Back to Alma Mater

Dear Friends,
After the hectic grill of the theory exams.,the break was a welcome change.I hope this has adequately rejuvenated our souls.And we are ready to face the firing line of Viva voce.
As I never tire of quoting the famous English Actor Sir Michael Caine "Practice is hard work..Performance is relaxation", let us all strive to practice very hard for our practs so as the quote goes the performance will be a breeze.
I had a word with Rakesh the other day.He was of the opinion all of you can spare a day or two with prior notice in the next week for ENT revision practicals.So please decide and let me know in advance so that I too can prepare myself adequately.TC.
Amol.

Surgery for Malignant Otitis Externa...

Surgery for Malignant Otitis Externa was used with contentious results in the pre Antibiotic era.Nowadays it is reserved only for cases where medical treatment doesn't arrest the disease leading to complications.
Otherwise it is definitely contraindicated as it is believed to facilitate the spread of the disease.
Personal experience about surgery is disappointing...of the 3 patients being treated now one was subjected to surgery.Lt Ear mastoidectomy...Patient developed HYPOGLOSSAL PALSY and LT. VOCAL CORD PALSY after 2 weeks .Uploading the VDO of the IDL of the said patient.

Note the following things while watching the VDO
1) Deviation of the tongue to LEFT on portrusion
suggesting Lt. Hypoglossal Palsy.
2) Pooling of saliva and food particles in the Lt.
PYRIFORM FOSSA.
3) LT. VOCAL CORD PALSY causing phonatory
gap.
SO THE TAKE HOME MESSAGE..?TREAT THE CONDITION AGGRESSIVELY MEDICALLY ....RESERVE SURGERY FOR THE ADVANCED CASES..

Malignant Otitis Externa...

Dear Friends,
Medical treatment mainly consisits of Antibiotics.New protocol contains fourth and third generation Cephalosporins....Cefepime which is a fourth generation Cephalosporin and has got Gram Positive and Gram Negative Coverage and needs to be given IV or IM for 6 to 12 weeks.Ceftazidime is a third generation Cephalosporin which is Beta Lactamase stable and has got good coverage against Pseudomonas.Needs to be given IV or IM 8 to 12 hrly for 6 to 12 weeks.Piperacillin is also given.
Oral Ciprofloxacillin given for 6 to 8 weeks show good results in milder cases.
Besides local treatment contains of Dry Aural Toilet,Antibiotic Ear Drops.Acetic Acid Drops are also used.
CONTROL OF DIABETES IS VERY IMPORTANT.

Malignant Otitis Externa....

Dear Friends,
Continuing our discussion of Malignant Otitis Externa, we will appreciate unless a late stage of complications is reached ( which is pretty late in the course of the disease) there are hardly any definitive symptoms or signs of Malignant Otitis Externa which are specific for the disease.Mind it even the HPE Report just talks about chronic granulation tissue.
In such a scenario,Radionucleotide Scanning (Scintigraphy) helps in confirming the diagnosis.Technecium-99 bone scan shows increased uptake in the involved area - it is suggestive of increased bony metabolism..so a very sensitive test.The only problem is that the uptake remains high even after the disease is responding positively to the treatment.Here another radionucleotide ....Gallium-67 is very useful..its uptake is dependent on the response to the treatment.So repeated Gallium scan can be done to monitor the effectiveness to the treatment.In absence of the availability of these facilities, even an ESR is a good indicator of the resolution of the disease.

Addressing the Misnomer...

Dear Rakesh,Signseeker and Swati,
First and foremost,Thank you very much for a prompt and involved response.Indeed MALIGNANT is a misnomer...probably it reflects the high incidence of mortality attendant with the condition in the pre antobiotic era.bu8t better antibiotics the incidence has come down from 20% to 01%.It is also called as NECROTIZING OTITIS EXTERNA because it is known to cause bone destruction.
The disease is classically known to spread along the floor of EAC and involve the cranial nerves.The first nerve to be affected is the 7th Cranial Nerve.Later on, the lower nerves are affected.... 9th,10th,11th and 12th.So one needs to look out for any cranial nerve palsy which implies an aggravation of the disease. In fact the cause of mortality is usually intracranial complication/s and aspiration pneumonitis.

Answer to the Quiz.

Dear Swati,
It is the Right Ear.That is the answer to first question.I would like to believe that the condition is NOT ACUTE SUPPURATIVE OTITIS MEDIA but it is SECRETORY OTITIS MEDIA.Patient named CB presented with c/o blocking sensation in the ear following cold.PAIN as we always claim, is conspicous but its absence.The TM as per my clinical experience is not bulging,congested but retracted....Subtle indicators of the same are 1) A Prominent LATERAL PROCESS OF MALLEUS; 2)The UMBO is not exactly in the center but it is foreshortened; 3)The CONE OF LIGHT is not reaching upto the Annulus; 4) The General Appearance of the TM is dull.....All these points go in favour of SOM.....Can be confirmed by checking the mobility of the TM (Valsulva or Siegelisation).
In Absence of any sign of infection in the focal region/s,my treatment would essentially include Decongestant,decongestant Nasal Drops and rarely oral Steroids (if not contraindicated).

Weekend Quiz...

1) Which ear is this?
2 ) What is the pathology?
3 ) What is the Treatment?

QUIZ...

Dear Friends,
Let us play a small quiz.It goes like this ...I will tell you the h/o the patient and show you his findings...then we answer a few questions..Let us start in right earnest...
Patient GP,69 years of age came with h/o severe earache and discharge Lt. Ear.Examination revealed granulations in the floor of the EAC and also a CP.Biopsy of the granulations showed chronic granulation tissue.Patient is a known diabetic....initially uncontrolled now better with proper medications.After reviewing the photo and VDO of the same let us answer a few questions.

LEVEL 1 -
1) What is the probable diagnosis?
2) What is the causative oeganism?

LEVEL 2 -
1) What is the line of Treatment?
2) What are the complications one needs to look
out for?


HINTS...
1) The name for this condition was first coined
by Chandler in 1968.
2) It is one of the 2 Famous MISNOMERS in
ENT.

BEST OF LUCK.......

Comments...

Dear All,
Have just read the comments. Would just like to say a big Thank you to deven,ROCKY,signseeker and Anmol for the flattering comments and encouragement.
Well signseeker, there doesn't seem to be a definite well documented time frame for the symptoms you mentioned to develop..I couldn't get hold of any reference for the same.Nor is there any parameter to objectively judge the size of the hypertrophied adenoids.Suffice to say that enlarged adenoids impinging on the nasopharyngeal airway are potential precursors to the said conditions.
Swati,I would just say this much...God willing...Insha Allah.

Another ASOM..

Dear Friends,
Long time since a new Post.I bit busy.Anyways,discussing another case of ASOM with otomycosis.The impatient purist may complain that we are seeing cases of ASOM only but what do I do with this season of heavy rains that seems to be the flavour of the day.(Sorry for the inappropriate simile.
Anyway,this patient RK 52 years of age came with complain of pain and discharge Rt. Ear.Patient had h/o cold preceding that.No definite h/o cleaning the ear or instilling oil.She doesn't vouch for not blowing the nose.
The ear finding shows congested TM and e/o otomycosis.Not surprisingly patient also has a DNS to Rt.

AA for follow up..

Remember our patient AA who came with ASOM Lt. Ear who responded well to the Medical Treatment.But then developed a small CP in the same ear.
Well the patient came today for F/U and her CP has healed but now there is SOM which is manifest by AIR BUBBLES behind an intact TM.
Sorry for the poor quality of the photo..in fact it is overexposed.
Also uploading the VDO of Siegelisation of the same ear.

Today examined a patient AA,30 Years of age .Had come 4 days ago with classical presentation of ASOM.Now patient better but complaining of blocking sensation in Lt. ear.Not surprising when we examine the ear- shows a small pinhole perforation - STAGE OF PERFORATION.The other ear on Siegelisation revealed a thin Drum with altered mobility..Initially gave Amoxy-Clav and other supportive treatment.Now put on Cefpodoxime.
Uploading the Snapshot of the Lt. Ear and VDO of the Siegelistion of the Rt. Ear.
Incidentally the patient has a Deviation of the Septum to the LEFT.

faces

Adenoid Photo

A photo of the nasopharynx in the lateral view showing the adenoid mass.

Of Empty Classrooms & Making a Difference..

Dear Friends,
Taking this opportunity of the Auspicious Day of Guru Pournima I intend to shed my garb of procastrination and laziness and be active on the blog.
Now it would be anybody's case to question this peculiarly pessimistic title of the initial blog.
But I would unabashedly admit this (the one in the accompanying picture) is the exact kind of response I got to one of my lectures which did 2 things to me.For one,it burst my inflated ego as an accomplished teacher and secondly it set me thinking....Where can I go an extra mile to generate interest in the students so that they take an additional step and make it a satisfying and memorable journey for all of us.
And then it dawned upon me to start a blog where besides being a totally interactive modality, it gives more time and freedom to share my clinical experiences with you.
"DIFFERENCE" here basically implies making a difference to me as a teacher....learning from my mistakes and your queries... and to you as students ...getting to see more of clinical cases in a visual form.
So hoping to see you regularly here...
Signing out for now...
Dr. Amol S. Khale.

Of Empty Classrooms and Making