up was successful we found subjective improvement of hearing. Therefore both the graft can be used successfully in underlay tympanoplasty.
3 4 5
10 11 12 13
REFERENCES Zoellner F — The principles of plastic surgery of the sound conducting apparatus. J Laryngol Otol 1955; 69: 567-9 Wullstein HL — Functional operations in the middle ear with split thickness skin graft. Arch Otorhinolaryngol 1952; 161: 422-35. Heermann H — Tympanic membrane plastic with temporal fascia. Hals Nas Ohren 1960; 9: 136-9. Shea JJ — Vein graft closure of eardrum perforations. J Laryngol Otol 1960; 74: 358-62. Preobrazhenski TB, Rugov AA — The employment of preserved dura mater graft in tympanoplasty. Vestn Otorinolaringol 1965; 5: 38-42. Sheehy JL, Anderson RG — Myringoplasty. A review of 472 cases. Ann Otol Rhinol Laryngol 1980; 89: 331-4. Dabholkar PJ, Vora K, Sikdar A — Comparative study of underlay tympanoplasty with temporalis fascia and tragal perichondrium. Indian J. Otolaryngol. Head Neck Surg 2007; 59: 116-19. Browning GG — Chronic otitis media. In: Merchant SN, Kelly G, Swan IRC, Canter R, William S McKerrow editors- ScottBrown’ Otorhinolaryngology, Head and Neck Surgery. 7th edition. 2008: 3: 3421. House WF, Sheehy JL — Myringoplasty: use of ear canal skin compared with other techniques. Arch Otolaryngol 1961; 73: 407. The restoration of the function of the middle ear in chronic otitis media. Ann Otol Rhinol Laryngol 1971; 80: 210-7. Hermann H — Tympanic membrane plastic with temporalis fascia. Hals Nas Ohrenh1960; 9: 136. Storrs LA — Myringoplasty with the use of fascia grafts. Arch Otolaryngol 1961; 74: 65-9. M Cavaliere, G Mottola, M Rondinelli, M Iemma — Tragal cartilage in tympanoplasty: anatomic and functional results in 306 cases. Acta Otolaryngologica Italica 2009; 29: 27-32 F Fiorino, F BarbieriB — Over-under myringoplasty with umbus-anchored graft. The Journal of Laryngology & Otology 2008; 122: 854-57. Gibb A, Chang SK — Myringoplasty (A Review of 365 operations). Journal of Laryngology and Otology 1982; 96: 915-920. Strahn RW, Ward P, Acquirelli M, Jafec B — Tympanic membrane grafting. Analysis of material and technique. Annals of Otology 1971; 80: 854-60. Mishra P, Sonkhya N, Mathur N — Prospective study of 100 cases of underlay tympanoplasty with superiorly based circumferential flap for subtotal perforations. Indian J Otolaryngol Head Neck Surg 2007; 59: 225-8. Spielmann P, Mills R — Surgical management of retraction pockets of the pars tensa with cartilage and perichondrial grafts. The Journal of Laryngology & Otology 2006; 120: 725-9. Chen Xiao-wei, Yang Hua, Gao Ru-zhen, Yu Rong and Gao Zhi-qiang — Perichondrium/cartilage composite graft for repairing large tympanic membrane perforations and hearing improvement. Chinese Medical Journal 2010; 123: 301-4. Page C, Charlet L, Strunski V — Cartilage tympanoplasty: postoperative functional results. Eur Arch Otorhinolaryngol 2008; 265:1195-8.
Ocular trauma : basic primary management Gunjan Prakash1, Nisha Chauhan2, Achin Rawat3, Ashwini Gangadher4, Arpita Gupta4, S K Satsangi5
Ocular trauma, is a common cause of avoidable uniocular visual morbidity. Many a times, it is a part of polytrauma. So ocular trauma patients’ first encounter general physicians or surgeons much more often than an eye specialist, in trauma centers. This article is being written to bring into light, the basic first aid measures, which if all the registered medical practitioners are aware of, can help in reducing the visual morbidity of ocular trauma. [J Indian Med Assoc 2016; 114: 23-7]
Key words : Ocular Trauma, Chemical Burns, Fire Works Injury, Perforating Eye Injury, Penetrating Eye Injury.
cular trauma is a major cause of unilateral visual loss worldwide, but this visual loss is preventable to a large extent, thus making awareness at the community level important . A recent Delhi based study reported a 2.4% prevalence of ocular trauma in urban slums . Ninety five percent of ocular injuries do not require admission suggesting that total prevalence of ocular trauma must be much higher than what is estimated by hospital based studies . But appropriate pre-hospital care of all ocular injuries is still needed to maintain functional visual acuity. Thus, all health facilities should be ready to deal with the cases of eye injuries by ensuring proper training & supply of equipments, drugs and other prerequisites to do the preliminary examination and provide first aid care & transport facilities to nearest referral centre. Many a times, patient of serious ocular trauma can have a near normal visual acuity and no visible examination findings. If any patient of ocular trauma is well managed in emergency room primarily, even then, a follow-up appointment with ophthalmologist is always recommended. Ask the patient to get retinal evaluation done within two weeks, in cases of blunt injuries. Whenever a patient with an ocular trauma is encountered, taking proper history regarding the time of onset and the mode of injury helps as a guide for further examination and management. Before proceeding to management, one should know
about the standard ocular trauma terminology ie, Birmingham eye trauma terminology (BETT) classification , so that all the documentations and communication betweens physicians and ophthalmologists are unambiguous. 5
BETT Classification :
Terminology : (1) Closed globe injury: No full thickness wound (2) Contusion: No wound in outer coats of globe. Injury is due to direct injury delivered eg, choroidal rupture or change in eye ball shape, eg, angle recession (3) Lamellar laceration: Partial thickness wound (4) Open globe injury: Full thickness wound (5) Rupture: Open globe injury due to blunt object. Occurs at the weakest point by inside out mechanism (6) Laceration: Open globe injury due to sharp object. Occurs at the point of impact by outside in mechanism (7) Penetrating injury: There is only entrance wound. There is usually prolapse of intraocular contents.
Department of Ophthalmology, Sarojini Naidu Medical College, Agra 282002 1 MBBS, MD (Ophthalmol), Assistant Professor 2 MBBS, Junior Resident 3 MBBS, MS (Ophthalmol), Senior Resident 4 MBBS Junior Resident 5 MBBS, MS (Ophthalmol), Professor 23
OCULAR TRAUMA : BASIC PRIMARY MANAGEMENT â€” PRAKASH ET AL
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
(8) Perforating injury: Through and through eye injury, ie, entrance and exit wound. Most severe form. Always check the visual acuity by finger counting and perception of torch light (with other eye closed) and see the pupillary reaction, especially in cases with blunt trauma, black eye and adnexal injuries, to see the functional status of optic nerve.
Pre-requisites for proper management : Torch, Direct ophthalmoscope, Anesthetic eye drop for examination [0.5% proparacaine eye drop is preferred, or 4% xylocaine solution], Cotton buds, Antibiotic eye drop (0.5% moxifloxacin or 0.3 % tobramycin), Lubricating eye ointment, Litmus paper, Fluorescein strips.
Depending on the cause of injury, patient can present to us in following ways: Cause of injury
Torch light examination
Chemical Red eye, Hazy/ Burns Cloudy cornea, intense photophobia
Foreign Body (Fig 1B)
Foreign body (FB) can be seen over bulbar conjunctiva/ Cornea. For fornix/ palpebral conjunctiva, evert eyelids (retract lower eyelid and ask the patient to look upward and for upper lid, hold eyelashes of upper eyelid with thumb and index finger of one hand and evert it over pulp of the thumb of other hand). Vertical corneal marks are telltale sign of hidden subtarsal FB (in upper eyelid)
Cause of injury
Torch light examination
Corneal Painful red eye, Intolerance to abrasion light (thus difficulty in opening eye). Surface defect, if large, can be seen on torch light.
Rule out any associated discharge/ infection. Pressure patch eye after putting lubricant and antibiotic eye drop. Refer.
Hyphaema (Fig 1C)
Discontinue NSAIDs Advice head elevation and limitation of activities. Refer immediately.
Blood present inferiorly in anterior chamber.
Its an ophthalmic emergency and should be treated without any delay. If not treated on time, it can lead to corneal scarring, corneal neovascularization (Fig 1A) or symblepharon formation. Immediate irrigation of all the parts of ocular surface, with drip set or any large bore tubing attached to 500 ml normal saline pack (use tap water for 30 minutes, if it is not available), flow should always be away from the cornea. The best indicator for end point of irrigation is neutral pH, which is to be tested by litmus paper after 10 minutes of stopping irrigation. Remove all the visible particulate matter or debris with moist cotton bud touch off, after eversion of lids as they act as depot of chemical. Do not bandage the eye. Put antibiotic eye drop. Then Refer. If the object is floating over tear film, flush it out with normal saline/ distilled water in 10 ml syringe. If it fails, remove the FB by moist cotton bud touch off and then flush again. Prescribe antibiotic and artificial tear eye drop. Do not manipulate if FB is embedded and is not easily removed. Instruct the patient to avoid rubbing eyes. Put the eye shield and tape it. If the object is embedded and protruding (eg, Pencil etc), then stabilize it with fluffy bandage to prevent movement during transport. Then Refer
Conjunc- Hemorrhagic rolled edges of tival conjunctiva with exposed laceration white sclera
<1 cm: Pressure patch eye for 24 hours using antibiotic eye ointment. >1 cm : Refer, as micro surgical repair might be needed.
Subcon- Hemorrhagic patch is seen junctival over bulbar conjunctiva hemorrhage
Check Blood Pressure. Discontinue NSAIDs esp. aspirin. Prescribe acetaminophen if painful. If all the boundaries of hemorrhage are visible, then start artificial tear drop, assure the patient that it resolves in 2-3 weeks. If even one of the margins canâ€™t be traced, refer the patient.
Black eye Periorbital ecchymosis (Fig 1D) (more in inferior eyelid) with purplish black hue Palpate the bony orbital margins for tenderness and eye lid skin for subcutaneous emphysema
Cold compresses 20 min/hour for 48 hours. After that, hot compresses for 3-5 days. Avoid aspirin. Prescribe acetaminophen if painful. Danger signs: Persistent headache Bony tenderness/ crepitus Double vision Inability to move eyes Blood on eye surface Decrease/ loss of vision Refer immediately if danger signs are present
Lid Usually a part of polytrauma laceration (Fig 2A)
Give tetanus toxoid 0.5 ml i.m. immediately if patient has not had a tetanus immunization within 5 years or if the status is unclear. If the patient was never immunized, 250 units of human tetanus immunoglobulins are given. Rabies vaccination in cases of animal bite. Clean with betadine, irrigate with saline to remove FB particles, debride all devitalized tissue. Put antibacterial drop, do the dressing. Clean and cover it with betadine or saline soaked gauze. Refer immediately after cleaning to ensure surgical repair with proper anatomical alignment and better cosmesis.
Superficial lid abrasion
Deep laceration (involving lid margin/ lacrimal drainage system/ extensive tissue loss). Penetra- Cause corneal/ scleral tear with ting or without uveal show (Fig 2B). injury Usually there is flat anterior chamber with tear drop pupil (due to iris prolapse from wound)
Give tetanus toxoid, as described above Ask the patient to remain nil per orally (as general anesthesia might be needed for tear repair). Give anti-emetics in cases of nausea/ vomiting. Advise patient to avoid sneezing, coughing or any type of pressure on globe. Instruct the patient to avoid ocular movements as contraction of extra-ocular muscles can cause extrusion of intraocular contents. Patient should lie in supine position Defer any further examination, put an eye shield, do not use any topical medication and ask the patient to keep movement of both the eyes to minimum. Refer immediately for micro surgical repair. If due to any reason referral is delayed, get the routine blood investigations done and patient should be started on broad spectrum intravenous antibiotics.
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
Fig 1 — (A) Left eye of a patient with extensive corneal neovascularization and lime deposits in deep layers of cornea. Patient suffered lime injury in his eye 2 years back and timely treatment was not taken. (B) White arrow pointing towards the corneal foreign body (C) Hyphaema (white arrow pointing towards the blood in anterior chamber) (D) Periorbital ecchymosis
Fig 2 — (A) A case of road traffic accident with extensive periorbital laceration. (B) A case of corneal tear by pencil. White arrow is pointing towards the site of tear and prolapsed iris
Usually a combination of cephazoline/ vancomycin and gentamicin/amikacin is preferred in cases of open globe injuries. For extra-ocular injuries ie, involving eyelids, amoxicillin- clavulanate is preferred. Clindamycin is to be added in both cases, if suspicion of retained intraocular foreign body or injury by vegetative matter/ gun shot injury/ animal bite.
Additional Information : (1) Ocular burns : Most commonly due to chemical injury, which constitutes around 80% of all ocular burns. The types of chemical can be acidic, alkali or neutral (e.g. Pepper spray or household detergent). Alkalis penetrate more than acids and thus cause more damage. Common causes of alkali injury are calcium hydroxide (lime/ plaster/ mortar/ whitewash/ cement), ammonia (fertilizers), sodium hydroxide/ lye (drain cleaners) and potassium hydroxide (caustic potash). Acid injuries are usually caused by sulphuric acid (battery acid/ vitriolage). For irrigation, no therapeutic difference is seen among normal saline/ normal saline with bicarbonate/ ringer lactate/ balanced salt solution . So any of the available fluid should be used, as the goal is to dilute 6
OCULAR TRAUMA : BASIC PRIMARY MANAGEMENT — PRAKASH ET AL
and remove the noxious chemical to prevent further damage. Aim is to dilute and wash the chemical, not to neutralize the acid/alkali; so never use acid wash for alkali burn and vice versa. Other causes are burns due to thermal and radiant energy. Thermal burns are due to flame burns of fire or contact burns by hot objects or liquids. Radiant energy burns are seen in welder’s, also known as welder’s keratitis. In thermal and radiant burns, irrigation is not usually done, rest management is same as chemical burns, also the eye should be pressure patched after applying antibiotic and lubricant eye ointment. In cases of eyelid burns, combination of antibiotic and steroid ointment should be prescribed. In all ocular burns, Swipe lubricant coated cotton bud across the fornices to break any adhesions which may lead to symblepharon formation. Always rule out globe perforations (high suspicion if eye is extremely soft to touch, compare it with other eye to know the normal rigidity of eyeball), especially if history of battery blast or firework injury. If globe perforation is suspected, refer immediately. (2) Firework injury : Usually causes thermal burns. Also can cause projectile based injury (penetrating or perforating trauma). Manage accordingly and then refer. (3) Gun shot injury and animal bites : Both can cause eye lid lacerations. Pick up all the visible pellets or foreign material with forceps in cases of gunshot injury. Anti tetanus prophylaxis is given in both the cases. In addition, give anti-rabies vaccine in animal bites. If the wound has clean margins, <24 hours duration and involving lacrimal system or medial canthal tendon, then it is washed with betadine scrub and saline and primary repair should be done. If margins are devitalized (purplish or black), clinically infected and >24 hours duration, then excise all the dead tissue, clean it with betadine and saline. According to traditional teaching, such cases should be repaired by delayed primary repair (after giving intravenous antibiotics for 3-5 days). Now a days, the trend is to do primary repair in all cases to ensure proper anatomical and functional outcome, because it is thought that although the eye, face and head fall in class III category of animal injuries and carry high risk of infection, but under prophylactic antibiotic cover and owing to high vascularity of eyelids, chances of infections are low. In cases of intraocular injuries, it is usually open globe injury, and should be handled as a case of penetrating injury, as explained above. In gun shot injuries, X- ray should be done to localize all the pellets. MRI is contraindicated. CT scan should be done if intracranial involvement is suspected. Then refer. Importance of direct ophthalmoscopy : Direct ophthalmoscope, if available, is used for assessing the fundal glow (like the red eye seen in a camera pic).
Preferable if done with dilated pupil. It is done from a distance of about 1 feet. Normal fundal glow seen in pupillary area is reddish orange. If it is dull (compare with other eye) or abnormal in color, then the patient should be referred to an ophthalmologist to rule out any underlying posterior segment pathology. Types of fundal glow seen on distant direct ophthalmoscopy : Media opacity Stands out as black against normal red fundal glow Endophthalmitis If early, then poor/ no fundal glow. Yellowish green in advanced cases. Vitreous hemorrhage If mild then maroon fundal glow, and if massive then poor/ no fundal glow Retinal detachment Grayish fundal glow In cases where corneal abrasion is suspected, stain the eye with fluorescein dye (impregnated sterilized strips are available commercially). If the abrasion is present, the dye adheres to that area and fluoresce with bright green color when seen through cobalt blue filter of direct ophthalmoscope. How to make an eye shield : Shielding an eye is an important prognostic factor in cases of penetrating ocular trauma as it protects the eye from further trauma, dust or any other foreign body during transportation. Eye shields or any protective covering should rest on the bone around the orbit so that minimum pressure is exerted on the globe. These are commercially available, but if not available they can be easily made: (a) Take small size clean disposable paper cup, keep the open side over the bony orbital margins of injured eye & tape it. (b) Take a thick clean paper (like medicine box), cut it in the form of a circle, make one radial slit, slide one end of the slit over another to make a shallow cone (Fig 3). Fix it with tape and apply over eye . One thing should always be remembered that accompanying life threatening emergencies, like respiratory distress, major bleeding and shock, should always be recog nized and managed (the basic 7
Fig 3 — Steps of making an eye shield
ABC’s: airway, breathing and circulation) and these emergencies take precedence over any ocular injury in cases of polytrauma. General medical and neurological: stability and clearance, should always be ensured and then proceed to eye care, which is but equally important. Even if there is no visible ocular trauma, a thorough ophthalmic examination is required to rule out posterior segment or optic nerve injuries. REFERENCES 1 Katz J, Tielsch JM — Lifetime prevalence of ocular injuries from the Baltimore Eye Survey. Arch Ophthalmol 1993; 111: 1564-8. 2 Schein OD, Hibberd P, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM, et al — The spectrum and burden of ocular injury. Ophthalmology 1988; 95: 300-5. 3 Vats S, Murthy GV, Chandra M — Epidemiological study of ocular trauma in an urban slum population in Delhi, India. Indian J Ophthalmol 2008; 56: 313-6. 4 May DR, Kuhn FP, Morris RE — The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol 2000; 238: 153-7. 5 Kuhn F, Morris R, Witherspoon CD — Birmingham Eye Trauma Terminology: terminology and classification of mechanical injuries. Ophthalmol Clin North Am 2002; 15: 139-43. 6 Herr RD, White GL Jr, Bernhisel K — Clinical comparison of ocular irrigating fluids following chemical injury. Am J Emerg Med 1991; 9: 228-31. 7 Tontu Zik — The importance of shielding eye in referral of ocular injuries. Community Eye Health 2006; 19: 14.
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PROFESSIONALISM IN MEDICINE — THE PRESENT SCENARIO — SIDARTHA AND SINGH
Professionalism in medicine — the present scenario Lukram Sidartha1, Lukram Amarjit Singh2
The practice of art and science of medicine is the best example of professionalism. In medicine, physicians regulate themselves through state medical councils, as well as hospital committees and other peer-review groups. Those in a profession practice in accord with a code of ethics. Finally, a profession has a contract with society. This article reviews other aspects of professionalism and focuses on the realm of teaching professionalism to medical students and residents with the hope of restoring the value of medicine to its pristine glory.
[J Indian Med Assoc 2016; 114: 28-9 & 31]
Key words : Medical professionalism, Professional virtues, Residential evaluation, Hippocratic Oath, Code of Hammurabi. “The practice of medicine is not a business and can never be one ….Our fellow creatures can never be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations” ?
History of Professionalism :
History of professionalism dates back to the early Vedic period. “Three kinds of medical practitioners are found in this world; firstly, the imposter in physician’s robes; secondly, the vain glorious pretenders and thirdly, those endowed with the true virtue of the healer”. ? — Charaka (120–162) .
— Sir William Osler, 1903 . 1
It is common knowledge that strong influences of political, legal and market-driven nature are producing great stress on the practice of medicine. There is wide spread concern among the medical professionals about the impact of these external forces which threaten the very relationship among the medical professionals, the society and the patients .
Usually documented in the form of professional codes, the origin of medical ethics dated back to antiquity with the Code of Hammurabi (2000 BC), the first known code of medical ethics, and later, the Hippocratic Oath (5th Century BC), which to this day is pledged (often in modified form) at medical school initiation and graduation ceremonies . It remains the defining traditional statement concerning the conduct of the physician. However, it was only in the eighteenth century that the concept of medicine as a profession was put into effect by two physicians – John Gregory Scott (1724–1773) and Englishman, Thomas Percival (1740–1804) . Before Gregory’s time, physicians employed the term “profession” to distinguish themselves from surgeons, apothecaries, and other perceived competitors, all regarded by the university- trained physicians as lower order practitioners of the day. With the establishment of the Royal College of Surgeons of Edinburgh, the study of surgery became more academic and scientific-oriented based on a sound knowledge of anatomy, physiology and pathology; and surgeons, as distinct from the barbers, became a member of the noble profession . In the early 20th Century, professionalism included
Professionalism, to be more precise, “constitute those attitudes and behaviour that serve to maintain patient interest above physician self-interest”. The word ‘profession’ is derived from ‘profess’ which means ‘to proclaim something publicly’. Physicians profess two things: to be competent to help the patients and to have the patient’s best interest in mind. Such commitment invites trust from their patients .
An occupation is considered a profession if practicing it requires a formal education; its members enjoy control over their own training standards; its members have their own disciplinary mechanisms; there is a scholarly journey devoted to its standards; its practitioners enjoy relatively high social status; and its practitioners have secured protection from state as well as from market pressures .
Department of General Surgery, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur 795001 1 MBBS, DNB (Gen Surg), Senior Resident 2 MBBS, MS, MNAMS, FACS (Retd) Professor and Head of the Department of Surgery, RIMS, Imphal 795001
issues like maintaining technical expertise and self regulation of medical practice. In the developed world, technical expertise made a quantum jump in tune with the technological advancement, but the quality of education is still a matter of concern in developing countries. Self regulation by the profession has always been its Achilles’ heel: most professional bodies do not effectively discipline their members; most do not publish records of their disciplinary actions, if any. Such short comings make it clear that effective self-regulation is almost non-existent and needs to be created . The de-mystification of medical profession in the early part of the 20th century resulted in two most unpleasant upheavals. First, medicine changed from an autonomous, publicly respected profession to one vilified in the public press. Doctors, once the ‘perfect angel’ had fallen from the pedestal of public adulation. Second, health managers appeared potent rivals for the authority that physicians thought they owned. Growing privatization and moneterization of medicine in the corporate sector have threatened the uniqueness of the ‘sovereign profession’ . Today, medical profession is in peril as several factors have weakened it. Increasingly physicians encounter perverse financial incentives as well as restrictions, fierce market competition, and the resultant erosion of patients’ trust. Professionalism has virtually vanished in the battle between market competition of the ‘health care industry’ and ineffective government regulation of health care service . 6
Professional Virtues : Medicine has always been considered a noble profession. “Virtue engenders excellence; therefore, virtue ought to be fostered more than life” ? — Tiruvalluvar – Tamil Saint Poet . The image of a doctor has always suggested integrity, loyalty and compassion – key aspects of a physician’s professional identity. The world over, for generations on end, communities permitted unique independence, power and privileges to the personals that practiced medicine; in turn, the societies expected medical professionals to altruistically serve the sick and the suffering. Some of the virtues of the physician need to encompass fidelity to trust, benevolence, intellectual honesty – to accept when one does not know, courage to face the dangers of contagion – possibilities of physical harm, compassion and truthfulness – enabling the patients to make choices on treatment modalities . 3
Threat to Professionalism : A special challenge arises in medicine because health care is often expensive and a third party generally reim-
burses these costs. Other professional relationships are different: a lawyer or an engineer charges clients directly for services rendered, and the clients can consider costs when they decide what kind of services they want. However, in medicine, the decisions are now heavily constrained by the payers’ (third party) decisions about whether a proposed treatment is ‘medically necessary’ and appropriately cost-effective. This intrusion of third party payers into health care decision making process has significantly curtailed physicians’ accustomed professional independence. Professionalism, hence, is seriously threatened. The New England Journal of Medicine has warned, on behalf of patients, against the “new medical-industrial complex” as detrimental to the free exercise of professional responsibilities. Another major threat to professionalism arises from the undue influence of the pharmaceutical industry over continuing professional education and research . 8
Challenges to Professionalism in India : “The medical profession is under siege. The public increasingly distrust us because we are too condescending to listen, too mediocre to keep up and too greedy to truly care about their welfare”. ? — S.Y.Tan, MD . No so long ago, in India and other developing countries, a doctor is greatly trusted, but more and more people are questioning the practice. Besides, ‘my-doctorknows-what-is-best” type of blind trust is giving way, especially among the educated, to the realization that decision-making is the right of the patient. There are numerous instances of unethical advertising by the doctors. The regulatory councils look into such matter but no tangible action is taken and the doctor goes scot-free. Of late, advertisements by hospitals and diagnostic centres vie with those put up by alternate system of medicine, often proclaiming their superiority over others. Is it ethical for the physicians to order expensive investigations without explaining to the patient how much it would cost to undergo the full treatment? It is estimated that about two-thirds of rural families are in debt because of health care expenditure . 3
Role Models in Medical Professionalism : How can medical colleges find physicians who can, without hypocrisy, teach professionalism to the young medical graduates? They have to start with a faculty development program on professionalism and create a critical mass of role models among the educators. Mentoring is clearly the most effective means of transmitting values. Another effective way is to create an environment for professionalism, not by telling students what to do but by raising their awareness by asking questions . 3
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REPAIR OF BILATERAL LUMBAR HERNIA USING PROLENE HERNIA SYSTEM — MANIPADAM REFERENCES
Repair of bilateral lumbar hernia using prolene hernia system 1
John Mathew Manipadam , Ebby Asirvathamm , Edwin Stephen , Sunil Agarwal
1 Swartz WT— Lumbar hernia. In: Nyhus LM, Condon RE editors- Hernia, 2nd edn. Philadelphia: Lippincot, 1978: 409-26. 2 Cocozza E, Pidoto RR, Ravera M — Bilateral lumbar hernia associated with abdominal hernias: A case report. Minerva Chir 1999; 54: 121-3. 3 Ponka JL — Lumbar hernia. In: Ponka JL editors- Hernias of the abdominal wall. Philadelphia: Saunders, 1980: 465-78.
4 Zhou X, Nve O, Chen G — Lumbar Hernia: Clinical analysis of 11 cases. Hernia 2004; 8: 260-3. 5 Cavallaro G, Sadighi A — Primary lumbar hernia: The open approach. Eur Surg Res 2007; 39: 88-92. 6 Armstrong O — Lumbar Hernia: Anatomical basis and clinical aspects. Surg Radiol Anat 2009; 31: 317.
Lumbar hernias are rare. Bilateral are even rarer. Repair of a case of bilateral lumbar hernia with prolene hernia system is reported. Mesh plug repair of lumbar hernia using the prolene hernia system has not been reported in English literature so far. [J Indian Med Assoc 2016; 114: 30-1] (Continued from page 29)
Key words : Lumbar Hernia, Prolene Hernia System.
drains were put. Antibiotics were continued for 48 hours postoperatively. He was ambulant by 6 hours after operation and was discharged on the third postoperative day with an uneventful recovery.
umbar hernias protrude through the superior or inferior lumbar triangle.The superior triangle is bounded by the 12th rib superiorly, the internal oblique muscle anteriorly and the erector spinae posteriorly. The inferior lumbar triangle is bordered by the latissmus dorsi posteriorly, the external oblique muscle anteriorly and the iliac crest inferiorly . A congenital or acquired defect in the transverse muscle aponeurosis is considered the main pathogenic factor involved in a lumbar hernia occurrence .
Lumbar hernias are rare posterolateral abdominal wall hernias with only about 300 cases reported in the world literature . Since this reference in 1980 roughly another 67 cases have been reported . Lumbar hernias protrude through the superior or inferior lumbar triangle.The superior triangle is bounded by the 12th rib superiorly, the internal oblique muscle anteriorly and the erector spinae posteriorly. The inferior lumbar triangle is bordered by the latissmus dorsi posteriorly, the external oblique muscle anteriorly and the iliac crest inferiorly. A congenital or acquired defect in the transverse muscle aponeurosis is considered the main pathogenic factor involved in a lumbar hernia occurrence. Fig 1 — Showing right lumbar hernia with a CT scan is important to confirm the defect in transversus abdominis aponeurosis through which there is herniation of diagnosis . The open approach and mesh 1
A 32 year old man presented to our outpatient with bilateral loin swellings which slowly increased in size for the past five years. He also complained of dull, aching pain which was intermittent for the past six months without any history of trauma or operations in the past on the back. Examination — Bilateral soft swellings with a cough impulse in the superior lumbar triangles. Investigation — CT scan confirmed our clinical suspicion ,the content being extraperitoneal fat; also seen are the divided extraperitoneal fat. latissmus dorsi fibres Surgery — He underwent Rutkow prolene hernia system (mesh plug) repair tension free repair is as an elective procedure in prone position under general a simple and anaesthesia. The defect in the transversus abdominis effective technique aponeurosis was identified after dividing the overlying to repair primary latissmus dorsi. The contents were reduced and the prolene lumbar hernias . hernia system was placed with the inner leaf below the Mesh Plug aponeurosis above the extraperitoneal fat and the outer leaf Repair of lumbar above the defect and below the latissmus with the plug sealing hernia using prolene hernia system which Department of Surgery-2, Christian Medical College, Vellore 632004 we have described 1 MBBS, MS, MRCS (Ed), Assistant Professor has not been 2 MBBS, DNB, Tutor reported in literature 3 MBBS, MS, Professor so far (Figs 1 & 2). 4 MBBS, MS, Professor and head of department
Today’s students need skills that will serve them well in future. The social milieu or “informal” curriculum of a medical school has great influence on the values and professional identities acquired by its students. A large number of medical schools in USA run a program to foster social environment that embodies and reinforces the value of competency based curriculum. A checklist is circulated for residential evaluation: 1) Empathy in patient care; 2) Appropriate fund of knowledge; 3) Soundness of clinical judgements; 4) Technical expertise with diagnostic and therapeutic procedures; 5) Communication with patients, families and staff; 6) Sensitivities and responsiveness to individual patient differences in economic status, ethnicity, age, gender and disabilities; 7) Honesty in dealing with patients and colleagues; 8) Accountabilities for actions; 9) Conflict-resolution skills; and 10) Adherence to regulatory, institutional and department norms . Professionalism obligates doctors to be competent and updated in their expertise and proficiency. It obligated doctors to suppress self-interest in their service for the well-being of their patients. It obligates doctors to cultivate a fiduciary relationship with their patients and be trustworthy. It obligates medical institutions to promote society’s trust and not to undermine it. If medicine is a profession, then the medical team – physicians, nurses, physician assistants, social workers, nutritionists, physiotherapists and other care givers – is a group of professionals obligated to share a core of common professional duties. All members have the ethical responsibilities to know and respond to their colleagues’ professional duties and to be caring and respectful in their professional interactions with each other. The professional actions, values and commitments of the medical team must be transparent to patients and the community. 3
Conclusion : Professionalism is an important component of medicine’s contract with society. Not only do we need to make good decisions for our patients based on the evidence in the literature, but we need to apply those decisions in a way that is professional and ultimately helps our patients. Certain behaviours early in medical education do correlate with unprofessional behaviour during a physician’s career. We need to be vigilant in looking for those behaviours, and let our students and trainees know why we’re so concerned about them. Physicians are likely to improve in professionalism with training and experience . “…….......…nothing is more estimable than a physician who, having studied nature from his youth, knows the properties of the human body, the diseases which assail it, the remedies which will benefit it, exercises his art with caution, and pays attention to the rich and poor”. ? —Voltaire . 9
1 2 3 4
Fig 2 – Showing left lumbar hernia with a defect in transversus abdominis aponeurosis through which there is herniation of extraperitoneal fat
REFERENCES Mackenzie CR — Professionalism and Medicine. Hospital for Special Surgery 2007; 3: 222-7. Barondess JA — Medicine and Professionalism. Arch Intern Med 2003; 163: 145-9. Sethuraman KR — Regional Health Forum 2006; 10: 1-10. Sethuraman KR — Debt – Yours or Mine? – In: Trick or Treat – a Survival Guide to Health Care. Pondicherry, India EQUIP Society, 2000. Markel H — “I swear by Apollo” – on taking the Hippocratic Oath. N Engl J Med 2004; 350: 2026-9. Stevens RA — Themes in the History of Medical Professionalism. The Mount Sinai Journal of Medicine 2002; 69: 357-62. Pellegrino ED — Professionalism, Profession and the virtues of the Good Physician. The Mount Sinai Journal of Medicine 2002; 69: 378-84. Bloom S — Professionalism in the Practice of Medicine. The Mount Sinai Journal of Medicine 2002; 69: 398-403. Lynne MK — Professionalism in Medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent) 2007; 20: 13-6.
Term Pregnancy in women with tetralogy of fallot — case report
Congenital fetal heart block — a rare isolated presentation of asymptomatic maternal SLE
Anil F Jasani¹, Vineet V Mishra², Rohina S Aggarwal³, Anju D Yadav4, Snigdha A Khurana5, Kunur N Shah6
D V Kurdukar1, Akanksha Sood2, Rekha G Daver3
Tetralogy of fallot is the most common cyanotic congenital heart malformation which accounts for 5 to 6% of Congenital Heart Diseases. There is a high incidence of spontaneous abortions, premature births, and low birth weights in pregnancy with TOF. Most important risk factor for adverse fetal outcome in pregnancy with TOF was the degree of cyanosis. We report a case of 38 weeks of pregnancy with uncorrected TOF with symmetrical IUGR delivered 1040 gms female child by emergency LSCS for fetal distress following cyanotic spell. Peri-operative period was remain uneventful without any maternal and neonatal complications. [J Indian Med Assoc 2016; 114: 32 & 34]
Key words : Tetralogy of fallot, Cyanosis, Symmetrical IUGR.
Fetal bradycardia is rings a bell of fetal distress! But it can be due to structural & functional abnormalities of fetal heart, due to maternal connective tissue disorders. We hereby are presenting a case of a maternal asymptomatic SLE presenting with isolated fetal conduction block and no other signs of neonatal lupus. [J Indian Med Assoc 2016; 114: 33-4]
Key words : Fetal bradycardia, maternal asymptomatic SLE.
ncidence of congenital atrio-ventricular arrhythmias is 1/ 20,000 live births . Out of them complete heart blocks are most common. 60-70% of these many are due to autoimmune disease in mother. 80% cases show structurally normal heart . On 26/11/11, 30 years old primigravida (married since 9 years), 9 month gestation with USG suggestive of fetal cardiac conduction block; was referred to JJ Hospital, Mumbai for further management. Her expected date of delivery was 13/12/11. Ultrasonography done during first trimester and congenital anomaly scan showed normal fetal heart rate (158174 / minute). In the third trimester at 34 weeks gestation, during per abdominal examination, on auscultation fetal bradycardia was detected. Immediately USG obstetrics was done on 4/11/11; mean gestational age 34 weeks 3 days fetus was showing heart rate of 71 beats / minute only!! But rest other parameters were normal. Patient was then investigated. She was screened for connective tissue diseases, found to be positive for Anti nuclear antibody, Anti Ro antibody & Anti La antibody, Serum TSH was 14.18 (raised). For hypothyroidism, Tab Thyronorm 50 microgram OD was started. Complete blood count and complement studies were within normal limits. Rest all investigations were within normal limits. Patient did not have any complaints or history suggestive of any connective tissue disorder in her family. Parents were screened for heart block and found negative. On examination patient’s pulse was normal 84 per minute and regular. No signs suggestive of any connective tissue disorder. General and Systemic examination was within normal limits. Per abdomen examination showed fundal height of 34 weeks of gestation with vertex presentation with heart rate of 7080 /minute. On 27/11/11 repeat sonography and Doppler revealed Fetal
Bradycardia as the only abnormality. Except for the Non stress Test all other parameters of Manning’s Score were normal. Fetal 2 D ECHO done was suggestive of anatomically normal heart with A-V conduction block. As per physicians opinion patient was put on Injection Dexamethasone 4 mg intramuscular thrice daily. Patient was closely monitored and she went into spontaneous labor 3/12/11. Emergency LSCS was done for failure of progress of labor. A male baby of 2.8 kg, cried immediately after birth. Except for the heart rate, APGAR score was 8/8; admitted in NICU for neonatal bradycardia. Post natal ECG and 2 D echo confirmed the diagnosis. Baby was gradually started on breast feeding which baby tolerated well. Baby’s thyroid assay was normal. USG abdomen suggested normal study. No rash or any other sign of Neonatal Lupus appeared even after 1 week. Need of pacemaker or any other active line of management was ruled out by cardiologist, however regular follow up was suggested. Baby along with mother was discharged on 11/12/11.
tated the patient. At the time of cyanotic spell, there was persistent fetal bradycardia (FHR 92 bpm) that persisted even after patient recovered from cyanotic spell and decision of emergency LSCS was taken for fetal distress. Emergency LSCS was performed under epidural anesthesia with infective endocarditis prophylaxis. Alive 1040 gms female child delivered which cried soon after birth. Baby was admitted in NICU for further management of LBW. Patient was kept in ICCU for 2 days for postoperative management. Peri-operative period remained uneventful. Patient was discharged on 8th postoperative day. There were no congenital anomalies reported in the neonate (Fig 1).
etralogy of fallot is the most common cyanotic congenital heart malformation which accounts for 5 to 6% of Congenital Heart Diseases . Full term Pregnancy with uncorrected tetralogy of fallot is rare clinical situation. 1
A 22 year old primigravidae patient conceived spontaneously after 4 years of active marriage life referred from private hospital with 38 weeks of pregnancy with uncorrected tetralogy of fallot with history of hemoptysis 2-3 episodes per day since 10 days without any other overt cardio-respiratory symptoms. Patient was not booked antenatally. Examination — Patient had clubbing, murmur on CVS examination and her SPO on rest was 86% on air. On obstetric examination, uterus was relaxed, 30-32 weeks in size, cephalic presentation and FHR was 140 bpm regular in rhythm. Her 2D echo findings were suggestive of tetralogy of fallot as evidenced by 18 mm VSD with right to left shunt, overriding of aorta and pulmonary atresia with patent ductus arteriosus and large aortopulmonary collaterals. On ultrasonography, fetal maturity was 32 weeks with moderate oligohydramnios with USG parameters suggestive of symmetrical IUGR. Patient was managed as high risk pregnancy and cardiology opinion was taken for CHD. On 2nd day of admission, patient had episode of hemoptysis followed by cyanotic spell with hypotension, low oxygen saturation and pulmonary edema for which a team of anesthetist, cardiologist and obstetricians had resusci
Hemodynamic Changes of pregnancy combined with uncorrected TOF leads to progression of RV dysfunction, atrial and ventricular dysrhythmias, thromboembolic phenomena and maternal or fetal death. Congenital Heart Diseases in offspring of mother with TOF are more likely with incidence of approximately 3.1%
Department of Obstetrics and Gynecology, Institute of Kidney Diseases & Research Center, Ahmedabad, Gujarat 380016 1 MS (Obst & Gynaecol) Junior Lecturer 2 MD (Obst & Gynaecol) Professor and Head of the Department 3 MD (Obst & Gynaecol) Assistant Professor 4 MD (Obst & Gynaecol) Clinical Fellow 5 MS (Obst & Gynaecol) Clinical Fellow 6 DGO (Obst & Gynaecol) Clinical Fellow
Fig — 2D Echo image showing large Sub-aortic VSD in patient with TOF 32
(Continued on page 34)
Patient has been followed up in OPD. At present, the infant is absolutely asymptomatic with heart rate of 70-80/minute. For confirmation of cause of the disease baby serological study was done & the same antibodies were found to be in high titers, anti Ro > 196, anti La > 200. DISCUSSION
Incidence of congenital A-V heart block is 1 in 20000 . Most common cause of atrio-ventricular block in structurally normal heart is maternal connective tissue disorder. The spectrum includes various entities like SLE, Sjogren syndrome, mixed connective tissue disease, Rheumatoid arthritis etc. Amongst all SLE is the most common. SLE shows great variation during pregnancy. In 1/3rd of cases the disease improves while in rest it may turn dangerous to the extent of taking toll of either mother or fetus. 3
Amongst asymptomatic SLE, fetal heart block may be early manifestation. 50% of asymptomatic cases with serologically positive findings in favour of SLE progress to develop Neonatal Lupus; on the contrary those who are known SLE are rare to have this complication . Characteristic of Neonatal Lupus are AV block, hepatomegaly and rash. Positive Anti RO and Anti LA antibody are very specific for Neonatal Lupus.
Department of Obstetrics and Gynaecology, Grant Medical College, Byculla, Mumbai 400008 1 MBBS, MD (Obst & Gynae), Associate Professor and Head of the Unit 2 MBBS, MS (Obst & Gynae), Assistant Professor 3 MBBS, DGO, MD (Obst & Gynae), Professor and Head of the Department
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The patho-physiology is deposition of Antigen Antibody Complex in fetal conducting system leading to inflammation & ultimately ending in fibrosis. Fetal therapy in the form of ‘fluorinated corticosteroids’ which cross placenta (Dexamethasone) reduce the titer of antibodies . Antiarrhythmic drugs are given to mother for impending congestive cardiac failure. Plasmapheresis can also be an alternative. Attempts of implantation of intrauterine pacemaker have not shown any promising results yet . This case emphasizes the importance and need of FHR measurement during antenatal check-up supported by sonographic confirmation. A-V blocks diagnosed and treated early can prevent complications like hydrops fetalis, intrauterine 2
fetal demise & improves perinatal outcome . 4
1 Denney JM, Porter TE, Branch DW — Autoimmune Diseases. In: Steer PJ, Weiner CP, Gonik B, et al editors – High Risk Pregnancy Management Options. 4th edition. Amsterdam: Elsevier Saunders, 2011: 772-75. 2 Connective-Tissue Disorders. In : Cunningham FG, Lenovo KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, et al editors – Williams Obstetrics. 23rd edition. New York: Mc Graw Hill Inc, 2010: 1150-51. 3 Lees MH, King DH - Heart Diseases in the Newborn. In: Adams FH, Emmanouilides GC, et al editors – Moss’ Heart Diseases in Infants, Children and Adolescents. 4 edition. Baltimore: Williams & Wilkins, 1989 : 85 4 McCune AB, Weston WL, Lee LA — Maternal and Fetal outcome in Neonatal Lupus Erythematosus. Annals of th
Medicolegal autopsy in a post embalming donated dead body — a case report Biplab Shee1, Saurabh Chattopadhyay2, Vikas Gurbani3, Vivek Kumar3 Post embalming medico legal autopsy is a very rare incidence. One such case has been conducted at Kolkata police morgue. The autopsy was performed after donation of the body at the department of Anatomy for academic purpose, as desired by the deceased before death. The autopsy was conducted on the order of the honorable court following a complaint lodged by one of the legal heirs, sixteen days after death. There was a history of head injury due to fall from bed. Surgical intervention was done at a nursing home but no police case was recorded. On postmortem examination all the injuries were clearly identified. The merits and demerits of autopsy on such embalmed body have been discussed in the case report. [J Indian Med Assoc 2016; 114: 35-6]
(Continued from page 32)
that is higher than that in normal population . Women with TOF can go through pregnancy with a low risk to themselves but there is a high incidence of spontaneous abortions, premature births, and low birth weights. Presbitero et al demonstrated that the most important risk factor for adverse fetal outcome in cyanotic patients was the degree of cyanosis . In this study, women with arterial oxygen saturation > 85% and a hemoglobin concentration < 18 g/dl were more likely to result in live birth, whereas hemoglobin concentrations > 20g/dl were associated with adverse fetal outcome. Siu et al. reported a 4% incidence of infants who were small for their gestational age in a series of pregnancy with cardiovascular disease . Veldtman et al. reported 23% incidence of cesarean deliveries in his study . Pregnancy in patient with uncorrected TOF can lead to adverse effects on fetomaternal outcome. These patients should 3
be monitored intensively in tertiary care centre. Multidisciplinary approach involving a team of obstetrician, cardiologist and anesthetist improves the prognosis. REFERENCES
1 Hofman JI — Incidence of congenital heart disease: I. postnatal incidence. Pediatr Cardiol 1995; 16: 103-13. 2 Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, Rabajoli F — Pregnancy in cyanotic congenital heart disease: outcome of mother and fetus. Circulation 1994; 89: 2673-6. 3 Veldtman GR, Connolly HM, Grogan M, Ammash NM, Warnes CA — Outcomes of Pregnancy in Women with Tetralogy of Fallot. J Am Coll Cardiol 2004; 44: 174-80. 4 Siu SC, Colman JM, Sorensen S — Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002; 105: 2179-84.
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Key words : Autopsy, Medico legal, Embalming.
mbalming is the procedure of preservation of dead bodies to prevent putrefaction using antiseptics and preservatives. The ancient Egyptian method of preservation involved evacuation of the intestinal contents and internal organs followed by use of some chemical agents. The exact method followed by the Egyptians is still not clearly known . By this method proteins are coagulated, tissues are fixed and organs are hardened. Normal rigor mortis does not develop as embalming causes chemical stiffness. Hanzlick has discussed regarding the predictable artifacts that may result from embalming . Rivers pointed out that such procedure may simulate injuries and diseases, alter surgical wounds, eradicate trace evidences and alter postmortem changes . In the present case embalming fluid was introduced via the femoral artery and the body was kept dipped into a formalin solution chamber for 16 days. Post embalming medico legal autopsy after a period of more than two weeks is a rare incidence and has seldom been reported in literature.
done but the person expired. No police case was registered in the nursing home. On the orders of the honorable court police seized the body from the Department of Anatomy and sent it for medico legal autopsy. Examination — A lacerated wound measuring 3cm X 1.5 cm X bone depth was noted on the left side of forehead 3 cm above the eye brow. It was stitched and the age matched with the date of fall. O n e s u rg i c a l l y made incised wound was found over left temporalparietal area of scalp measuring 12 cm in length (Fig 1). A loose bone segment measuring 8cm X 3.5cm was found underneath Fig 1 — Stitched up left temporal-parietal area (Fig 2). The duramater was stitched and blood clot weighing 150 grams was found in the subdural space (Figs 3&4). Subarachnoid haemorrhage was also noted. No other ante mortem injury could be Fig 2 — Evidence of burr hole with a loose bone segment detected.
A dead body of a male subject aged 70 years was donated at the Department of Anatomy, Medical College, Kolkata, India. The body was embalmed as a routine procedure before use for academic dissection by the students. Sixteen days after death, one of the relatives of the deceased complained to the police demanding post mortem examination as he was not satisfied regarding the cause of death as certified by the doctor – “cardio respiratory arrest in a case of intra cranial haemorrhage”. There was history of fall from bed followed by unconsciousness before admission at a nursing home. Neurosurgical intervention was
Department of Forensic & State Medicine, Medical College & Hospital, Kolkata 700073 1 MD (F Med), WBUHS, Assistant Professor 2 MD (F Med), BHU, Associate Professor, Department of Forensic Medicine, Murshidabad Medical College, Berhampore, West Bengal 742101 3 MD (F Med), WBUHS, 2nd year PGT
Any case of death following trauma is treated as unnatural death. In all such cases medico legal autopsy is compul 35
J INDIAN MED ASSOC, VOL 114, NO 12, DECEMBER 2016
sory in this country. In the present case as no police intimation was given by the nursing home authority, doubts were raised. Death certificate was issued apprehending the possibility that the body would not b e a c c e p t e d f o r Fig 3 — Stitched up duramater with blood clot donation, as desired by the deceased prior to death, if it was considered as unnatural death. On o t h e r h a n d objections were raised regarding insurance claims as autopsy was not conducted in a case of death following trauma. This Fig 4 — Subdural & Subarachnoids ultimately led to the hemorrhage delayed claim for medico legal autopsy after 16 days by the relative. In the present case embalming had both advantages as well as disadvantages during autopsy. As the body was hardened usual meticulous dissection was hindered. Preservation of viscera was of little value as toxicological examination by usual methods cannot be performed in formalin fixed organs . However AlunniPerret and co workers have detected heroin from bile and liver in embalmed bodies. Steinhauer has devised a useful test for detection of ketosis in such cadaver. Detection of carbon monoxide form blood clot in cardiac chambers and alcohol from vitreous of preserved bodies have also been reported. On the other hand as the body was well preserved the injuries could be examined in detail. Artifacts due to decomposition did not alter the appearance, shape or size of the injuries and the intracranial hemorrhage was also very evident. This would not 4
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have been possible had the body been cremated by burning as per Hindu custom. In exhumed bodies decomposition limits the findings in autopsy. Opeskin reports of a case of unusual injury and highlighted the difficulties that may be encountered in interpretation of injuries. Possibilities of imaging studies by X ray and CT scan in embalmed bodies have also been reported in literature . Moritz has correctly stated “The mistake of a body to be embalmed before autopsy may be as disastrous as the performance of an incomplete autopsy”. Thus care must be taken in all cases of unnatural deaths to avoid embalming prior to autopsy, else miscarriage of justice may result. 10
1 Robert G Mayer. Embalming. History, Theory & Practice. 3rd ed. New York: Mc Graw-Hill; 2000. 2 Hanzlick R — Embalming, body preparation, burial and disinterment. An overview for forensic pathologists. Am J Forensic Med Pathol 1994; 15: 122-31. 3 Rivers RL — Embalming Artifacts. J Forensic Sci 1978; 23: 531-5. 4 Simpson K — Modern Trends in Forensic Medicine. London: Butterworth & Company; 1953. 5 Alunni-Perret V, Kintz P, Ludes B, Ohayon P, Quatrehomme G — Determination of heroin after embalmment. Forensic Sci Int 2003; 134: 36-9. 6 Steinhauer JR, Volk A, Hardy R, Konrad R, Daly T, Robinson CA — Detection of ketosis in vitreous at autopsy after embalming. J Forensic Sci 2002; 47: 221-3. 7 Iffland R, Madea B, Balling P — Diagnosis of carbon monoxide poisoning following embalming and exhumation. Arch Kriminol 1988; 182: 100-6. 8 Scott WU, Root I, Sanborn B — The use of vitreous humor for determination of Ethyl Alcohol in Previously Embalmed Bodies. J Forensic Sci 1974; 19: 913-6. 9 Coe JJ — Comparative Postmortem Chemistries of Vitreous Humor Before and After Embalming. J Forensic Sci 1976; 21: 583-6. 10 Opeskin K — An unusual injury. Med Sci Law 1992; 32: 5860. 11 Ciranni R, Caramella D, Nenci R, Fornaciari G — The embalming, the scientific method and the paleopathology: the case of Gaetano Arrighi (1836). Med Secoli 2005; 17: 251-62. 12 Moritz AR — Classical Mistakes in Forensic Pathology. American Journal of Clinical Pathology 1956; 26: 1383-97.
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