EDITORS SPEAK

Vol. 6 Editor-in-Chief Sectional Editors Dr. Ashok Grover Dr. Madhumita Puri Dr. Parkash Gera Dr. S. Arul Rhaj Dr. Yogesh Jhamb Dr. Neeraj Jain Mr. S.K. Singhal Photographer Design and Layout Issue 1 Oct - Dec 2007 Dr. Vinay Aggarwal Dr. L.D. Sota Dr. Atul Jain Editorial Board Dr. Hariharan Dr. Sharda Jain Dr. Rajiv Gupta Dr. Deepak Pande Dr. Vineet Jain Dr. B.K. Gupta Mr. Atul Gandotra Mr. Mukesh Kapoor Ms. Tabassum

The Eye and ENT specialties take care of 4 out of 5 special senses which are needed for orientation and fulfillment of human needs. There was a time when Eye and ENT used to be a common specialty, but nowadays there is so much advancement that the right ear does not know what the left ear is hearing and the right eye does not know what the left eye is seeing. In short there are subspecialties in these two major specialties. The advancement in instrumentation is taking ENT surgery beyond the confines of Ear Nose and Throat. Now Pituitary tumors are removed through endoscopic Trans sphenoid approach, reducing the morbidity of the patient. DCR is done Trans nasally eliminating the skin scar. CSF leaks are repaired through nasal endoscopes. Clivus tumors are also removed endoscopically. Humans have a few fads i.e., cleanliness. Johnson and Johnson a big name in pharma industry came out with ear buds and people started using them. They are doing more harm to their ears by pushing the wax inside the ear canal and by causing excoriation of the ear canal wall; which leads to infection. The OTC drugs for common cold contain antiallergic agents which thicken the nasal secretions; it relieves the patient on day one from excessive nasal discharge but prolongs the agony. Rhinorrhoea is natures way to wash out the offending agents to get rid of infection of the nose. The ear wax protects the ear from water, dust and small insects to enter the ear; this wax is expelled naturally from the ears in the form of small dried lumps. If we do not interfere with nature in its cleansing cycles; life will be more comfortable. After the rampant use of Ear buds the number of patients with ear complaints has increased. 1 in 1000 live births have hearing handicap. Cochlear implant A new dimension to severe hearing loss is a boon to many hearing handicaps. The cochlear implants have improved a lot in the last 20 years from just perception of sound to enjoying music. Similar work is going on visual cortex stimulation for blindness. The topics which can be covered in this issue are enormous but we have tried to touch a few topics to show where we are heading and Eye and E.N.T. are no more a minor specialty. Dr. L.D. Sota Dr. Atul Jain

CONTENTS
1. Eye Flu 2. Diabetes and Eye 3. Aesthetically Speaking : Botox and Blepharoplasty 4. Fracture Penis A Rare Case 5. How to Manage Difficult Patient Encounters 6. Allergic Rhinitis : Current Concepts in Diagnosis and Management 7. Endoscopic Dacryocysto Rhinostomy 8. Early Hearing Loss: Detection and Intervention 9. Cochlear Implants 10. Uterine Balloon Therapy : A Reason to Smile for DUB Cases 11. Intraoral Removal of Dermoid Cysts by Sublingual Approach 12. Pushpanjali Family Physicians Forum (PFPF) 13. Pushpanjali Healthcare Events and Initiatives 14. Guidelines for submission of Manuscripts Owned, Edited, Printed and Published by Dr. Vinay Aggarwal for and on behalf of
Pushpanjali Medical Publications Pvt. Ltd., A-14, Pushpanjali, Vikas Marg Extn., Delhi-110092 Printed at Kumar Offset Printer, 381, Patparganj Industrial Area, Delhi - 110 092 All disputes to be settled in Delhi Courts only.

5 8 11 13 15 17 25 27 29 31 33 37 39 43

All rights reserved. No responsibility is taken for returning unsolicited manuscripts unless a self-addressed stamped envelope is enclosed. Views expressed in articles in Pushpanjali Medi-Focus do not necessarily reflect those of the editorial board.

Vol. 5, Issue 3 & 4 April - Sept 2007

EMPANELLED ORGANISATIONS
1) 2) 3) 4) 5) Genins India Ltd United Healthcare Pvt. Ltd MD India Pvt. Ltd Medicare Service Club Park Mediclaim Consultants Pvt. Ltd 6) Paramount Healthcare Management 7) Alankit Capsec. Pvt. Ltd. 8) Vipul MedCorp. Pvt. Ltd 9) E-meditek Solutions Ltd 10) TTK Healthcare Services Pvt. Ltd. 11) Heritagge Health Club 12) Medi Assist Licensed TPA 13) MedSave India Pvt. Ltd 14) Family Health Plan Ltd 15) Raksha TPA 16) East West Assist 17) BSES Yamuna/ Rajdhani/ IPGCL (Genco) Power Ltd 18) Bajaj Allianz Life Insurance Co. Ltd. 19) Good Health Plan Ltd.20) Pawan Hans Helicopters Ltd 21) Heritage Health Services Pvt. Ltd 22) Bajaj Allianz Life Insurance Co. Ltd. 23) Hygenice Care ( OPD) 24) Central Electronics Limited (OPD) 25) Mother Dairy 26) National Textile Corporation (NTC) 27) National Building Construction Corporation Ltd. 28) Dabur & Excelcia 29) Arankari Placement Services Pvt. Ltd. 30) Micromatic Machine Tools Pvt. Ltd. 31) Gopal Industries Pvt. Ltd. 32) National Industrial Development Corporation Ltd. 33) Maruti Udyog Ltd. 34) National Projects Construction Corporation Ltd. 35) Bharat Heavy Electricals Ltd. (BHEL) 36) National Agricultural Cooperative Marketing Federation of India Ltd. (NAFED) 37) Universal Medi-Aid Services Ltd. 38) Health India Pvt. Ltd. 39) Met Life India Insurance Co. Pvt. Ltd. 40) Medicare Services Pvt. Ltd. 41) M/s Venus Medicare Services 42) Medicare Foundation Pvt. Ltd. 43) India Trade Promotion Organization 44) Health India (BAISPL) 45) WHO 46) Safeway Mediclaim Services Pvt. Ltd 47) Consortium for Educational Communication 48) National Small Industries Corporation Ltd. 49) Mecon Ltd. 50) Focus Healthcare 51) E-Medlife

LIST Of CONSULTANTS
CONSULTANT RESIDENCE CHAMBER 22371818 22075641 22441900 22094921-22 22140637 22411236 MOBILE 9811050403 9818599722 9810000944 9810249001 9810115132 9810121609 9811008306 9312644808 9810183236 9810089120 9810262229 9818088114 9810630691 9811168281 9810061958 9810366571 9810121098 9312248808 9810060565 9811703004 9810025926 9810038879 9312010421 9811073613 9312070380 9810244149 9.00 am - 5.00 pm (Daily) 11.30 am -1.00 pm (Daily) 9.00 am - 10.00 am (Daily) 8.00 pm - 9.00 pm (Daily) 4.00 pm - 5.30 pm (Daily) 11.00 am - 1230 pm (Daily) 8.00 am - 9.00 am (Daily) 10.00 am - 12.00 noon (Tue, Wed, Fri) 7.00 pm - 8.00 pm (Mon, Fri) 1.00 pm - 2.00 pm (Daily) 9.00 am - 11.00 am (Mon, Thur, Sat) 5.00 pm - 6.00 pm (Mon, Thur) 11.30 am - 1.30 pm (Daily) On Call 11.30 am - 1.00 pm (Daily) 10.00 am - 12.00 noon (Daily) 5.00 pm - 6.30 pm (Daily) 1.00 pm - 2.00 pm (Sat) 6.00 pm - 8.00 pm (Daily) 9.30 am - 12.30 pm (Tue, Thu, Sat) 10.30 am - 12.00 noon (Daily) 9.30 am - 12.30 pm (Mon, Wed, Fri) 5.00 pm - 6.00 pm (Daily) 6.00 pm - 8.00 pm (Daily) On Call On Call (Tue, Thu, Fri, Sun) On Call (Mon, Wed) On Call (Sat) 12.00 noon - 1.30 pm (Daily) 8.30 pm - 9.30 pm (Daily) 4.00 pm - 6.00 pm (Daily) On Call by appointment 4.00 pm - 6.00 pm (Wed) 11.00 am- 12.00 noon (Sat) On call 10.00 am- 1.00 pm Daily (except Wed) 4.00 pm - 7.00 pm (Wed) On Call DAY/TIMING MEDICAL DIRECTOR Dr. Vinay Aggarwal 22374612 MEDICAL SUPERINTENDENT Dr. H. S. Nagi 95120-4125563 PHYSICIAN Dr. Parkash Gera Dr. Sangeeta Bhargava Dr. Navin Atal 22375440, 22371284 42440940 42408075

PHYSICIAN-CHEST SPL. Dr. Ashok Grover 22541854

PHYSICIAN & NON INASIVE CARDIOLOGIST Dr. Mukesh Ajmera 22374502 GYNAECOLOGIST Dr. Sharda Jain Dr. Kanika Gupta Dr. Bakul Arora Dr. Anita Jain Dr. Rekha Sarin Dr. Sunita Lal SURGEON Dr. Yogesh Jhamb Dr. Sameer Paruthi 22238838-22238847 22414049-22453724 22149718, 22169718 22750757, 22750551 95120-4112881, 2640397 22582002 65261328 659014833 22378281

CHILD SPECIALIST Dr. Deepak Pande 22243742, 42182025 22432218 Dr. Vineet Jain 95120-4112881, 2640397 22582002 Dr. Alok Gupta 65374625 9910227227 PAEDIATRIC SURGEON Dr. Anurag Krishna 24112687, 24114887 ORTHOPAEDIC SURGEON Dr. B.K.Malik Dr. Girish Chhabra 95120-2628200, 2625200 Dr. P.K.Dhar 22244801 Dr. Ashish Sao Dr. R.K.Sachdeva 22162135 Dr. Alok Sharma Dr. Daulat Singh 22120442 ANAESTHETIST Dr. Rajesh Dhall Dr. Swaraj Garg Dr. Rakesh Atray ENT SURGEON Dr. Atul Jain Dr. Anurag Jain 22167122 22543003 22152245, 22157745 22376205 22720901 22507728 22094892 22111872

9810110405 22548796, 22519888 9811441064 9810272563 22545000 22545000 95121-2668149 22149256 9811120545 9810249015 9810166989 9810227340 9412201474 9810139314 9312876694 9810064554

GASTROENTEROLOGIST Dr. Neeraj Jain 22371024 ONCOLOGIST Dr. Sudersan De ONCO SURGEON Dr. Umang Mittal Dr. Praveen Jain EYE SPECIALIST Dr. L.D. Sota Dr. P. C. Bhatia 26252065 22146173 26016636 26515263, 26863998

2 Vol. 6, Issue 1 October - December 2007

CONSULTANT URO-SURGEON Dr. C.M.Goel PATHOLOGIST Dr. Vandana Arora Dr. Archana Sood MICROBIOLOGIST Dr. Narinder Saini RADIOLOGIST Dr. Mukesh Koshal NEUROLOGIST Dr. B.K.Gupta Dr. Nirmala Lahoti Dr. Aditya NEURO SURGEON Dr. J. Kumar NEPHROLOGIST Dr. Neeru Aggarwal PSYCHIATRIST Dr. Raman Jeet Jaswal Dr. Vikas Mohan Sharma

RESIDENCE 95120-2630717 22246806 22096401 22376289 22546704 22371675, 22371033 22540271, 22526601

CHAMBER 95120 2630365 22381445 30946399

MOBILE 9811047047 9811009938 9312319887 9810252127 9810062179 9811084263 9810061981 9810556353 9810273684

DAY/TIMING 1.00 pm - 2.00 pm (Mon, Thu) 9.00 am - 4.00 pm (Daily) On Call 8.00 am - 9.00 am (Daily) 12.00 noon - 1.30 pm (Daily) On Call On Call 9.00 am - 11.00 am (Tue, Thur, Sat) On Call

LIST Of CONSULTANTS CONSULTANT PHONE NO PHYSICIAN Dr. Ruby Bansal R) 2614076 M) 891376756 9 DAY / TIMINGS

95120-2724591 22526533 22623183

95120-2780736 26140058 9871650111 95120-2921446 9811415489 22094879

9810266275 1.00 pm - 2.00 pm (Mon to Fri) 9.00 am to 10.00 am (Sat) 9810526533 9810412911 9891192777 9818425297 9810113922 On Call 6.00 pm - 8.00 pm (Fri) 6.00 pm - 8.00 pm (Fri) 4.00 pm - 6.00 pm (Wed, Fri) 6.00 pm - 8.00 pm (Mon - Sat.) On Call

9.00 am - 11.00 am (Daily)

PSYCHOSEXUAL DISORDERS Dr. (Col.) V.K. Wadia 55469686 PSYCHOLOGIST Dr. Deepali Batra CARDIOLOGIST Dr. Dhirendra Singhania

CHILD SPECIALIST Dr. (Mrs.) VT Dophal 9.00 pm - 10.00 am M) 811161590 9 (Daily) SURGEON Dr. Vijay S. Pandey R) 95120-2628254 M) 818492809 9

ENDOCRINOLOGIST Dr. S.K.Wangnoo 22618242, 22621357 DENTIST Dr. Geeta Paul PHYSIOTHERAPIST Dr. Md. Majid Khan HOMOEOPATHIC PHYSICIAN Dr. M.M. Aggarwal 22434770 PLASTIC SURGEON Dr. R.K. Sandhir 95120-2458588 Dr. Manoj Bansal 22155057 SKIN SPECIALIST Dr. V.K. Upadhyaya 22152084 Dr. Mukesh Girdhar 95120-2625544 Dr. Ritu Gupta Dr. Ritika Gupta 9818560759 CHEST SURGEON Dr. R.C. Jain 26803436, 26808035 RHEUMATOLOGIST Dr. Anish Aggarwal 95120-2753546 Courtesy consultants Dr. Poonam Gupta 22095708 Dr. S.P. Singh 22152036 Dr.Jyoti Aggarwal 22238871 Dr. Deepak Lahoti 9810123067 Dr. Madhu Ahuja 22516733 Dr. Deepak Sarin 65901485 fAMILY PHYSICIANS Dr. V.K.Malhotra 22157127 Dr. Ajay Aggarwal (B/o MD) Dr. Ajay Arora 22156672 Dr. Vipin Jain 22372065 Dr. K.B. Bhatia 22372727 Dr. Hari Haran 22549804 Dr. Atul Aggarwal 22459608 Dr. D.R. Rai Dr. V.P. S. Chawla Dr. Sangeeta Gupta Dr. Ashwani Goyal Dr. A.K. Jain Dr. Rakesh Gupta 22155979, 55298198

11.00 am - 1.00 pm (Mon, Thur)

9810292498 10.00 am - 2.00 pm (Daily) 5.00 pm - 8.00 pm 9873207660 22513835 9.00 am - 1.00 pm (Daily)

ENDOCRINOLOGIST Dr. S.K. Wangnoo 7.00 pm - 9.00 pm R) 22618242 (Mon, Wed) 22621357 M) 810113922 9 CARDIOLOGIST Dr. Dhirender Singhania M) 871650111 9

22592073, 22169732 9810033525 On Call 22097417, 22093107 9810003628 11.00 am - 1.00 pm (Daily) 22091758 22372484 22161397 22541842 22147652 9810130292 22510904 22412008 22372728 22540624 22112343 9810033882 9810078198 9891063467 9811106203 9810073795 9811744426 9811152254 9910081484 9810067539 9811022434 9313100602 On Call 9810049714 9811047912 9811319070 9810197049 9811137098 9312504480 9811305435 9810395657 9811112688 9871803070 On Call On Call On Call On Call On Call On call On call 10.00 am -11.00 am (Mon to Fri) On call On call 4.00 pm - 7.00 pm (Fri)

7.00 pm - 9.00 pm (Mon, Sat)

ORTHOPAEDIC SURGEON Dr. Ashish Sao 6.30 pm - 8.30 pm M) 312010421 9 (Tue, Thur, Sat)

DERMATOLOGIST Dr. Ritu Gupta R) 22371114 M) 891063467 9 ENT Dr. Saket Aggarwal M) 811231599 9

7.30 pm - 9.00 pm (Wed, Fri)

11.00 am - 1.00 pm (Mon, Thurs)

PHYSIOTHERAPIST Dr. Md. Majid Khan 1.00 pm - 4.00 pm M) 873207660 9 (Daily) Dr. Sonika Saraswat 8.00 am - 3.00 pm M) 899649920 9 (Daily)

3 Vol. 6, Issue 1 October - December 2007

Eye Flu
Rachna Agarwal and Sachin Raj Kumar
Eye flu is the common name for Infective conjunctivitis. Approximately 2% of all primary care visits and 1% of emergency room visits are related to conjunctivitis. cause systemic symptoms. Keratitis which may be severe develops in 80% of cases.

Signs and Symptoms

Symptoms v Red eye noted by the patient v Watering eyes v Swollen lids v Patients notice it in one eye perhaps with later spread to the other eye. v In pharyngo conjunctival fever - sore throat, fever and headache may be present. Signs Follicular conjunctivitis (seen particular iv inferior palpebial conjunctiva) v Watery, mucoid discharge v Crusting may be evident on lashes v Edematous lids v Palpebialprecircular lymphadenopathy v Pin point sub conjucntival hemorrhage v In epidemic kerato conjunctivitis pseudo membranes and subepithehal (stromal) infiltrates seen.

Definition and Epidemiology

Conjunctivitis is an inflammation of the conjunctiva which is a thin transparent layer covering the surface of the inner eyelid and the front of the eye. v Eye flu or red eyes is most commonly viral in nature caused by adenovirus v Affects males and females equally v No racial predilection is observed v Commonly seen in 20-40 yrs age group v It is highly contagious outbreaks can sometimes be traced to infected individuals or locations.

Causative virus / Mode of spread

v It is most frequent caused by Adenovirus, 8, 19 but several other serotypes like 37, 22 may be responsible. v It is a deoxyribonucleic acid (DNA) virus. v Incubation period is 4-10days. Following the onset of conjunctivitis the virus is shed for about 12 days. It is highly contagious; as the virus is readily transmitted by hand to eye and ophthalmic solutions and instruments (conometers) are potential causes of contamination. The virus is readily transmitted in respiratory or ocular secretions, contaminated fomites (including eye droppers and mascara bottles) and even contaminated swimming pools. The disease commonly occurs in individuals who are in close contact with others e.g. in schools, nursing facilities, persons etc.

Stages of Keratitis
Stage I occurs within 7-10 days of onset of symptoms and is characterized by a punctate epitheial keratitis which resolves within 2 week. Stage II is characterized by focal, with sub epithelial opacities sub epithelial lesion are thought to represent immune response to virus and may be associated with mild transient anterior uverlis. Stage III characterized by anterior stromal infiltrates which gradually fade over months to years.

Types
1. Pharyngo conjunctional fever (PCF) is most commonly caused by adenovirus types 3, 4 and 7 and occasionally by type 5. It is transmitted by droplets and typically affects children who also develop an upper respiratory tract infection. Keratitis develops in 30% of cases but is seldom severe. 2. Epidemic keratoconjunctivitis (EKC) is most frequently caused by adenovirus types 8 and 19, but several other types may be responsible. The infection is transmitted by hand to eye contact, instruments and solutions. In contrast to PCF it does not 5 Vol. 6, Issue 1 October - December 2007

Management
v Test snellens V/A v Look for conjucntival hypermia, chemosis, superior and inferior sub conjucntival hemorrhages, follicles and watery discharge. v Palpate for pre auricular lymphadenopathy. v Refer the patient to an ophthalmologist for examination of corneal surface with flourescein dye and slit lamp if there is any blurred vision, foreign body sensation and photophobia suggestive of corneal involvement.

Rachna Agarwal Junior Resident

Mohan Eye Institute New Delhi

Sachin Raj Kumar Assistant Professor

Kasturba Medical College Manipal

History and Physical Examination for Viral Conjunctivitis

Category History History History History Physical Examn Physical Examn Physical Examn Physical Examn Physical Examn Physical Examn Physical Examn Physical Examn Element Pink eye Watery discharge light sensitivity Clinical contents Indicates epidemic nature of disease Indicates conjunctival inflammation May present in both eyes simultaneously or second eye involvement after 3-5 days Follicles are accumulation of lymphocytes and other inflammatory cells forming a little mound with vascular frill around the base indicating viral infection Exudative response cause the formation of pseudomembrane of upper and lower lids Indicates severity of the disease Consistent with adenoviral infection Typically seen in epidemarkeratic conjunctivitis. Refer to ophthalmologist with slit lamp or high magnification with direct ophthalmoscopy Indicates superadded bacterial infection. Refer to an ophthalmologist Notes Usually starts in one eye and can spread to 2nd eye within 2-4 days. Acute infection last for 7-10 days. Indicates viral infection may indicate corneal involvement

Conjunctival infection Bilaterally

Conjunctival follicles Pseudomembrane formation in palpebral conjunctival Sub conjunctival hemorrhage Preauricular lymphadenopathy Corneal infiltrates Matting of lashes

Lab Diagnosis
Conventional lab identification can be expensive and time consuming but may be helpful in certain circumstances. Use of selected testes should be done to assist in the differential diagnosis of unusual form of conjunctivitis. Consider obtaining v Cytology specimen of conjunctival epithelium, which may show intra cytoplasmic inclusions in suspected chlamydial conjunctivitis. v Cytology specimen, who may show eosinophilia in suspected allergic conjunctivitis. v Culture of conjunctiva in suspected chlamydia or herpes virus v Bacterial culture if there is purulent discharge particularly in patients with hyper acute purulent conjunctivitis, which may reveal N-gonorrhea. v Conjunctival biopsy specimen in patient with suspected sarcoid and ocular cicatricial pemphigoid. TESTS 1) Conjunctival scraping and cytology 2) Viral cultures 3) Bacterial cultures 4) Conjunctival biopsy

Management Adenovirus is a very robust virus that can survive outside the body on hard surfaces and has been cultured from such surfaces up to 7 weeks after an infection. It is somewhat resistant to alcohol disinfection and is recommended diluted bleach based cleaner if for proper disinfection. No treatment is an option for mild disease. The tears contain chemicals that fight off bacteria many symptoms get cleared on the own in 2-5 days without treatment.

General measures
Infective conjunctivitis is contagious. The likelihood of passing it on is not high unless contact is direct. Patients should be instructed to: v Wash hands regularly especially after touching eyes. v No sharing of towels, pillows, utensils v Application of cold compress to the infected eye(s) 3-4 times per day for 10-15 minutes using clean washed cloth each time. This should help reduce itching and swelling and provide some comfort.

NOTES Eosinophil seen in allergic conjunctival and intra cytoplasmic inclusion bodies in Chlamydia conjunctivitis

are necessary to document etiology. In adenoviral, picornaviral and HS conjunctivitis Indicated in purulent conjunctivitis e.g., gonorrheas Granulomas seen in sarcoid; basement membrane immunoflorcence in ocular cicatricial pemphigoid 6

Vol. 6, Issue 1 October - December 2007

v Avoid rubbing eyes to decrease irritation v Wear sunglasses if eyes are sensitive to light v Avoid exposure to irritants that may be causing conjunctivitis v Avoid wearing contact lenses which you are using or if eyes are uncomfortable v Clean contact lens thoroughly v Temporary leave of absence should be considered for patients who work with the public and have acute infection v No antibiotic or antiviral drops are routinely used. In cases where bacterial or super infection is suspected, antibiotic drops are indicated v There are no anti viral drugs approved for adenoviral conjunctivitis v In EKC only: pseudomembranes should be manually pealed after 2-3 days v Topical corticosteroid may be needed to prevent scarring.

of larger epithelial infiltrates. These sub epithelial infiltrates generally disappear in 2 weeks but the subepithelial lesions mostly located centrally remain for varying periods usually weeks to months. Q3 Can it spread from mother to child? A) No, not transplacentally but definitely it can spread from mother to the child as they are in close contact by hand to eye transmission. Q4 Can it spread during antenatal period from mother to child? A) No. Q5 Should patients with eye flu be excused from work? A) Yes if they have such a job concerned which involves with public contact they can be excused for about 10 days. Q6 When is a patient no longer infectious? A) After 10 days. Q7 Are antibiotics beneficial in eye flu? A) Antibiotics have no role to play. Q8 Can personal hygiene prevent the spread of adenoviral conjunctivitis? A) Yes, of course. As already mentioned eye flu has hand to eye transmission so an infected person should have separate handkerchief, towel, bed sheet, bed spread, pillow cover for himself. Frequent washing of hands is a must. Q9 Should patient discard contact lenses after the bout of viral conjunctivitis? A) Yes. Q10 Can adenoviral conjunctivitis be associated with chronic visual disturbances? A) Not usually.

Medications
v Topical artificial tears : 4-8 times/day v Vasoconstrictor/antihistamine: 4 times/day for severe itching v Topical antibiotics prevent bacterial super infection

Commonly asked questions

Q1 Is adenoviral conjunctivitis spread by hand to eye contact? A) Yes. Q2 Can adenoviral conjunctivitis cause vision loss? A) No, it cannot cause vision loss but definitely when cornea is infected then blurring of vision is present. This keratitis can last from days to weeks and may clear spontaneously, or may persist with the formation

7 Vol. 6, Issue 1 October - December 2007

Diabetes and Eye

Sachin Raj Kumar and L. D. Sota
Diabetes is a chronic disease in which there is deficiency or ineffective utilization of insulin. It results in hyperglycemia which in turn damages the end organs with special reference to nerves and blood vessels. This ultimately leads to increased morbidity and mortality. It is estimated that the number of people with diabetes is likely to increase to 366 million by the year 2030 from 171 million at the turn of the century. In India there will be 79 million people with diabetes by 2030 making it the diabetic capital of the world. 1. Duration: The single most important factor is the duration of diabetes. A number of studies have shown that the duration of disease is the best predictor of diabetic retinopathy. Type 1 diabetic patients do not develop diabetic retinopathy during the first five years of the disease but after 20 years 50% of the patients develop Proliferative Diabetic Retinopathy (PDR). In type 2 diabetic patients the time of onset and the duration of the disease are difficult to predict precisely and it has been found that 3-4% of these patients would have diabetic retinopathy at the time of presentation. 2. Control of blood glucose: The two large multicentric trials Diabetic Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) have shown that intensive treatment of diabetes delays the onset and reduces the progression of retinopathy both in Type 1 and Type 2 diabetes mellitus, respectively. 3. Puberty: Progression of retinopathy has been found to be associated with the onset of puberty. The exact mechanism is not known. 4. Type of Diabetes: Proliferative retinopathy is more prevalent in type 1 than in type 2 diabetes. The incidence of macular edema over a period of 10 years follow up has been found to be 20.1% in the younger onset group, 25.4% in the older onset group taking insulin and 13.9% in the older onset group not taking insulin. 5. Nephropathy: A diabetic patient with retinopathy is at a moderate risk of having nephropathy, but the patient who has nephropathy is at a much higher risk of having retinopathy. Both proteinuria and serum creatinine levels are associated with increasing severity of retinopathy. 6. Hypertension: A strong correlation between hypertensive retinopathy and diabetic retinopathy exists. 7. Pregnancy: Pregnancy causes increase in Diabetic retinopathy.

Diagnosis of Diabetes
As per the American Diabetes Association (ADA) the diagnosis of diabetes is made when the casual plasma glucose is 200 mg/ml with the symptom of polydypsia, polyphagia, polyuria or weight loss. Casual plasma glucose level is defined as plasma glucose level at any time of the day without regard to the time of last meal. Fasting glucose level is defined as plasma level of glucose with no caloric intake for at least 8 hours. Fasting plasma glucose level is preferred over casual plasma glucose. In 1977, ADA added a new entity called impaired fasting glucose (IFG). Persistent hyperglycemia progressively damages every system of the human body. The excess glucose and fatty acid exert their toxic effect on various organs. The nerves, retina and kidney are the main organs that are affected. Hyperglycemia induces various hemodynamic, biochemical and endocrinological alterations. Diabetic eye disease refers to a group of eye problems that people with diabetes may face as a complication of diabetes. Diabetic eye disease includes diabetic retinopathy, cataract and glaucoma.

Risk factors for Diabetes Retinopathy:

For diabetic retinopathy the major risk factor of course is diabetes. However, number of other factors may modify the risk.

Sachin Raj Kumar Assistant Professor

Kasturba Medical College Manipal

L.D.Sota
Eye Surgeon and Contact Lens Specialist Pushpanjali Medical Centre Delhi Fundus shows Proliferative Diabetic Retinopathy (PDR)

 Vol. 6, Issue 1 October - December 2007

8. Genetic factors: Strong association has been found between proliferative retinopathy and presence of HLA-DR phenotypes 4/0, 3/0 and X/X.

Prevention
The key to preventing diabetes-related eye problems is good control of blood glucose levels, a healthy diet and good eye care. The Diabetes Control and Complications Trial (DCCT), a 10 year study which ended in June 1993, proved among type 1 patients that improved blood glucose control prevents or delays diabetic retinopathy. Therapy that keeps blood sugar levels as close to normal as possible reduced damage to the eyes by 76% . Since a person with diabetes can have retinopathy and not know it, a regular checkup with an ophthalmologist can detect retinopathy early and possibly prevent blindness. Health care team education is vital: Diabetes is a multi-system chronic disease, and is best monitored and managed by highly skilled health care professional trained with the latest information on diabetes to help ensure early detection and appropriate treatment of the serious complications of the disease. A team approach to treating and monitoring this disease serves the best interest of the patient. Patient education is critical: People with diabetes can reduce their own risk for complications if they are educated about their disease, learn and practice the skills necessary to better control their blood glucose levels, as well as blood pressure and cholesterol levels, and receive regular checkups from their health care team. Smokers should stop smoking and those who are overweight should develop a moderate diet and exercise regimen under the guidance of a health care provider to help them achieve a healthy weight.

factors reducing the prevalence

Various factors are glaucoma myopia carotid artery stenosis and eyes with inflammation disorder.

Treatment
According to the American Academy of Ophthalmology, 95% of those with significant diabetic retinopathy can avoid substantial vision loss if they are treated in time. The possibility of early detection is precisely why it is so important for diabetics to have a dilated eye exam at least once a year. Diabetic retinopathy can be treated with laser photocoagulation to seal off leaking blood vessels and destroy new growth. Laser photocoagulation does not cause pain, because the retina does not contain nerve endings. In some patients, blood leaks into the vitreous humor and clouds vision. The ophthalmologist may choose to simply wait to see if the clouding will disappear on its own, a period called watchful waiting. A procedure called vitrectomy removes blood that has leaked into the vitreous humor. The body gradually replaces lost vitreous humor, and vision usually improves. Small studies using investigational treatments for diabetic retinopathy have demonstrated significant vision improvement for individuals who are in early stages of the disease. Two treatments that are closely related, Lucentis and Avastin, may be able to stop or reverse vision loss, similar to very promising results that have been reported when the two drugs have been used as treatments for macular degeneration.

 Vol. 6, Issue 1 October - December 2007

Aesthetically Speaking : Botox and Blepharoplasty

Dinesh Bhargava
Blepharoplasty: Bleph = eyelids : Plasty= to correct Surgery of the eyelids to correct the aging changes in the eyelids The aging changes in the eyelids are noticeable in the late 30s and early 40s but are not of concerns to many at that age. The puffiness of the lower eyelids is the first to attract attention which may be present in some in teenage years as well. With years the upper lid redundancy and the puffiness of the lower lid continues to progress till such time that the upper lid comes to rest on the upper lashes producing an undue weight on the upper lid muscle which often is reported as early tiredness in the evening and especially after attempting to read. The lower lid puffiness creates shadows under the eyelids contributing to the tired appearance of the person. These changes are will concern some people early and others late in their life. Its recognition is after a LASIK procedure is intriguing in that for those who have been wearing glasses for a long time these aging changes go hidden behind the frames and once those are removed a sudden changes that they witness are disturbing. The operation called blepharoplasty is designed to correct these and other changes that occur with aging process. A relatively simple procedure done generally under local anesthesia and sedation. In this the upper and lower lid excess skin and the puffiness is removed giving the eyelids a youthful appearance when the healing process is complete. While the initial process is quick the final results may take several months to evolve. As with any surgery the risks and concerns need to be discussed with the surgeon who will be able to share these with you on your consultation and be able to give specific details about the surgical procedure you may need. Not withstanding the reasons for which people seek the correction this operation can undo several years of aging for those who elect do so. Find out if this operation is for you and how you can benefit from it. Let us help you discover A New You

About Botox
For a long time an attempt to reverse the process of aging had been assigned to the face lift or Rhytidectomy. While surgery has its place and its indications, the advent of Botox and the soft tissue fillers has changed the landscape of the patient requesting rejuvenation. Early changes of aging in form of crows feet, the frown lines and the forehead creases that distract from youthful appearance can be easily, effectively and safely addressed by Botox. Botox is a medication derived from the bacteria Clostridium botulinum. While long known for its poisonous properties, botulinum toxin in refined and controlled doses it is a powerful medicine that has been used in various neurological and spastic disorders. Its use in aesthetic surgery is, however, recent. Since its approval by FDA in US about 5 years ago,

it caught on as a number one procedure in plastic surgery, pushing the need for surgical procedures till later in life. The benefit of the procedure is that it takes less than half an hour to perform, with no scarring and minimal risks. There is a role of adequate practice and proper technique to produce the appropriate result of which the consumer must be aware. As with any procedure there are risks with this treatment but these can be mitigated

Dinesh Bhargava
A New You, Aesthetic Plastic Surgery Centre, Pushpanjali Healthcare

11 Vol. 6, Issue 1 October - December 2007

Fracture Penis A Rare Case

Manoj Bansal
A 42 year old healthy male presented in the emergency room at early hours of morning with complaints of something snapping in the penis followed by swelling and distortion while having intercourse. At the time of presentation patient was fully conscious and his vitals were stable. On local examination he was found to have huge swelling of penis, scrotum and pubic area. Penis was distorted and deviated to right side. He was clinically diagnosed to be having fracture of penis.

Preparative photograph

Post Operative Photographs

Patient was prepared and taken to operating room. Patient was catheterized and the urine was clear indicating that urethra was intact. Degloving of penile skin and fascia was done by a circum coronal incision. On exploration there was found to be teat of tunica albungrinea of Rt corpora cavernosa with collection of clots in the area. All clots were evacuated, the tear was

Review of Literature Although relatively uncommon, penile fracture is interesting. According to one estimate, it occurs once in 1,75,000 hospital admissions. Knowledge to recognize this condition and manage it properly is important to avoid late sequelae. The injury typically is a consequence of external trauma to erect penis, causing a tear in the tunica albungrinea of one of the corpora. It may occur during intercourse, rolling over in bed over erect penis or other forceful injuries. The patient reports bearing a cracking sound, followed by flaccidity. Painful swelling, ecchymosis and penile deviation rapidly occur. Urethral rupture occurs in perhaps one-third of reported cases. If adequate facilities are available, penile deformity and impairment of erections may be avoided by surgical exploration drainage of hematoma and repair of corpora. Penile shaft should be approached through either a circumferential coronal incision, undermining of the skin proximally or a direct longitudinal incision over the injury if the site is localized easily.

found to be going proximally up to the base of penis and for complete exposure an additional linear incision in the midline of ventral aspect of penis was given. The tear in the tunica albunginea was repaired with absorbable sutures with second layer of reinforcement with Bucks fascia. Incisions were closed in layers and a pressure dressing done.

Operative photographs
Dr. Manoj Bansal Senior Plastic Surgeon
Pushpanjali Medical Centre Delhi

Post operative period was uneventful urinary catheter was removed after 7 days and sutures were removed on 10th day. Patient was advised setz bath and local cream for a week. He was also advised to abstain from having intercourse for six weeks. 13

Vol. 6, Issue 1 October - December 2007

How to Manage Difficult Patient Encounters

an Article by: Sharon K. Hull, MD, MPH; Karen Broquet, MD American Academy of Family Physicians

Introduction
About 15% patient-physician encounters are rated as Difficult. Presence of depressive or anxiety disorders, more somatic symptoms and greater symptom severity are suggestive of likelihood of difficult encounters. Not all difficult encounters can be blamed on the patient side of the interaction. The physicians attitude about care, fatigue, stress and burnout can create circumstances in which physicians are responsible for the difficulties. Language barriers, and cross cultural issues can also make for challenging encounters.

Somatizing Patients Signs These patients present with a chronic course of multiple vague or exaggerated symptoms and often suffer from comorbid anxiety, depression and personality disorders. They often have doctor-shopped and likely have history of multiple diagnostic tests. How to handle v Describe the patients diagnosis with compassion. v Empathizing that regularly scheduled visits will help to mitigate any concerns. manage any comorbid v Effectively psychological conditions as well. v Refrain from suggesting that it is all in your head.

Patient Characteristics/factors
Angry, Defensive, frightened or Resistant Signs Clenched fists, furrowed brows, wringing of the hands, restricted breathing patterns and warnings How to handle v Try to uncover the source of difficulty for the patient and pay attention to the way his/ her emotions relate to the medical issue at hand. v Empathize with the patient. v Use reflective statements such as I can understand why you might feel that way. A patient in pain waiting for long time may say My time is precious. Dont be angry, take a deep breath, offer a sincere apology and respond I can understand why you are upset and appreciate your waiting for me. Manipulative Patients Signs Threatening rage, legal action or suicide, Impulsive behavior directed at obtaining what they want. It is often difficult to distinguish between borderline personality disorders and manipulative behavior How to handle Contributed by Atul Gandotra GM - Marketing and Business Development Pushpanjali Healthcare
Delhi

Grieving Patients
Recognizing the effect of grief on some patients health requires familiarity with the normal stages of grief and the cultural context in which it occurs. How to handle v Look for vegetative signs of depression and maladaptive behaviors that prevent progression through the normal grieving process and treat them. v Help grieving patients by validating their emotional experience. v Encourage open communication and caution against major lifestyle changes too early in the process. frequent fliers Signs Frequent fliers may sand out due to the sheer bulk of their medical charts. They may be lonely, dependent or too afraid or embarrassed to ask the question they really want answered. How to handle v Indulge with patient to identify the underlying reasons for the frequent visits. v Acknowledge that you notice the pattern of frequent visits. v Showing understanding of the patients reasons often will foster an open discussion of the reasons behind the reasons v Contract with patient for regularly scheduled visits.

v The key is to be aware of your own emotions. v Attempt to understand the patients expectations. v Realize that sometimes you have to say No 15

Vol. 6, Issue 1 October - December 2007

v Well-honed pain-management skills may also come in handy for patients who schedule frequent appointments due to chronic pain

Will the third person be involved in health care decisions, or are there cultural reasons for him or her to be present? When the patients have companions in the E.Room, be sure to speak directly to the patient, avoid taking sides in any conflict, and evaluate all parties understanding of the information and the management plan. Breaking bad news When it is necessary to give patients information that will be difficult for them to hear, preparation is critical. Know who will be present for the discussion, allow adequate time and privacy, and review the clinical situation. Disclose the news directly, allowing adequate response time for the patients and others in the room to experience their emotions and process the information. After giving the news, discuss the implications, offer additional resources, agree on next steps, summarize the discussion and be certain to arrange for follow-up. Environmental issues Physicians often overlook the fact that their surroundings may increase the likelihood of a difficult patient encounter. If the environment is noisy, chaotic or doesnt afford appropriate privacy, the patients are likely to be unhappy. These factors can often be alleviated with a bit of forethought. Communicate with care Being aware of the factors that contribute to difficult clinical encounters and being prepared to address them will go a long way toward preventing them. Good interpersonal and communication skills can make positive difference to these situations. Attending to your own physical and mental processes as you see patients and remaining aware of your own emotional baggage in the E.Room may decrease the number and intensity of difficult encounters you experience. Hard fact No physician can avoid the difficult clinical encounters, but having the tools to deal with these situations when they arise can make a better experience for both you and your patients.

Physician Characteristics/factors
Angry or Defensive Physicians Signs Physicians who are burned out, stressed and generally frustrated over long term concerns are more likely to react negatively to patients How to handle Recognizing own trigger issues and knowing what personal baggage we bring into the examination room/place can be valuable way to manage self, in the process avoid, what could have been a possible difficult patient encounter. fatigued or Harried Physician Signs Overworked (extremely common situation), sleep deprived, generally busier than needed, over commitment (common trait among high achieving professionals). How to handle It is important to be sensitive to the impact of physician fatigue on medical errors and patient safety and set a reasonable limit for self. Diplomatically bow out of commitments, delegate to others as appropriate and seek work environments that value setting appropriate limits. Dogmatic or Arrogant Physicians Signs Each one of us has things we feel strong about. Personal beliefs and values, as well as beliefs and values about medical care, can sometimes lead to overemphasize own beliefs and emotions in ways that disempower patients and may prevent them from providing with adequate information about their care. How to handle Identify your trigger issues and avoid situations in which your beliefs may inappropriately close off adequate exchange of information that ultimately could emerge as difficult patient encounter.

Situation Characteristics/factors
Language and literacy issues We have a diverse population, accordingly a physician increasingly find himself needing to communicate with individuals whose primary language is different from his own. Try to allow extra time for these encounters. Wherever possible, work with a middle man. Direct your eyes and speech toward the patient rather than the support person. Working across cultures requires sensitivity to different beliefs about health and illness, religious issues and gender issues. Your goal should be to remain culturally sensitive and not culturally competitive. Multiple people in the Examination Room A high percent of adult patients have a companion present along with them. In a situation as above consider: Does the patient want the other individual in the E.Room - for the history and the physical examination? Is there a need to talk with the patient alone? 16 Vol. 6, Issue 1 October - December 2007

Please sumit your contributions by email at pmc_pub@yahoo.co.in, pmc_pub@hotmail.com or by post at the address given below A-14, Pushpanjali, Vikas Marg Extn., Delhi-110092 Ph: 22162818, 42427641, 22372852-58 Extn. 1602 Fax no. 011-22372851

invites case studies, original, and review articles on different specialties

Allergic Rhinitis : Current Concepts in Diagnosis and Management

Sanjay Sood
The word allergy means an altered reactivity of the body to otherwise harmless environmental substances. The allergies such as Hay fever and Allergic Rhinitis are considered to be a trivial and inconsequential disease. Symptoms such as running nose, itchy eyes and nose, with sneezing and blockage are obviously not life threatening, but affect a large volume of the population and are the cause of significant disability and cost to society. Allergic rhinitis, the most prevalent chronic condition affects 40-50 million people worldwide. It is the commonest allergy encountered in clinical practice and constitutes more than 50% of all allergies seen in India. A rough estimate says that 1 in 6 people suffer from rhinitis and the incidence is steadily increasing. The effect of nasal symptoms of allergic rhintis on quality of life justifies the aggressive and rational approach in the treatment. Allergic rhinitis and asthma frequently coexist and that adeqate nasal treatment improves the pulmonary functions, is also a well known fact. The concept of allergy was introduced by the Viennese pediatrician Clemens von Pirquet in 1906 after noting that some of his patients were hypersensitive to normally innocuous entities such as dust, pollen, or certain foods. Pirquet called this phenomenon allergy, from the Greek words allos meaning other and ergon meaning work. Historically, all forms of hypersensitivity were classified as allergies, and were all thought to be caused by an improper activation of the immune system. Later, it became clear that several different disease mechanisms were implicated, with the common link between these varying hypersensitivities being a disordered activation of the immune system in one way or another. A new classification scheme was designed by Dr Philip Gell and Dr Robin Coombs to reflect what were then renamed hypersensitivity reactions. The word allergy was then restricted to type I hypersensitivities, which were rapidly developing reactions. A major breakthrough was the discovery of the antibody class labeled immunoglobulin E (IgE) - Kimishige Ishizaka and co-workers were the first to isolate and describe IgE in the 1960s. Systemic allergic response is also called anaphylaxis; multiple systems can be affected including the digestive system, the respiratory system, and the circulatory system. Depending on the rate of severity, it can cause cutaneous 17 Vol. 6, Issue 1 October - December 2007 reactions, bronchoconstriction, edema, hypotension, coma and even death. This type of reaction can be triggered suddenly or the onset can be delayed. Allergic rhinitis involves reactions in the nasal mucosa from repeated allergen exposures that cause hypersensitivity. These reactions may be seasonal or perennial. Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes of the nose. Etiology: The exact cause of the IgE malfunctions that result in allergic reactions are not always apparent, but genetic-basis, environmentalbasis and intermediate proponents exist with varying validity and acceptance. Genetic basis: There is a lot of evidence to support the genetic basis of allergy. Allergic parents are more likely to have allergic children, and their allergies are likely to be stronger than those from non-allergic parents. It seems that the likelihood of developing allergies is inherited but not to a specific allergen. Relationship with parasites: It has been shown that common parasites, such as intestinal worms (e.g. hookworms), secrete immunosuppressant chemicals into the gut wall and hence into the bloodstream, which prevents the body from attacking the parasite. This gives rise to the hygiene hypothesis that co-evolution of man and parasites has led to an immune system that only functions correctly in the presence of the parasites. Without them, the immune system becomes unbalanced and oversensitive. Increasing use of chemicals: The air quality is getting worse, indoor as well as outdoor. Adverse reactions to toxins vary considerably from one person to another and cause allergy symptoms. In 2004, a joint Swedish-Danish research team found an association between allergic symptoms in children and exposure to household dust containing the phthalates DEHP and BBzP, commonly used in PVC production. It is hypothesized that use of antibiotics and vaccination affects the immune system, and that allergies are a dysfunctional immune response.

Pathophysiology
The pathophysiology of allergic responses can be divided into two phases; the acute response, which can then either subside or progress into a late phase response.

Sanjay Sood ENT Consultant

Walia Nusing Home Delhi

Mechanism of allergic reaction

Initial Allergen contact Stimulates Antibody formation
allergen source

Immunologic Mechanisms Involved in Allergic Disease

sensitization allergen leaching allergen leaching provocation allergen source environment

Antibodies attach to mast cells and basophils

submucosa antigen presenting cell Fc epsilon receptor

Subsequent Allergen contact

Allergen + antibody reaction Degranulation of mast cells

MHC class II protein and epitope

Allergy

T helper cell

help

B cell

mediators IgE IgE binding inflammatory cell

clinical effects, e.g. asthma, hayfever eczema

Physiologic effects

Adapted from Slide Atlas of Allergy, Holgate ST, Church MK; 1993

The allergy reaction in the nose involves a complex interaction between various inhalant allergens and immune cells. A type I hypersensitivity reaction against an allergen via the normal humoral response against a foreign body results after plasma cells secrete IgE as opposed to other immunoglobulins such as IgM or IgG. IgE binds to receptors on the surface of mast cells and basophils, involved in the acute inflammatory response An allergen will link to specific IgE antibodies on mast cells resulting in degranulation. These granules release histamine and other inflammatory chemical mediators (cytokines, interleukins, leukotrienes, and prostaglandins) into the surrounding tissue causing several systemic effects, such as vasodilation causing swelling and nasal obstruction., mucous secretion, nerve stimulation and smooth muscle contraction. This results in symptoms of rhinorrhea, itchiness, dyspnea, and anaphylaxis.

This is termed as the Immediate Allergic Reaction. Other chemicals released by mast cells include tryptase, kinase and other enzymes. It also has a reflex effect via sensory nerves causing sneezing, itching and further mucus production. Subsequent nasal symptoms that develop between 3 and 12 hours after the initial allergen exposure are due to the Late Phase Reaction. This is due to the migration of leukocytes such as neutrophils, lymphocytes, eosinophils and macrophages to the initial site. The reaction is usually seen 4-6 hours after the original reaction and can last from 1-2 days. Cytokines from mast cells may also play a role in the persistence of long-term effects. Further immune mediator production occurs in the already inflamed nasal membranes and blood cells (eosinophils and basophils) infiltrate causing progressive nasal blockage and swelling.

Pollens in India vary according to the region and their seasonality. Some major pollen allergens reported in different regions of India are mentioned below (check seasonality and look for pollen forecast). Common Allergen Sources Group Examples Seasonality Air-borne Pollens Delhi & Jaipur Helianthus, Amaranthus, Cassia, Cenchrus, Morus, Imperata Cynodon, Seasonal Holoptelia, Prospis (Shivpuri et al) Bhopal Argemone, Cannabis, Brassica Seasonal Kolkata Lantana, Cucurbita, Cassia, Cocos nucifera (Chanda et al) Seasonal Andhra Pradesh Cassia, Ageratum, Ricinus, Salvadora Seasonal Bangalore Parthenium, Artemisia, Albizia (Agashe) Seasonal Moulds Aspergillus spp., Cladosporium spp., Alternaria spp., basidiospores, Perennial Ascomycetes Cereal flours Wheat, rye, oat Perennial Plant products Latex, papain Perennial Animal dander Cat, dog, horse, rabbit, guinea pig, mouse, rat, cow Perennial Bird feathers Parrot, pigeon, duck, chicken Perennial House dust mite Dermatophagoides farinae, Perennial Insects Cockroach, fly Seasonal Oral Foods Drugs Injected Insects Drugs Seafood, legumes, peanuts, tree nuts, Non-seasonal sesame, soya, cereals, dairy products, eggs, fruits, tomatoes, mushrooms, alcoholic beverages, coffee, chocolate Penicillins, sulfonamides and other antibiotics, sulfasalazine, carbamazepine Bee and wasp stings, ant and mosquito bites Blood products, sera, vaccines, contrast media, drugs (including anti-asthma drugs and antibiotics) Non-seasonal

Non-seasonal

Summer Non-seasonal

For more details on pollen aerobiology, refer to: Singh A B and Malik P. Pollen aerobiology and allergy. Ind J Aerobiology 1992:5(1-2) 1 Vol. 6, Issue 1 October - December 2007

Allergic rhinitis may be either seasonal or perennial:

Seasonal allergic rhinitis known as Hay fever: Tree and grass pollens and some fungi trigger seasonal allergic rhinoconjunctivitis (nose and eye allergy) during springtime and early summer. These people do not develop the typical allergy face but have seasonal puffiness of the eyes and eyelids with associated nasal membrane swelling. Perennial allergic rhinitis or a permanent cold: Allergens such as house-dust mite droppings, cat and dog dandruff, horse hair, and cockroach droppings result in perennial allergic rhinitis with symptoms all year round. In 1999, the World Health Organisation introduced a new classification for Allergic Rhinitis at the initiative of Allergic Rhinitis and its Impact on Asthma group (ARIA guidelines). The purpose was to try and create similar treatment guidelines for asthma and allergic rhinitis which often co-exist in the same patient (80% of asthma sufferers have concomitant allergic rhinitis). ARIA introduced the terms Intermittent Allergic Rhinitis and Persistent Allergic Rhinitis. Intermittent would replace the Seasonal (Hay fever) type disease and Persistent would replace Perennial Rhinitis (but some overlap does take place). These two groups are then further sub-divided into Mild
ARIA CLASSIFICATION: Based on both severity & duration of symptoms

and Moderate/Severe symptoms and treated according to the new guidelines. Aims of ARIA: 1 . to update clinicians knowledge of allergic rhinitis 2. to highlight the impact of allergic rhinitis on asthma 3. to provide an evidence-based approach to diagnosis and treatment 1. to provide a stepwise approach to the management of the disease. Signs and symptoms Nose: Nasal blockage intermittent, alternating unilateral blockage, Sneezing often paroxysmal, Rhinorrhoea can be anterior resulting in persistent sniffing and nose-blowing, or posterior resulting in a postnasal drip Headaches often without sinusitis Eyes: redness and itching of the conjunctiva (allergic conjunctivitis), epiphora, , swelling of eyelids, Airways: Sneezing, bronchoconstriction, wheezing and dyspnea,

ALLERGIC RHINITIS: COMORBIDITIES

Intermittent symptoms <4 days per week or <4 weeks

symptoms >4 days/week and >4 weeks

J. Bousquet, Allergy 2002: 57: 841855

Persistent

Mild normal sleep normal daily activities, sport, leisure normal work and school no troublesome symptoms

Moderate-Severe one or more items abnormal sleep impairment of daily activities, sport, leisure problems caused at work or school troublesome symptoms

SYMPTOMS Of ALLERGIC RHINITIS

Figure 2: Clinical assessment and classification of rhinitis History nasal discharge blockage sneeze/itch

2 or more symptoms for > 1 hr on most days

sneezers and runners

blockers

sneezing rhino rhea itching nasal blockage diurnal rhythm conjunctivitis

especially paroxysmal watery anterior and posterior yes variable worse during day improving at night often present

little or none thick mucus more posterior no often severe constant, day and night, may be worse at night

Lund, V.I et al., International Concerns Peporton the Diagnosis and Management of Rhinitis. International Rhinitis Management Working Group. Allergy 1994: 49 (Suppl 19:1 34. 1 Vol. 6, Issue 1 October - December 2007

Ears: feeling of fullness, possibly pain, and impaired hearing due to Eustachian tube dysfunction, Skin: various rashes, eczema and hives (urticaria), Others: Reduced smell or taste, Sleep disturbance and Impaired cognition. Chronic Allergic Rhinitis sufferers often have typical facial features called the allergy face. Nasal blockage and sinus congestion predispose to the bluish discoloration of the lower eyelids called allergic shiners, the characteristic linear creases under the eyelid are referred to as Dennes lines. Constant nasal rubbing typifies the allergic salute and results in a prominent nasal crease across the nose. Continuous nasal blockage causes nasal speech and mouth breathing with disturbed sleep. This results in a high arched palate and the long face syndrome with dental crowding and malocclusion (Buck teeth). Diagnosis: Diagnosis is based on history, clinical examination and investigations Leukocyte count: DLC Increased eosinophils Cytology of nasal secretions: Nasal mucus sample is tested for presence of eosinophils using Hansels Stain. Radiology: Radiological examination (sinus x-rays and CT scanning) does not help in the diagnosis of allergic rhinitis, but will identify complications such as chronic sinusitis, infections, nasal polyps and sinus fluid levels. Nasal endoscopy: Fibre-optic nasal endoscopies to visualize the nasal membranes, septum and osteo-meatal complex of the nasal sinuses. Specific Allergy Work Up Aim to establish the diagnosis -- to confirm the causative allergens -- to ascertain the degree of allergencity in a case

Skin tests for type I allergy: Scratch tests Charles Blackley Skin prick tests Lewis and Grant (1926) and Jack Peppy (1970) Intradermal tests Skin end point titration tests Prausnitz-Kustner tests Aim: To introduce an appropriate amount of allergenic material beneath the stratum corneum epidermis so that it comes in contact with specific IgE antibody bound to mast cells Advantages: 1. Establishes whether an antigen tested is the causative allergen or not 2. Does not precipitate actual attack of symptoms 3. Reliable, safe, convenient and able to assess sensitivity to many antigens at a single testing. 4. OPD procedure and economical as compared to RAST. Skin Prick /Puncture tests 1. Confirm hypersensitivity to varied allergens 2. Most convenient and specific screening method for detecting IgE antibodies 3. Less sensitive but more specific than intracutaneous tests Intra-cutaneous tests 1. Often positive in absence of clinically significant allergy 2. Done when prick/puncture test is negative to allergens that are strongly suggested by patients history or exposure Epicutaneous (Patch) tests 1. To determine the causative agent in contact eczematous dermatitis. 2. Approximately 20 to 30 antigens used in the routine screening panel of patch tests identifies the causative agent in 50% to 70% of the cases. Treatment: In Perennial Allergic Rhinitis, treatment should be taken continuously, whilst in Seasonal Allergic Rhinitis treatment only needs to be taken for symptom control during the peak pollen season. Allergen avoidance: Treatment and management of allergies revolves around avoiding the allergen or otherwise reducing exposure to allegern but it may not be possible for those with pollen or similar air-borne allergies. It may be easy for patients to avoid allergen, if only 1-2 allergens have been identified and if the sensitivity is mild. However, most patients suffer from a combination of allergen sensitivities. If a specific trigger cannot be avoided (dust and mold are good examples), management of the environment must be considered. Some of the measures are: Encasing all mattresses, pillows, and box springs in allergen (mite)-impermeable covers; Washing all bedding and stuffed toys in hot water at least once a week; Removing animals (pets and stuffed) and carpets from bedrooms; Minimizing upholstered furniture; Using air-conditioning; Using HEPA (high-efficiency particulate air) filters in bedroom; 20

In vitro tests: Total IgE estimation has limitation in tropical countries due to high prevalence of the parasitic infestations. Methods used are Radioimmunoassay (RIA), Paper Radio Immunsorbent techniques (PRIST) ELISA and Chemiluminiscence Specific IgE Estimation Radio Allergo Sorbent Technique (RAST). Estimation of Allergen specific IgE in the serum of a patient - One sample of serum tests several allergens Limitations 1. Serum must contain significant quantity of the specific IgE, 2. Allergen must be adequately potent with the antigen protein, 3. Serum must not contain large quantity of blocking antibodies. 4. Expensive test not a routine test. In vivo tests: Provocation tests simulate natural allergen-antibody reaction Nasal challenge tests Buffer saline based allergens are applied to the nasal mucosa in serially increasing concentrations until symptoms of sneezing, rhinorrhea and obstruction appear. Skin tests for allergy main tool for allergy diagnosis Patch tests based on delayed type IV reaction Vol. 6, Issue 1 October - December 2007

 Drying clothes in vented dryers -- not outside; Stay indoors during the midday and afternoon when the pollen count is high; Avoid sources of mould (wet leaves and garden debris); Use cockroach traps, insecticide sprays; Remove all indoor plants; Use of vacuum cleaner especially with a filter; Careful assessment of the workplace is essential; The use of face mask near chemicals and paints; The presence of tobacco smoke to be avoided. Pharmacologic treatment: Many patients need medication in addition to allergen avoidance and environmental control methods. Antihistamines: Antihistamines are the mainstay of treatment in seasonal allergic rhinitis. They control nasal itching, sneezing, runny nose and itchy eyes. There are 2 generations of available antihistamines. The first-generation agents cause sedation. However, they remain highly effective in symptomatic treatment, chlorpheniramine (Piriton). The second-generation antihistamines are favored by ARIA for their efficacy/safety ratio and rapid onset of relief. These antihistamines are not very effective against nasal congestion. The newer non-sedating antihistamines are Loratadine, desloratadine, fexofenadine, Mizolastine and cetirizine , or levocetirizine. Local antihistamine nasal spray such as azelastine and various ocular antihistamines are also effective for symptom control of nasal and ocular itching. They have no effect on nasal blockage and have an unpleasant taste. Intranasal corticosteroids: Steroid sprays applied directly to the nasal membranes have revolutionized the treatment of allergic rhinitis - particularly the chronic perennial type. Intranasal corticosteroids are the most effective agents for the management of allergic rhinitis because of their direct reduction of nasal inflammation and their ability to reduce nasal hyper reactivity. All agents are safe to use for prolonged periods of time at the recommended dosages and improves the patients quality of life if the patient uses them on a daily basis. Many patients do not like the odor or taste associated with specific agents. They act on various components of the nasal inflammatory process, causing blood vessel contraction, reducing blood vessel leakiness and reducing inflammatory cell numbers. Nasal steroids such as Flunisolide (Syntaris), Budesonide (Rhinocort Aqua) and Beclomethasone (Beconase) are particularly useful for their preventative effects and newer preparations such as Fluticasone (Flixonase), Triamcinolone (Nasacort) and Mometasone (Nasonex) can be used effectively on a once daily basis. Betamethasone (Betnesol) nose drops although very effective, may be absorbed into the circulation and should not be used continuously. Once symptom control is achieved, the daily dosage should be slowly reduced. Intranasal corticosteroids can be used with asthmatic patients and with those who have co morbid nasal polyposis. They may cause local nasal irritation and nose bleeds. They do not relieve palate and eye itch, so antihistamine tablets may also needed to be used. If significant nasal obstruction is present at commencement of treatment, then pre-treatment with a decongestant spray will be necessary for a few days. 21 Vol. 6, Issue 1 October - December 2007

Oral corticosteroids: These drugs reduce nasal inflammation and hyper reactivity but have potentially serious side effects when used over a long period. A short course of tapered corticosteroids is advisable only for moderate-to-serious exacerbations of allergic rhinitis. An oral steroid such as Prednisilone has significant generalized side effects and should therefore only be used in severe disease for short periods of 5 to 14 days. Use of injection long-acting steroids (Depot Medrone, Kenalog) should be discouraged as they can lead to osteoporosis, muscle damage, raised blood pressure, diabetes, glaucoma, cataracts, stomach ulceration and chronic infections. Mast cell stabilizers: These agents are particularly effective in patients with intermittent allergies, especially when prevalent in only one season of the year. They should be started 3-4 weeks before a peak allergy season occurs. Their effect on the nose is short-acting and makes compliance more difficult as several doses are needed per day. Intraocular agents are also very effective. Cromolyn in the form of sodium cromoglicate, has antiinflammatory activity and relieves nasal itch, sneezing, mucus production and congestion particularly in seasonal allergic rhinitis. It is an extremely safe product but must be used 4 times a day, and is very effective in the eyes for treating allergic conjunctivitis. Olopatadine eyedrops are very effective for grass pollen-induced eye allergies when used twice daily. This eye drop has both antihistaminic and mast cell stabilising properties and has a simple twice daily dosage. Olopatadine oral preparation is used for allergic rhinitis. Oral decongestants: These common drugs, widely available without prescription, are very effective in treating nasal congestion. Oral decongestants such as pseudoephedrine treat nasal blockage by constricting blood vessels in the nasal membranes and throughout the body to some degree. They have significant side effects like blood pressure problems, dry mucus membranes, cause urine retention and trigger glaucoma. Some patients experience insomnia, restlessness, headache and palpitations. Intranasal decongestants: Decongestant sprays/drops can be used in the nose for relief of nasal blockage and congestion but over-use of these ephedrine containing sprays is associated with rebound nasal congestion and rhinitis medicamentosa. The safest preparations are Oxymetazoline and Xylometazoline but continuous use should be limited to 7 - 10 days at a time. Used in combination, the decongestant often compensates for the sedative effect of the anti-histamine although this may result in the side effect of restlessness and insomnia. Intranasal anticholinergics: These drugs are used by patients with gustatory rhinitis, as they prevent rhinorrhea. They are effective against nasal discharge only and have no anti-inflammatory effects. Ipratropium bromide, a spray derived from atropine, provides good relief for the profuse watery nasal discharge including non-allergic or vasomotor rhinitis. Ipratropium is very safe to use, with rapid onset of activity and minimal side effects. It has no effect on nasal blockage, itch or sneezing. Antileukotrienes: The leukotriene antagonists Zafirlukast and Montelukast are useful additions in treating allergic rhinitis, especially in aspirin-sensitive people. They have beneficial effects in treating patients with asthma and co-existent allergic rhinitis as they block the activity of Leukotrienes in the nasal membranes. ARIA recommends antileukotriene use in combination with other therapies, especially when nasal congestion is not ameliorated by other modalities.

Immunotherapy: Immunotherapy is indicated in patients who present with any of the following characteristics: Insufficient control by pharmacotherapy; Insufficient control of symptoms; Non-compliance to prescribed medication; Undesirable side effects; A desire to avoid long-term pharmacotherapy. Immunotherapy, also known as hyposensitization or desensitization, is a treatment in which the patient is gradually vaccinated with progressively larger doses of the allergen. This can either reduce the severity or eliminate hypersensitivity altogether. It relies on the progressive skewing of IgG (the blocking antibody) production, as opposed to the excessive IgE production seen in hypersensitivity type I cases. In a sense, the person builds up immunity to increasing amounts of the allergen. Studies have demonstrated the long-term efficacy and the preventive effect of immunotherapy in reducing the development of new allergy. A randomized trial demonstrated that injection immunotherapy reduces the risk of developing asthma. Allergen immunotherapy is safe and effective for allergic rhinitis and conjunctivitis, allergic forms of asthma, and stinging insect hypersensitivity. The conclusion states: Allergen

immunotherapy should be strongly considered for patients with poor symptom control or adverse reactions to medications. A second form of immunotherapy involves the intravenous injection of monoclonal anti-IgE antibodies. These bind to free and B-cell IgE, signalling such sources for destruction. They do not bind to IgE already bound to the Fc receptor on basophils and mast cells as this would stimulate the allergic inflammatory response. The first agent in this class is omalizumab. Sublingual immunotherapy is an orally-administered therapy which takes advantage of oral immune tolerance to nonpathogenic antigens. This therapy currently accounts for 40 percent of allergy treatment in Europe. In the United States, sublingual immunotherapy is gaining support among traditional allergists and is endorsed by otolarygologists who practice allergy treatment. Unproven or ineffective treatments: An experimental treatment, enzyme potentiated desensitization (EPD), has been tried for decades. EPD uses dilutions of allergen and an enzyme, betaglucuronidase, to which T-regulatory lymphocytes are supposed to respond by favouring desensitization, or down-regulation, rather than sensitization. EPD has also been tried for the treatment of autoimmune diseases but again is not of proven effectiveness.

TREAT IN A STEPWISE APPROACH

(adolescents and adults) Diagnosis of allergic rhinitis (history skin prick tests or serum specific lgE) q Allergen avoidance q Persistent symptoms q mild q moderate severe q intranasal CS q review the patient after 2-4 weeks q improved q step-down and continue treatment for 1 month q increase intranasal CS doses q q failure q review diagnosis review compliance query infections or other causes q q rhinorrhea add ipratropium blockage add decongestant or oral CS (short term) q failure q surgical referral

q Intermittent symptoms q mild q Not in preferred order oral H1 blocker intranasal H1 blocker and/or decongestant q moderate severe

q Not in preferred order . oral H1 blocker . intranasal H1 blocker . and/or decongestant . intranasal CS . (chromone) q in persistent rhinitis review the patient after 2-4 weeks q if failure: step-up if improved: continue for 1 month

If conjunctivitis add: oral H1- blocker or intraocular H1 blocker or intraocular chromone (or saline) consider specific immunotherapy in case of improvement: step down. In case of worsening: step up. 22

itch/sneeze add H1 blocker

Vol. 6, Issue 1 October - December 2007

Treatment of allergic rhinitis with lactic acid bacteria: v Heat-killed Lactobacillus paracasei for treatment of perennial allergic rhinitis induced by house-dust mite; v Lactobacillus rhamnosus in infants with moderate to severe atopic dermatitis; v Long-term consumption of fermented milk containing lactobacillus casei in pre-school children with allergic asthma and/or rhinitis; v Probiotics are perceived to exert beneficial effects in the prevention and treatment of allergic diseases by modifying the gut ecosystem. Surgery: Surgery is indicated in select cases of severe nasal blockage due to hypertrophied turbinate and nasal polyps or chronic sinusitis associated with the allergic rhinitis. Various surgical procedures used are Antral wash out, Chemo-cautery and Eletro-cautery, Submucosal diathermy, Turbinectomy, Septoplasty, Laser and Cryuo surgery and Functional Endoscopic sinus surgery (FESS) Other measures: Nasal douching: Normal saline douching with a touch of bicarbonate of soda added is a useful non-drug treatment for clearing the nasal passages in allergic rhinitis. v Menthol nasal preparations also give some symptom relief while steam inhalations using a Eucalyptus extract will help decongest the nasal passages. v Application of a small amount of Petroleum Jelly (Vaseline) to the lower nasal passages with a cotton bud also helps relieve symptoms. Alternative therapies: In alternative medicine, a number of treatment modalities are considered effective by its practitioners in the treatment of allergies, particularly naturopathic, herbal medicine, homeopathy, traditional Chinese medicine and kinesiology. These modalities are frequently offered as treatment for those seeking additional help when mainstream medicine has failed to provide adequate relief from allergy. Most recently the herb Butterbur was shown to have some beneficial effects. Antioxidants: Vitamin C, Vitamin E, Beta-Carotene, Selenium and Zinc are included in this category. There is no evidence that these products have any beneficial effect in treating allergic rhinitis. N-acetyl cysteine (Solmucol) a mucus reducer with antioxidant activity may be of some benefit. Other medications such as carbocisteine, which is used in Cystic Fibrosis, is often co-prescribed in allergic rhinitis. Role of dietary restriction: Some people will benefit from dietary exclusion of common food allergens such as cows milk and food additives (benzoate, sulphites, colouring and nitrite) from their diet. Food additive such as sodium benzoate, sulphite, tartrazine and nitrites have been implicated as triggers for chronic non-allergic rhinitis and avoidance may benefit rhinitis sufferers. Patient education: A comprehensive and individualized educational program is essential to the treatment of allergic rhinitis. Education should include: v Learning about specific triggers and mechanisms for avoidance and control. v Understanding all the reasons and options for treatment. v Learning how to manage allergic problems at home and at work. v Having an emergency-action plan available to family members. 23 Vol. 6, Issue 1 October - December 2007

Stepwise Approach to Long-term Therapy

Once the patients symptoms are under control, ARIA recommends that maintenance be based on a minimum quantity of medication so that exacerbations can be easily managed. This stepped approach is similar to the approach used in asthma management and facilitates patient understanding when there is co-morbidity present. Conclusion The ARIA guidelines create an important tool for the successful treatment of allergic rhinitis. The conclusions drawn from the panel have important implications for decreasing the severity of asthmatic symptoms. It has recently been proposed that the prevention or early treatment of allergic rhinitis may actually help prevent the occurrence of asthma, but more data are needed. Nurses in advanced practice are in a position to develop and oversee comprehensive allergic rhinitis treatment plans for their patients that will help to clarify this issue.
References 1. Allergic rhinitis and its impact on asthma. ARIA guidelines. z1999. 2. American Academy of Allergy, Asthma, and Immunology. The allergy report: diseases of atopic diathesis. The allergy report: volumes 1-3, 2001. 3. Atlas of Allergy, Holgate ST, Church MK, 1993. 4. Fromer L. Allergy avoidance. Program and abstracts of the American Academy of Family Physicians Annual Scientific Assembly; October 13-17, Orlando, Florida. Session 122, 2004. 5. Guei-Cheng Peng and Ching-Hsiang Hsu. The efficacy and safety of heat-killed Lactobacillus paracasei for treatment of perennial allergic rhinitis induced by house-dust mite. Pediatric Allergy and Immunology, Volume 16, Issue 5, Pp 433-438, Aug 2005. 6. Lund, V I. et al. International consensus report on the diagnosis and management of Rhinitis. International Rhinitis Management Working Group. Allergy, 49 (suppl 19): 1.34, 1994. 7. Lynch JS. What are the new guidelines for classifying allergic rhinitis? Medscape Advanced Practice Medscape Nurses. 2004;6(1). 8. Moller C, Dreborg S, Ferdousi HA, et al. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol. 2002;109:251-266. 9. Boyle RJ and Tang MLK. The role of probiotics in the management of allergic disease. Clinical & Experimental Allergy 2006:36:5, 568576. 10. Satya Prakash, Jasmine Bhathena. Live bacterial cells as orally delivered therapeutics. Expert Opinion on Biological Therapy2005: 5:10, 1281 11. Shaikh WA. Allregies in India : An analysis of 1619 patients attending an allergy clinic in Bombay,India. Int Rev. Allergol. Clin. Immunol. 1997; 3(2) : 101-104 12. Shaikh WA. Allergic rhinitis: Current concepts and mangement guidelines. Ind. J. Clin. Pract. 1997; 7(10): 37-44 13. Singh, A B. and Malik, P. Pollen aerobiology and allergy. Ind. J. Aerobiology, 1992:5 (1-2). 14. Wang MF, Lin HC, Wang YY, Hsu CH. Treatment of perennial allergic rhinitis with lactic acid bacteria. Pediatr Allergy Immunol 2004: 15: 152158. 2004 Blackwell Munksgaard.

Endoscopic Dacryocysto Rhinostomy

Atul Jain
Endoscopic dacryocystorhinostomy or DCR has traditionally been performed for nasolacrimal duct obstruction via an external approach. Eighty per cent of lacrimal pathways belong anatomically to the nose. It is therefore feasible that dacryocystorhinostomy (DCR) may be performed through an endonasal approach. which is about 12-15-mm long, which eventually narrows into the nasolacrimal duct, which is about 18-mm long, and that eventually empties into the inferior meatus. The sac and the duct comprise the lower lacrimal system. Tears move from the eye into the nose through a mechanism called the lacrimal pump. Lid movement causes the puncta to close against each other, pushing tears into the lacrimal sac which contains the lacrimal lake. When the eyes open a negative pressure is created in the lacrimal lake, pushing it down further into the nose.

History
Caldwell in 1893 was the first to try endonasal Dacryocystorhinostomy. In 1895 he presented his experience with the endonasal approach. Due to paucity of instruments the results were not good & the technique fell into disrepute. Toti in 1904 started the external approach. In 1989, McDonogh and Meiring described the endoscopic trans nasal DCR. Rice in 1990 reported his experience using endoscopic instruments to create this neo-ostium and since then there has been quite a bit of literature on the subject.

Indications
Endoscopic dacryocystorhinostomy (DCR) is indicated for patients with lacrimal sac obstruction or nasolacrimal duct obstruction (NLDO). NLDO is common, and presenting symptoms include watering of the eye and dacryocystitis (infection). Endoscopic DCR is usually considered for patients who have been refractory to conventional treatment such as warm compresses, massage and probing of the nasolacrimal duct. If NLDO is left untreated, the symptoms persist and may be distressing for the patient. In the patients history it is important to note whether or not the epiphora is unilateral or bilateral, and whether the tearing is constant or intermittent. Unilateral constant tearing will usually direct you towards an obstructive phenomenon. The nature of the discharge is also important: clear or purulent. The key for a correct indication is to exclude a presaccal stenosis, which is not suitable for an endoscopic procedure. The best method to assess the site of obstruction consists of probing the lacrimal pathways. If it is possible to pass the proximal canaliculi (superior and inferior) and to enter the superior third of the lacrimal sac through the common canaliculus, a presaccal obstruction can be excluded. Fluorescein dye tests (Jones I and II) or dacryocystographies (of

Anatomy
The lacrimal system consists of superior and inferior puncta, which turn into the superior

Fig 1. Coronal section of Lacrymal system

and inferior canaliculi, which then join into the common canaliculus. This region is known as the upper lacrimal system. The common canaliculus turns into the nasolacrimal sac,

Atul Jain Senior Consultant ENT

Pushpanjali Medical Centre and Fortis Hospital, Noida Fig 2. Axial section of Lacrymal system with pumping action of the Orbicularis muscle.

25 Vol. 6, Issue 1 October - December 2007

any type) are no longer performed. Since dacryocystographies use a probe to apply the contrast, there is no further need for a Radiological evaluation if the probe passes. You can image the nasolacrimal system using a dacryocystogram. You can also use a dacryoscintigraphy with radio labeled materials, and certainly you would not proceed with an endoscopic case without performing computed tomography. A CT can be very useful to find extrinsic tumors, lacrimal sac mucoceles, show the state of the sinuses and find dacryoliths for you. The external incision is made just inferior to the medial canthus, taking care to avoid the angular artery. The lacrimal sac is exposed, and you drill through the lacrimal fossa through the frontal process of the maxillary bone until you enter the nasal cavity. You can also create mucosal flaps, which will keep the ostium open. The introduction of rigid nasal endoscopes enabled an endoscopic approach. In a cadaver study, Rice demonstrated the feasibility of endoscopic intranasal DCR and the first clinical study was published by McDonogh and Meiring in 1989. The search for an alternative to the external approach is motivated by the desire to improve this DCR success rate and to add other advantages, such as a better aesthetic result or better compliance by the patient. The endonasal DCR is a one-stage procedure that permits correction of associated pathology, such as septal deviation or chronic paranasal sinusitis that may be a causative factor in lacrimal obstruction. Since an external incision is not used, the possibility of pathologic scar formation and/or injury to the medial canthus is avoided. Furthermore, it preserves the pumping mechanism of the orbicularis muscle. Active infection of the lacrimal system is not a contraindication to intranasal DCR, as it drains mucus or pus into a contaminated nasal cavity. Endoscopic DCR requires special training in the use of endoscopes, but it can be considered a routine since endoscopic sinus surgery was introduced. For revision DCR, the endoscopic approach is especially superior to the external approach. The normal scarring produced after the external incision makes a revision procedure very uncomfortable, and the final aesthetic and functional results are usually poor. In contrast, endoscopic revision DCR is an easy procedure with mainly good results.

Fig. 4. Punching the ascending process of maxilla

Fig. 5. Lacrymal sac

A silicone lachrymal stent may be passed through the canaliculi and brought out through the nose. The mucosal flap is fashioned to cover the raw area leaving the neo-ostium exposed. There are certain complications to an external DCR. There is an external scar, which is avoided with the endoscopic procedure. There is also danger of injury to the medial canthal structures, and damage to the pumping action. There are certain advantages of the endoscopic DCR. There is no external scar. It preserves the lacrimal pump system. Fig. 6. incision of sac with purulent Any intranasal pathology that secretions. might have caused failure of the first procedure can be addressed, including adhesions, enlarged middle turbinate and septal deviation. More of the lacrimal sac is preserved with the endoscopic procedure. There is actually only a 1 in 40 instance of air regurgitation during nose blowing noted after endoscopic procedures, Fig 7. Neo ostium after 8 weeks while the incidence is higher with the external procedure.

Conclusions
The intranasal approach has been shown to be a safe alternative to the external approach for endoscopic DCR. The introduction of a mucosal flap to partly cover the lateral wall seems to provide quicker healing and to prevent haematomas of the cheek. The results of intranasal DCR are comparable to those obtained using the external approach, and the cosmetic advantages are clear. In the near future, more ear, nose and throat surgeons will be performing this surgery.
References 1. M McDonongh and H Meiring, Endoscopic transnasal dacryocystorhinostomy, J. Laryngol. Otol., 103 (1989), pp. 585587. 2. M Bernal Sprekelsen and M Toms Barbern, Endoscopic dacriocystorhinostomy. Surgical technique and results, Laryngoscope, 106 (1996), pp. 187189. 3. R M Bumsted and L V Lindberg, External dacryocystorhinostomy, Arch. Otolaryngol., 108 (1982), pp. 303307. 4. D L McLachlan, G M Shannon and J C Flanagan, Results of dacryocystorhinostomy: analysis of the reoperations, Ophthalmic Surg., 11 (1980), pp. 427430. 5. Jokinen K, Karja J. Endonasal dacryocystorhinostomy. Arch Otolaryngol 1974;100:41-44. 6. Whittet HB, Shun-Shin GA, Awdry P. Functional endoscopic transnasal dacryocystorhinostomy. Eye 1993;7:545-549.

Procedure
The surgery is performed either under General Anaesthesia or Local Anaesthesia. After infiltrating the mucosa anterior to the attachment of the middle turbinate with 2% Xylocaine with Adrenaline; a C shaped incision is made anterior to and above the attachment of the middle turbinate. The mucosa is elevated and the junction of the lachrymal bone with the uncinate and the ascending process of the maxilla are identified. The lachrymal bone along with the ascending process of the maxilla is nibbled with a bone punch to expose the lachrymal sac. The sac can be made prominent by pressing the sac area from outside or it can be made prominent by passing a lachrymal probe through the inferior or the superior canaliculi. An incision is made near the anterior end of the sac and purulent material can be seen to be draining out. The medial wall of the sac is excised. 26 Vol. 6, Issue 1 October - December 2007
Fig. 3. Endonasal incision.

Early Hearing Loss: Detection and Intervention

Meenakshi Wadhera
Significant hearing loss is one of the most common major abnormalities present at birth and, if undetected, will impede speech, language, and cognitive development. Significant bilateral hearing loss is present in 1 to 3 per 1000 newborn infants in the well-baby nursery population, and in 2 to 4 per 100 infants in the intensive care unit population. Ninety percent of children with hearing loss are born to normal-hearing parents. Over 50% of babies born with hearing loss have no known risk factors for hearing loss. Hearing loss is the most frequently occurring birth defect, occurring more frequently than all metabolic disorders screened for at birth combined. In addition, the screening cost per confirmed diagnosis of hearing loss is far less than the cost per confirmed PKU diagnosis. Hearing loss is the inability to detect sound. It is important to understand that hearing loss does not necessarily equal deafness. There are varying degrees of hearing loss, ranging from mild to profound (deaf). Several national committees, including the National Institutes of Health, the American Academy of Otolaryngology/Head and Neck Surgery, and the American Academy of Pediatrics, have recommended that hearing loss in infants be identified, and when possible treated, prior to six months of age. This recommendation is based on studies that have shown that children identified with hearing loss prior to six months of age have a better chance of developing skills equivalent to their peers by the time they enter kindergarten. Children not identified until later (for example, it is very common to first identify hearing impaired children at age 2 to 3 years) may ultimately suffer from irreversible and permanent impairments in speech, language, and cognitive abilities when compared to their peers.

Importance of Universal Neonatal Hearing Screening

Screening programs for hearing impairment may be either universal or highrisk population based. High risk means those newborns who had known significant risk factors for hearing loss. This group includes infants with the following conditions: v v v v v v v v v v v v v v Family history of childhood hearing loss Parental or caregiver concern A congenital infection, such as CMV A syndrome associated with permanent or progressive hearing loss. Craniofacial anomalies, including those with anomalies of the pinna and ear canal Chronic middle ear problems Birth weight of less than 1500 grams Severe hyperbilirubinemia requiring exchange transfusion Exposure to ototoxic medications Bacterial meningitis APGAR scores of 0-4 at 1 minute or 0-6 at 5 minutes Mechanical ventilation for greater than 5 days A stay in a NICU for longer than 48 hours Head trauma

Effects of Hearing Impairment

Hearing impairment (which is an invisible condition), not only restricts speech language development but also adversely affects educational, social, intellectual, emotional and cognitive development. A child who is identified late may never be at par with his hearing peers in terms of academic performance, intellectual development, or later in the work place. The severity of these learning disabilities is generally related to the length of time the hearing loss is left untreated. Hence, with hearing impairment a wait and watch attitude hoping that the child will grow out of it cannot be adopted. To reduce the negative effects of hearing loss, it is important to identify hearing impairment and begin amplification and habilitation as early as possible.

Benefits of Early Screening

The rationale for screening is based on the fact that early diagnosis, followed by intervention will either prevent or diminish the severity of the disability. There is general agreement that early identification and intervention ensures better parent-child bonding, and has a greater potential for normal/near normal speech language and social development. Thus, intervention enhances the potential of most hearing impaired children to become adults who are fully independent, participating and contributing members of society. 27 Vol. 6, Issue 1 October - December 2007

Meenakshi Wadhera Audiologist and Speech Language Therapist

Meenakshi Speech & Hearing Clinic

However, despite the testing of all infants who fall into this high risk registry, over half of all newborns with hearing loss are missed! So in order to identify this large group of hearing impaired infants not identified with high risk protocols, it becomes very important that all newborns have a hearing test. The goal of this program is to identify all hearing impaired infants at an early age i.e shortly after birth.

Prior to discharge, each newborn has his/her hearing tested. If, for some reason, the newborn does not pass the screen, a re-screen is usually done. If the infant still does not pass the second hearing test, he/she is referred to a specialist for further testing.

Occasionally, (due to the age factor) a conductive loss cannot be corrected with surgery. However, these children typically do extremely well with hearing aids. A sensorineural loss is indicative of a problem in the inner ear or somewhere along the nerve to the ear (auditory nerve). This type of loss is typically permanent and cannot be corrected with surgery. A hearing aid or a cochlear implant may be utilized in this situation. v Hearing aids are instruments that make sounds louder. They are worn in or behind the ear and come in several different shapes and sizes. Hearing aids can be used for varying degrees of hearing loss, moderate or severe. An audiologist will fit a hearing aid that will work best for the childs hearing loss. v Cochlear implants are electronic devices that restore partial hearing to the deaf. It is surgically implanted in the inner ear and activated by a device worn outside the ear. Unlike a hearing aid, it does not make sound louder or clearer. Instead, the device bypasses damaged parts of the auditory system and directly stimulates the nerve of hearing, allowing individuals who are profoundly hearing impaired to receive sound. A microphone is also worn outside the body as a headpiece behind the ear to capture incoming sound. The speech processor translates the sound into distinctive electrical signals. These codes travel up a thin cable to the headpiece and are transmitted across the skin via radio waves to the implanted electrodes in the cochlea. The electrodes signals stimulate the auditory nerve fibers to send information to the brain where it is interpreted as meaningful sound. In addition to the early medical or surgical treatment of the hearing loss, parental involvement is essential. Parents need to monitor the childs progress and facilitate and encourage the use of the hearing aids and other therapeutic exercises that are designed to help the child become a careful listener and talker. Research has found that the one common denominator among successful hearing impaired children is the parents willingness to help the child throughout his/her lifetime.

Screening Tools for Hearing

Hearing in infants can be tested using two different methods; the auditory brainstem response (ABR/BERA) evaluations, or the otoacoustic emission (OAE) measures. Both tests are accurate, non-invasive, and do not require any observable response from the infant. For a screening tool, both methods are extremely effective. Otoacoustic emissions (OAE): Otoacoustic Emissions (OAE) can identify infants with hearing loss of approximately >30 dBnHL. This technique measures sounds in the ear canal that are generated and emitted by the outer hair cells of the cochlea in healthy ears in response to acoustic stimuli. The test is performed by placing a small probe that contains a microphone and speaker into the infants ear. As the infant rests quietly, sounds are generated in the probe and responses that come back from the cochlea are recorded with the microphone probe. If there is an emission present for those sounds that are critical to speech comprehension, then the infant has passed the hearing screen. Auditory brain stem response (ABR): An ABR is a physiological measure of the brainstems response to sound. It tests the integrity of the hearing system from the ear to the brainstem. The test is performed by placing four to five electrodes on the infants head, after which a variety of sounds is presented to the infant through small earphones. As the hearing nerve fires, the sound stimulus travels to the brain. This electrical activity generated by the nerve can be recorded by the electrodes and is represented as waveforms on a computer screen. The audiologist can then present different loudness levels of each sound and determine the softest levels at which the infant can hear. The click is typically presented at a loud level and a soft one. If a healthy response is recorded, then the infant has passed the hearing screen. The OAE is easy and more cost effective. The two tests, however, rely on different mechanisms of hearing for the screening. For indepth testing and a complete hearing evaluation of infants, these tests work best together as a complement to each other. A newborn who fails an initial hearing screen may not necessarily have a permanent hearing loss or a hearing loss at all. There are many possible reasons why an infant may fail a hearing screening test like: v fluid from the birth may still be present in the ear canal. v fluid in the middle ear v excessive noise or movement from the infant during the test. If an infant does not pass the screening test, then a full diagnostic test will be necessary to determine the type and amount of hearing loss.

Conclusion
Left undetected, hearing impairments in infants can negatively impact speech and language acquisition, academic achievement, and social and emotional development. If detected, however, these negative impacts can be diminished and even eliminated through early intervention. The dynamic changes in technology and education may soon make infant hearing screening programs viable in our country. Successful hearing screening programs involve commitment and support from Pediatricians, Health Care Administrators, ENT Surgeons, Physicians, Audiologists, families and caregivers and a community educated about the importance of the relationship between hearing and infant development.
References 1. Northern JL, Downs MP. Hearing in Children. 3rd ed. Baltimore, MD: Williams & Wilkins; 1984:89 2. Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early and later-identified children with hearing loss. Pediatrics. 1998;102: 11611171 3. Robinshaw HM. Early intervention for hearing impairment Br J Audiol. 1995; 29:315334 4. Robinshaw HM. The pattern of development from noncommunicative behavior to language by hearing-impaired infants. Br J Audiol. 1996;30: 177198 5. AAP, Joint Committee on Infant Hearing 1994 position statement. Pediatrics.1995;95:152156.

Intervention of Hearing Loss in Infants

The ability of an infant to compensate for the hearing loss will depend on both the type and the degree of hearing loss. The type of hearing loss refers to where in the ear the hearing loss is located and what is causing it. There are two basic types of hearing loss, conductive and sensorineural. A conductive loss is caused by problems in the outer or middle ear. This is the type of loss that results when a child has a middle ear infection, trapped fluid from birth, or impacted wax in the outer ear. It is usually correctable with medical treatment or surgery. 2 Vol. 6, Issue 1 October - December 2007

Cochlear Implants
Sharad Kumar Maheshwari and Vijay Rangachari
Cochlear implants, due to their technological advances, have emerged as a boon and a wonderful working solution to the millions of profoundly hearing impaired children and adults all over the world. Cochlear Implants are the first true bionic sense organs. The human cochlea is, in effect, an electromechanical transducer. Similarly, the cochlear implants, like the human hair cell, also receives mechanical sound energy and converts it into a series of electrical impulses. Therefore, cochlear implants are very different from hearing aids, which only amplify the mechanical sound waves.

How does a cochlear implant work?

A cochlear implant is very different from a hearing aid. Hearing aids amplify sounds, so they may be detected by damaged ears. Cochlear implants bypass damaged portions of the ear and directly stimulate the intact auditory nerve. Signals generated by the implant are sent by way of the auditory nerve to the brain, which recognizes the signals as sound. Hearing through a cochlear implant is different from normal hearing and takes time to learn or relearn. However, it allows many people to recognize warning signals, understand other sounds in the environment, and enjoy a conversation in person or by telephone.

What is hearing impairment?

External or middle ear pathology affects the conductive component of hearing which usually can be corrected by medicines or routine surgery. What is more challenging is severe to profound sensori neural hearing impairment or nerve deafness which usually is not benefited by hearing aids. This is because the hair cells of the cochlea are damaged, they do not function and the hearing of the patient becomes impaired. Intact auditory nerve fibres capable of transmitting electrical impulses to the brain become unresponsive because of hair cell damage. A cochlear implant makes use of this intact auditory pathway by bypassing the damaged hair cells of the cochlea. A cochlear implant is a small, complex electronic device that consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin (see figure 1). An implant has the following parts: 1. A microphone, which picks up sound from the environment. 2. A speech processor, which selects and arranges sounds picked up by the microphone. Sharad Kumar Maheshwari Senior Consultant Ear
Nose and Throat Surgeon Max Balaji Hospital Delhi

Candidates for a cochlear implant

Children and adults who are severely hard-ofhearing can be considered for cochlear implant surgery. Adults who have lost all or most of their hearing later in life due to meningitis or viral infections can benefit from cochlear implants. They learn to associate the signal provided by an implant with sounds they remember. These sounds provide the recipients with the ability to understand speech solely by listening through the implant, without requiring any visual cues such as those provided by lip reading or sign language. Cochlear implants, coupled with intensive postimplantation therapy, can help young profoundly deaf children to acquire speech, language, and social skills. Most children between two to six years of age can be considered for cochlear implant. Early implantation provides exposure to sounds that can be helpful during the critical period when children learn speech and language skills. Presently, the newer implants have proven to be safe even in children as young as nine months of age. Implants are designed only for individuals who attain almost no benefit from a hearing aid.

3. A transmitter and receiver/stimulator, which receive signals from the speech processor and convert them into electric impulses. 4. An electrode array, which is a group of electrodes that collects the impulses from the stimulator and sends them to different regions of the auditory nerve. An implant does not restore normal hearing. Instead, it can give a deaf person a useful representation of sounds in the environment and help him or her to understand speech. 2

Vijay Rangachari Consultant Ear Nose and Throat Surgeon

Surya Hospital Delhi

Vol. 6, Issue 1 October - December 2007

The process of Cochlear Implant surgery and rehabilitation

Cochlear implant surgery involves a dedicated team consisting of an ENT surgeon, an Audiologist and speech therapist, a Child psychologist, Radiologists, Medical and nursing staff and the patients family.

Post-surgical implant switch-on and rehabilitation

Usually after four weeks, the signal processor, microphone, and implant transmitter are placed outside the ear and settings are adjusted. Rehabilitation takes several weeks of speech and audiological training and lot of motivation is required on the part of the patient and parents.

Evaluation and planning for a cochlear implant

v Otological evaluation: The ENT Surgeon examines the middle and external ear to look for congenital or acquired deformities or infections in the external ear, ear canal or other abnormalities that can hamper the success of the implant surgery. v Audiological evaluation: The audiologist performs a Brainstem Evoked Response Audiometry which is an extensive hearing assessment test to determine the intactness of the auditory pathways. v Radiological evaluation: The CT and/or MRI scans evaluate the temporal bone and the cochlea to rule out anatomical abnormalities or syndromic abnormalities. v Thorough Systemic Examination: This includes a complete general, cardiovascular and neurological examination to rule out syndromic causes of deafness. v Psychological evaluation: Some patients may need a psychological evaluation to learn if they can cope with the implant. v Counselling: Proper counselling about the extent of postoperative rehabilitation and the motivation and hard work required after the surgery to achieve optimum benefits should be explained to the patients and the parents.

further advances
Bilateral cochlear implantation is also a possibility in the appropriate candidates these days to give the additional benefits of binaural hearing which is always better appreciated by the cortex over mono aural hearing through a single implant. A more recent advance is the emergence of Auditory brain stem implants where the implant is placed in the brain stem directly in patients where both auditory nerves are also damaged due to Vestibular Nerve Schwannoma surgery.

Conclusion
Appropriate selection of candidates, proper counselling about the benefits and shortcomings, understanding and matching the expectations of the surgeon and the patients, post-operative motivation and rehabilitation and good team work are the essential ingredients of a successful cochlear implant programme.

Cochlear Implant Surgery

Implant surgery is performed under general anaesthesia and lasts from two to three hours. An incision is made behind the ear to open the mastoid bone leading to the middle ear. The implant is embedded in a well made in the cortex of the mastoid bone and then through a conduit, the electrodes are taken towards the inner ear and inserted into the cochlea through a cochleostomy opening made anterosuperior to the round window. After the electrodes are inserted, the position of the electrodes is confirmed by mapping. Then, the wound is closed. Usually, the implant is switched on four weeks after the surgery.

invites case studies, original, and review articles on different specialties

Please sumit your contributions by email
at

pmc_pub@yahoo.co.in pmc_pub@hotmail.com
or

by post at the address given below

Fig 2. An Implantee showing the cochlear implant external components in place.

A-14, Pushpanjali, Vikas Marg Extn., Delhi-110092 Ph: 22162818, 42427641, 22372852-58 Extn. 1602 Fax no. 011-22372851
30

Vol. 6, Issue 1 October - December 2007

Uterine Balloon Therapy : A Reason to Smile for DUB Cases

Sharda Jain
World over it is now discussed that global Endometrial Ablation Techniques should be tried as an alternative to hysterectomies. Dysfunctional uterine bleeding (DUB) is a common gynaecological disorder. If affects 1 in 5 women One in 20 women aged 30- 49 years, consult a doctor with a history of excessive bleeding and surgical intervention. One in five women in the UK with present trends, need a hysterectomy before the age of 60 years, and 1:3 women in USA will have hysterectomy . It is a well known fact that in at least 50% of those who have undergone hysterectomies, menorrhagia is the main presenting problem. About half of all women (50%) who have had a hysterectomy for menorrhagia, have a normal uterus removed! DUB describes the spectrum of abnormal menstrual patterns that may occur in ovulatory and anovulatory women who have had o medical n illness or pelvic pathology. Anovulatory bleeding can be managed with Medical treatment based on sound physiologic concepts. The goal of medical management of Anovulatory DUB is to reverse the abnormalities of endometrial growth and development associated with chronic anovulation and to induce and restore cycle and predictable menses. However it is effective in 20-30% cases only. Ovulatory DUB is most common in parous women age 30-45 years . it is associated with a series of vascular and haemostatic disturbances which contribute to increased loss of blood at menstruation. Medical treatment invariably is not effective in this group. In recent years, a number of new surgical techniques that aim to destroy the endometrium have been developed. Hystereocopic endometrial resection has been there since 1983. But alternatives were sought due to the difficulty in perfecting the techniques, the risks of fluid overload associated with the use of glycine and the higher incidence of complications by poorly trained doctors. Sharda Jain Consultant Gyanecologist,
Pushpanjali Medical Centre

For newer ablation therapies, it is essential that strict criteria for patient selection are implemented. These include. v Assessment of patient expectations. v Desire to conserve uterus. v Absence of anatomical abnormalities in the uterus including polyps and fibroids. v Uterine cavity depth not greater than 10-12 cm v Exclusion of malignancy cervical and uterine

v Absence of previous uterine surgery. Thermachoice UBT consists of a 16 cm long and 4.5 mm wide catheter with a latex balloon at its distal end, which houses the heater element. The catheter is connected to a control unit that monitors, displays and controls pre-set intrauterine balloon pressure, temperature and duration of treatment. After the balloon catheter insertion, sterile 5% dextrose is injected into the balloon until the intra-uterine pressure stabilizes between 160 and 180 mm Hg. The fluid within the balloon is heated to approximately 87o C and the treatment automatically continues at that temperature for 8 min. For safety, the device automatically deactivates if the pressure or the temperature fluctuates below or above preset values.

Thermachoice UBT is a much simpler technique. It is easy to learn; and does not require an elaborate set-up as one requires for hysteroscopic ablation technique. The complications are hardly any compared to the traditional ablation therapy using Yag laser or resectoscope. More than 100,000 women have been treated world wide with UBT without using any additional medical treatment. More than 95% of patients have remained satisfied with treatment at the 3 year followup. The ease of use, patient tolerance, demonstrated safety profile and comparable efficacy of nonhysteroscopic endometrial ablation using Theramachoice UBT system provides a good alternative to hysterectomy. The introduction of UBT to treat DUB has significantly reduced the incidence of hysterectomy in USA and in my own practice.

Secretary General
Delhi Gyanecolgist Forum

Millions of global ablation cases have been performed world wide without the use of hysteroscopy . With a view to simplifying and expediting the procedure of endometrial resection, the Uterine Balloon Therapy (UBT) procedure was introduced by Neuwirth in 19941. 31

Vol. 6, Issue 1 October - December 2007

Among women with excessive bleeding who undergo an endometrial ablation, 80-90% report significantly reduced bleeding, 25-50% develop amenorrhoea, 70-80% report markedly less pain and bleeding , over 90% are satisfied with the outcome. I have personally performed more than 300 uterine balloon therapies over a period of seven years. The ease of operation, safety of the procedure and the results are remarkable. . It is very patient friendly procedure, though not cheap if new balloon is used. Endometrial sampling with in 6 months of UBT is mandatory. We liberally used Injection Depoprovera post operatively at 3 monthly interval for first two years in perimenopasual patients , both for contraception and procure amenorrhea state. 63% of our patients had amenorrhoea. This was significantly more in cases after the age of 45 years. No patient required hysterectomy so far . One patient (aged 53 years, Principal, College of Delhi University) opted for repeat Balloon Therapy for post menopausal spotting instead of hysterectomy after 4 years of initial balloon therapy. The satisfaction level is almost 100%. The reason of very good results in my practice are strict criteria of patient selection and use of injection Depoprovera. Twenty seven patients with 1 or 2 cesarean section were not excluded in my series of UBT. It is a safe technique if proper evaluation is done. Ablation is usually performed during the early follicular phase and after the endometrium is first attenuated for 4-6 weeks prior to ablation using progestin, danazol or GbRh-a. In my practice, we have not used any such agents for endometrial priming. Eighteen patient had haemoglobin less than 5 gm%.

Cooley et al4 studied the medium (1-3 year) and long term (3-5 year) outcomes of women who had undergone UBT and found over 90% success rate after three years with out any adjuvant therapy.

factors which affect success of treatment are:

v Properly chosen cases (No fibroids, polyps or suspected malignancy). v Increased age (> 40 years) v Shorter utero cervical length v Good balloon pressure during the procedure Cooper et al5 studied the safety and effectiveness data from the FDA on Global Ablation Devices and noted that at one year follow up, Thermachoice and Novasure had the highest success rates. According to Solnik J M et als6 study, 72% of all cases of ablation in a large university hospital were being performed using Thermachoice uterine balloon. At the end of two years, 94% of the women were satisfied with this procedure. So, today UBT appears to be the chosen method for treatment of DUB. In USA the trend is emerging that few insurance company insist that Global Ablation technique to be tried prior to hysterectomy in cases of DUB. I hope it will be good reading and the benefits of this information are passed on to your patients.
Gynaecare Thermachoice Definitive treatment for he majority of women Minimally invasive No overnight stay required Most patients return to normal activity within 1 week Hormone Therapy D & C Hysterectomy

Thermachoice for high risk patients

This procedure is simply a boon for treatment of Heavy bleeding in high risk patients for surgery, such as those with morbid obesity, multiple previous abdominal surgeries, heart, lung or renal disease patients and those with bleeding disorders etc. Since this can be done under local anesthesia the risks of general anesthesia are eliminated. Also, the procedure has a minimal complication rate, is simple, fast and ideal for these patients. In my own practice, 28 cases have been done with 100% satisfactory results at 3-5 years follow up. However, it was made amply clear in counseling session that it is palliative treatment in presence of fibroid seedlings only to control bleeding and follow up is mandatory. 1. Renal failure 3 2. Morbid Obesity 7 (BMI > 40) 3. Bleeding disorders- 3 4. Leukaemia 2 5. Compromised cardiac status - 13 - LVEF < (30%) Ten of these patients had heamoglobin of less than 5 gm% as well.

References

Comparisons and outcome

An RCT conducted by Van Zon Rabelink et al2 showed that uterine thermal balloon ablation is equally effective as hysteroscopic roller ball ablation of endometrium at the end of 3 years. Barrington3 compared UBT to LNG-IUD and concluded that both are equally effective for the treatment of DUB. 32 Vol. 6, Issue 1 October - December 2007

1. Neuwirth RS, Ob Gynaecol 1994;83792-796 2. Van Zon Rabelink etal ,EUR J Obs Gynaec Biol 2004 May 10;114(1) 97-103 3. Barrington Eur J Obs Gynaec Reprod Biol 2003 May1. 108 (1) 72-4 4. Cooley etal EUR J Obs Repord Biol 2005 Aug 1; 121(2) 233-5 5. Cooper etal J Reprod Med 2004 April, 49 (4) 267-73 6. Solink J M etal Am J Obs Gynae 2005 Jul; 193 (1) 98-102

Intraoral Removal of Dermoid Cysts by Sublingual Approach

Sanjay Sood and V. K. Sapra
Three cases of submental cysts removed through the floor of mouth out of which two were young girls aged 15 and 17 years and one a boy aged 14 years. All cases were done under general anesthesia with nasotracheal intubation. Sublingual Incision was given in the mucosa of the floor of the mouth, posterior to the Submandibular duct (SMD) opening. SMD was identified and retracted anteriorly while continuing the dissection. Cyst wall identified and dissection continued. Cyst delivered out per orally and removed. Incision stitched in 2 layers after achieving the homeostasis. to the sublingual gland and is wrapped around the posterior margin of the mylohyoid muscle. It is found in the digastric triangle of the neck. Its long duct runs anteriorly on the medial surface of the sublingual gland to open into the sublingual region the lingual nerve lies between the two salivary glands, just lateral to the hyoglossus muscle. It passes beneath the submandibular duct to enter the tongue from

beneath. Advantages
Cyst delivered per orally

No external incision Less chances of injury to lingual nerve Disadvantage Exposure is limited Time taken is more

Read

Size of the cyst

Anatomical considerations

Anatomy of floor of the Mouth

Sanjay Sood ENT Consultant
Walia Nusing Home Delhi

V.K. Sapra Senior Consultant

Holy Family Hospital Delhi

The mylohyoid muscles are attached to the inner surfaces of the mandible, the hyoid bone and are also attached to each other in midline rapnae. The two muscles thus form a muscular sling which marks the floor of the oral cavity. The sublingual salivary glands lie immediately on top of the mylohyoid muscle and along the inner surface of the mandible. The submandibular salivary gland lies posterior 33

A Journal for Medical Practitioners

Vol. 6, Issue 1 October - December 2007

Unusual foreign Body in Oesophagus

Sanjay Sood A young boy aged 21 years presented to the ENT OPD with a history of difficulty in painful swallowing for 3 days. He gave a history of ingestion of mutton bone three days ago. He was taken to the emergency room on the same day and advised to report to ENT OPD. However, he did not do so as he was on a fast and hence did not feel any untoward effect.

Unusual Case of Accessory Nose

Atul Jain Nasal Proboscis (Accessory Nose) A female newborn was seen on the 19th day of birth with an accessory nose. It was excised and the Histopathoplogy showed it to be hamartomatous structure. Congenital developmental anomaly of the nose.

Fig.1

Pedunculated mass on the Rt side of the root of nose with a pit like depression. Discharge came out on pressing the Pedunculated mass.

When he did report to the ENT OPD, a repeat X-Ray neck was done which indicated a foreign body at the level of C-6 and C-7 vertebrae. Flexible oesophagoscopy was tried by the Gastroenterologist. Foreign body was visualized but could not be removed.

Management
The patient was taken up for Rigid Oesophagoscopy and foreign body removed under general anesthesia. The foreign body, a flat mutton bone with mutton fibers measuring almost 1 inch in size was removed from the oesophagus. Mild bleeding from the site was controlled and Ryles tube introduced after a check esophagoscopy. Patient was advised nil orally for 48 hours with intravenous antibiotics and fluids. He started taking oral fluids followed by semisolids and discharged from the hospital after 72 hours of the procedure.

Fig. 2 Gross Pathology

Cut section of the mass shows a tract in formation along with a pit.

Fig. 3 Histopathology

Microscopic structure show Puncta lined with epithelium & cartilage tissue also visualised

Foreign Body Removed

Fig. 4 Histopathology

Discussion
Foreign body in aero digestive tract is very common in small children and it may vary from coins, marbles, metallic foreign bodies, button cells etc. In adults common foreign bodies are fish bone, small chicken and mutton bones, needles, safety pins, dentures - partial or complete etc. Flat bones are rarely seen as foreign body in esophagus. Rigid Endoscopes still have the role to play in the era of flexible endoscopes. Earlier the foreign body is removed; the better it is for the patient as it reduces the morbidity. Endoscopy should be done in all cases of suspected foreign body with symptoms. 34 Vol. 6, Issue 1 October - December 2007

Has sebaceous glands and Hair follicle

Fig. 5

8 days after the excision of the mass with minimal scar

Pushpanjali Family Physicians Forum (PFPF)

V. K. Malhotra

6 November 2007: CME series

The CME series of the Family Physicians Forum was held on 6th November 2007. The previous session of Basic Life Support (BLS) was followed up by a session on Advanced cardiac Life Support (ALLS). The same team comprising Dr

shared his valuable experiences of role surgery in management of Acute Coronary Syndrome while Dr Gupta informed the audience about the current Indian scenario. Dr D Singhania, an eminent cardiologist associated with Pushpanjali Healthcare convened the proceedings. About 75 doctors attended the meeting. Delegates had good interactions with the speaker and the chairpersons. The meeting ended with a vote of thanks.

4 December 2007: Guest Lecture on Peripheral Vascular Disease

A guest lecture on Peripheral Vascular Disease - Critical Limb Ischemia was organized on the 4th of December, 2007 at Dr AKN Sinha Auditorium, IMA, Convention Centre, ITO, New Delhi. Dr Nishit Choksi, Chief Intervention Cardiologist from Michigan, USA delivered the talk. He covered various modalities, practiced for endovascular revascularization in Critical Limb Ischemia. Dr (Col) Kumud Rai, Sr. Vascular Surgeon from Max Devki Devi Heart & Vascular Hospital, and Prof Gurpreet Singh, Deptt. of Cardiothoracic radiology, AIIMS, chaired the session . They gave their valuable comments regarding the role of surgery and various imaging techniques used for evaluating the patterns of Critical Limb Ischemia.

Dr. Alok Basu Roy talking to Family Physicians

Alok Basu Roy and Dr Atul Gupta both Senior Anesthesiologists educated the audience about the latest ACLS recommendations issued by American Heart Association (AHA). The session was enlivened by some very interesting videos. The audience who listened with rapt attention enjoyed the interactive session enormously.

16 November 2007: Guest lecture on Acute Coronary Syndrome

A guest lecture on Acute Coronary Syndrome was organized on the 16th of November 2007 at IMA, East Delhi Bhawan. Dr SP Garg, an eminent interventional cardiologist from Detroit, USA delivered the talk. He covered all internationally recognized issues in managing Acute Coronary Syndrome.

Dr. Nishit Choksi delivering his lecture while (L To R) Dr. Praveen Gulati, Dr. Parkash Gera, Dr. (Col) Kumud Rai and Prof. Gurpreet Singh look on

V. K. Malhotra Head, Department of Family Medicine

Pushpanjali Medical Centre Delhi

(L to R) Dr. Ganesh Mani, Dr. Surinder Garg Dr. S.K. Gupta and Dr. Dhirender Singhania

Dr Praveen Gulati an eminent radiologist associated with Pushpanjali Healthcare convened the proceedings. More than 100 leading doctors from various fields of medicine from across the Delhi region attended the lecture and their participation made the session interactive. The meeting ended with a vote of thanks.

Dr GK Mani, a renowned cardiothoracic surgeon and Dr SK Gupta, senior intervention cardiologist, chaired the session. Dr Mani 37

Vol. 6, Issue 1 October - December 2007

Pushpanjali Health Care Events and Initiatives

Prestigious Appointments
Dr Vinay Aggarwal, Chairman & Managing Director, Pushpanjali Healthcare was elected as Dean, College of General Practitoners (IMA) for the year 2008. Dr S. Arul Rhaj, Director, Pushpanjali Medical

Mr. Sasidhar reaffirming commissioning of prestigious Pushpanjali Crosslay Hospitals to the guests Dr. Vinay Aggarwal Dr. S. Arul Rhaj

Publications Pvt. Ltd has been sworn in as the new president Commonwealth Medical Association for the period 2007-2010.

visitors to ensure that the final product is user friendly. Speaking on the occasion Mr. Sasidhar, Chief Architect, assured the audience of delivering PCH on schedule by April 2008.

3 November 2007 : friends of Pushpanjali dine together

Following he oard eeting f rosslay emedies t b m oC R Ltd on the 3rd of November 2007, the promoters of the 400 bedded multi specialty Pushpanjali Crosslay Hospital met over an informal dinner organized for Directors, Investors, Consultants

4 December 2007: North West University Medical Team Visit

A high power medical team from North West University, Michigan, USA visited on 4 December 2007. The team was comprising Dr. Nishit Choksi, (Chief, Interventional Cardiology); Dr. Dheeraj Mittal, (Sr. Oncologist); Dr. Faber, (Sr. Oncologist); Dr. Chrisman, (Radiation Oncologist); Dr. Kumar, (Gastroenterologist) and Dr. Geoseph Chalil. The one-day schedule of the team was very busy beginning with a breakfast meeting with Pushpanjali Healthcare Directors at the Corporate office followed by a site visit of Pushpanjali Crosslay Hospital.

(L to R) Dr. Gaurav Aggarwal, Dr. Narottam Puri and Dr. Vinay Aggarwal

and friends of Pushpanjali at Dome hall, The Ambassador Hotel. Dr. Vinay Aggarwal briefed the select gathering on the progress of the project and affirmed the commissioning of the Hospital by April 2008.

Dr Dey explaning the key features relating to Oncology

4 November 2007 : Breakfast meeting

A breakfast meeting was organized at the project site of Pushpanjali Crosslay Hospital on the morning of 4th November 2007. A large gathering of over 150 guests including select health reporters from the print and electronic media and members of Pushpanjali Healthcare were present. A sample patient room was kept ready to elicit the views and suggestions of the 3 Vol. 6, Issue 1 October - December 2007

There was a guest lecture by Dr. Nishit Choksi in the afternoon which was attended by over 100 medical practitioners. The last activity on the agenda was an informal dinner on the lush green lawns of Hotel Oberoi Maiden. The team was amazed to see the pace and quality of work for Pushpanjali Crosslay Hospital. Dr. Vinay Aggarwal and Dr. Vijay Agarwal briefed the team on the project.

16 November 2007 : Health in Color

On the spot painting competition for school children Pushpanjali Healthcare under the umbrella of Health-in-Color undertakes a variety of activities viz. Health Checkup Camps, Run for Health, Baby Shows, Painting competitions etc, as a part of its social commitment.

Fig 3

Participants having refreshments

Mr Deepak Jolly, Dr Vinay Aggarwal, Dr PD Garg and Mr Chandra, addressing the press conference

Before the event, a press conference was organized on 15th November, inviting Health Reporters from Print and Electronic Media. The press conference was attended by a large contingent of reporters. Dr Vinay Aggarwal shared his vision of building the future of the nation by investing in children. He spoke of the value of creative pursuits in the realization of dreams and the purpose of organizing a painting competition on various themes like Nasha Ek Abhishap, Health - Yoga & Meditation, Delhi - 2010, Our Heritage, Traffic discipline, Care for Elders etc. The event on the morning of 18th was inaugurated by Swami Atama Swarupji, who lit the lamp followed by an invocation prayer by the devotees of the Ashram.

An on-the-spot Painting competition for school children from over 200 schools was organized on Sunday 18th November, 2007 on the lawns of the famous Akshardham temple.

40 Vol. 6, Issue 1 October - December 2007

Speaking on the occasion, Chief Guest Mr Gyanedra Srivastava, Secretary, Dept. of Social Welfare, Government of Delhi appreciated Pushpanjalis initiative and committed unequivocal support of his Department for this noble work. Mr Deepak Jolly, Vice President, Coca Cola India Pvt. Ltd. expressed his gratitude to Pushpanjali in making his organization a partner to the event and shared the details of thiei work on Water Conservation. Mr Mohammed Akeel, President, Coca Cola (North) gave a few tips to the participating children on the role they can play in Water Conservation and the subsequent impact it would have in improving the depleted water table.

Participants in-action

Mr MM Kamath, DGM Canara Bank was all praise for Pushpanjali initiative and wished the event a grand success. The painting competition started at 9.30 am and continued till 11.30 am followed by refreshments and snacks for all the budding artists. A parallel event of Health Lectures for accompanying parents, teachers and others was organized in the Auditorium of Swaminarayan Akshardham. Dr Sharda Jain, Dr Ashok Grover and Dr Vineet Jain addressed the gathering on various health issues and gave simple to follow tips on How to Live a Health Life. There was a tremendous appreciation of the session by the guests. Leading artists of India with the support of Dr Madhumita Puri consented to select the winning entries. The winners will be recognized in a special Prize Distribution Ceremony to be held on the 15th of December 2007. In view of the very encouraging response and support from various organizations, Pushpanjali has decided to make this competition, an annual event at a much larger scale of participation.

Swami Atma Swarup ji lighting the lamp. Also seen in the picture Dr Hari Haran and Dr PD Garg

Dr PD Garg, Director Pushpanjali Healthcare shared the vision of Pushpanjali Catch them Young initiative and expressed his sincere thanks to the participating children and encouraged them to let their imagination run wild while painting on a particular theme.

15 December 2007 : Prize Distribution Ceremony

On the spot painting competition for school children On the afternoon of the 15th of December, 2007, a Prize distribution ceremony of the Painting competition for children held on Sunday 18th November, 2007 at Swaminarayan Akshardham, was organized at Dr AKN Sinha auditorium, IMA convention centre, New Delhi. Ten winners from over 1,200 entries were felicited. The function was attended by the winners, their parents and friends together with Pushpanjali Team members.

Dr Sharda Jain giving her tips to accompanying adults at How to Live a Healthy Life

Dr Atul Gupta, President, IMA-EDB blessed the children for their participation and appreciated the Health-in-Color initiative of Pushpanjali Healthcare.

Dr. Vinay Aggarwal, Dr Ajay Kumar and Dr PD Garg addressing the winners and their family members while Mr Mohit sharing his experience

41 Vol. 6, Issue 1 October - December 2007

Dr PD Garg in his welcome address reiterated Pushpanjali Healthcares commitment to promote Health for All under the banner of Health-in-Color and lauded the excellent efforts made by the children at the competition. He informed the audience that as per a feedback from Judges (renowned artists), selecting the best paintings was a very difficult task. Dr Vinay Aggarwal profusely thanked Dr Ajay Kumar, Chief Guest and President, Indian Medical Association for gracing the occasion and being with the winners. He appreciated the association of Coca Cola India, Kaleidoscope Events, IAPA, Canara Bank, Delhi Traffic Police and IMA-East Delhi Branch for their support and announced that the event would henceforth be an annual feature with the continued support from all the associates. Dr Aggarwal also expressed his gratitude for the gesture of Swami Atmaswarupji of Swaminarayan Akshardham for not only offering the premises for competition but also for blessing the event by lighting the lamp during the inaugural function. Speaking on the occasion, Chief Guest Dr Ajay Kumar spoke about karma, samskars and sangati that makes men different than other living beings and added that it was the children of the world who were symbolic of these three essentials. He congratulated the winners and appreciated the support given by their parents and teachers in grooming and cultivating their budding talent. Dr Kumar praised Dr Vinay for his pathbreaking initiatives in the field of healthcare and social service. Mr Parveen Aggarwal, Sr. Manager Coca Cola India announced that all winning entries shall be used for Coca Cola Calendar for 2009; this announcement was cheered by the gathering of elated parents and winners. Then children, 5 each from each category (Class V-VIII & Class IX XII) were honored with Trophies and cash awards. The Ceremony concluded with a lunch for all. 42 Vol. 6, Issue 1 October - December 2007

Guidelines for Submission of Manuscripts

You are invited to contribute your articles, case reports, clinical experiences and any other relevant material which is for the benefit of clinical community at large. The articles/ contribution should be sent to: The Editor in-Chief Dr. Vinay Aggarwal & The Editor Dr Ashok Grover PUSHPANJALI MEDICAL PUBLICATIONS PVT. LTD. A-14, 15, Pushpanjali, Vikas Marg Extn. Delhi 110092 E-mail : pmc_pub@hotmail.com pmc_pub@yahoo.co.in Manuscripts can be submitted by e-mail, but it is mandatory that photographs (if any) should be submitted in glossy paper by post. To maintain the uniformity the articles, authors should follow the following pattern: All Manuscripts submitted to Medi-Focus should not have been published in any form in any other publication, and become the property of the publishers. All manuscripts must be accompanied by the following written statement signed by all the authors. The undersigned author (s) certify (ies) that the article is original, is not under consideration by any other journal, and has not been previously published. All copyright ownership of the manuscript entitled (title of article) is hereby transferred to the publishers of Medi-focus. Articles will be edited for style and grammar. Technical jargon is to be kept to a minimum. American spellings are used in the Journal.

Structured Abstract. Should be a factual condensation of the entire work with objective, methods, results, conclusions and should be in one para. The abstract should state the purposes of the study or investigation, basic procedures (selection of study subjects or laboratory animal; Observational and analytical methods), main findings (giving specific data and their statistical significance, if possible), and the principal conclusion. It should emphasize new and important aspects of the study or observations. Clinical Briefs must not exceed 1000 words with one figure and 5-8 references. Text. Authors must consider and follow the format : Introduction, Material and Methods, Results, Discussion, and Conclusion (if necessary). The matter must be written in a manner which is easy to understand, and should be restricted to the topic discussed. Do not use vertical lines or underlining in the text. Acknowledgments should be placed as the last element of the text before references. Abbreviate measurements (cm, ml). Abbreviations should be used sparingly and must be preceded by the full form initially. References. In citing other work, only references consulted in the original should be included. If it is against citation by others this should also be stated. Use the Sequential numbering system. Arrange the reference list in the sequence in which the references are first cited. In the text, references cited should be superscripted and should appear on top of the line after the punctuation. Responsibility for the accuracy and completeness of references lies with the author. References should not exceed 15-20 in number. The Journal follows the Vancouver system of references. References should be numbered and listed consecutively in the order in which they are first cited in the text. Tables should be identified in the text by superior Arabic numerals. The full list of references at the end of the paper should include : names and initials of all authors (unless more than 6, when only the first 3 are given followed by et al); the title of the paper; the journal title abbreviated according to the style of Index Medicus; year of publication; volume number; first and last page numbers. References of books should

Preparation of Manuscripts
Format. The manuscript must not exceed 1012 pages typed in double space (including 1520 references). Number all pages in sequence, beginning with the title page. Submit a copy of all elements arranged as follows: Title Page. This should contain the title of the manuscript (5-6 words title) the names of all authors, and their affiliations, a short title (not more than 20 letters to be used as running head) and at the bottom of the page, institution where the work has been carried out, and the address for all correspondence and reprints, including Fax, Phone and E-mail. 43 Vol. 6, Issue 1 October - December 2007

give the book title, place of publication, publisher and year; those of multiple authorship should also include the chapter title, first and last page numbers, and names and initials of editors. 1. Mehta MN, Mehta JN. Serum lipids and ABO blood groups in cord blood of neonates. Indian J Pediatr 1984; 51 : 30-43. 2. Smith GDL. Chronic Ear Disease. Edinburgh; Churchill Livingstone, 1980 : 78-81. 3. Malhotra KC. Medicogenetic problems of Indian tribes. In Verma IC, ed. Medical Genetics in India. Vol. 2., Pondicherry; Auroma Enterprises, 1978; 51-55. Papers accepted but not yet published should be included in the references followed by In press. Those in preparation, personal communications and unpublished observations should be referred to as such in the text only. For more detailed information about the Vancouver system, authors should consult Uniform requirements for manuscripts submitted to biomedical journals (Br Med J. 1982; 284 : 1766-70). Legends. A descriptive legend must accompany each illustration and must define all abbreviations used therein. Illustrations and graphs. Submit glossy black and white photographs. The cost reproduction of colour photographs will be borne entirely by the author. Number all illustrations with Arabic numericals (1, 2).

Tables. These must be self-explanatory. The data must be clearly organized and should supplement and not duplicate the text. Explanatory matter should be given as footnotes. Statistical analyses used must be appropriate. Each table must have a title and should be numbered with Arabic numericals (1, 2).

Manuscript Submission Checklist

1. Three copies of manuscript in hard copy 2. Name and address correspondence. of author responsible for

3. Structured Abstract (150-200 words) & 3-5 key words. 4. References, cited consecutively in the text. 5. Three glossy prints for illustrations. 6. Documentation of permission to reuse any previously published material. 7. Covering letter, including statement of originality and signifying approval of final copy by all authors. 8. Upon final acceptance of the manuscript, a CD disk in MS Word should be submitted. The disk should be labeled with the title of article, file name and version used and must contain the final revised manuscript material.

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44 Vol. 6, Issue 1 October - December 2007

45 Vol. 6, Issue 1 October - December 2007

RNI No. DELENG/2002/9685