Tuesday, November 30, 2010

Tracheostomy Care


  1. Three things are needed for tracheostomy tube change : Proper light, good suction, proper position of patient. if possible make the patient lie on a bed with cushion under the shoulder so that front of neck gets exposed adequately. keep a good light above the stoma and keep suction ready. before taking the tube out, keep the new tube ready with the jelly smeared over its cuff. Remove the tube gently following the curvature and then inspect the stoma. Do not make haste here and do not delay the insertion of new tube unnecessarily also. put the new tube under vision and not just blindly.
  2. Ideally tracheostomy tube should be changed daily. because it avoid formation of a layer above the tube also known as SUPRASTOMAL LEDGE that otherwise may delay the decannulation process. 
  3. No need to inflate the cuff unless patient is aspirating (i.e. liquids are going to windpipe from the mouth) or patient is unconscious. If cuff has to be inflated, then its pressure has to be kept below 20 mmHg otherwise the wall of windpipe may be damaged because of continuous pressure.
  4. In country like ours, it's not practical to ask for purchase of new tube every time. Better, reuse the tube after thoroughly washing it running water and then keeping it in Cidex or boiling it. Portex tube may last many weeks with this.
  5. It's better to show it to ENT Specialist in case of tight fitting, bleeding from the stoma.


You can post your question or suggestion in comment section regarding tracheostomy.

Dr. Ajay Jain

Delhi Medical Council Certificate

Hearing aids and how to get one

Hearing aids and how to get one

A hearing aid is a device that is used to increase the loudness of the sound reaching the ear of a person with a hearing difficulty. Modern hearing aids consist of three basic electronic components: a microphone, an amplifier and a loudspeaker.

The most common types of hearing aids are those that are worn in or behind the ear, but there are others, such as implantable hearing aids, which can be used in certain situations (see below).

Externally worn hearing aids

The most commonly used type of aid is the behind-the-ear hearing aid, where all the electronic components are contained in a skin-colored plastic case that sits behind the ear.

Cosmetically more popular is the in-the-ear hearing aid, which is a smaller, more compact device worn in the ear canal, but it is inappropriate for people with severe deafness because it is not powerful enough to compensate for their hearing loss. It is not suitable for those with some loss of manual dexterity, because the control switches are quite small.

Even smaller is the completely-in-the-canal hearing aid, which is virtually invisible when worn. Again, because of its small size, its casing is too small to be able to hold a very powerful amplifier and so it is only useful for mild hearing losses.

For people with very severe deafness, the electronic components needed to amplify sounds can become too bulky to fit into small hearing aids and a separate body-worn hearing aid with larger switches would be most suitable. However, with the advances in hearing aid technology this type of hearing aid is now much less common.

People with a conductive hearing loss may benefit from a device which is held in place behind the ear with a headband or 'Alice band'. This is known as a bone conduction hearing aid.

People tend to benefit from this type of hearing aid if they have problems in the ear canal or middle ear, for example because of recurrent ear infections, previous surgery, or anatomical abnormalities such that they are unable to wear conventional hearing aids. Bone conduction aids can work very well, but can be quite bulky and obvious, and a more sophisticated type of bone conduction aid has been developed. This is the bone anchored hearing aid (see below).

Analogue or digital hearing aids?

There has been a lot written in the media recently about digital hearing aids. The ‘digital’ part of the hearing aid implies that these types of aids are more sensitive and better at restoring hearing than the older type of aids, and this is often, but not always, the case.

Digital hearing aids process sound in a fundamentally different way to analogue aids, by dividing up the sound into 'packets' and then processing them. This means that it is possible for digital aids to be more selective in filtering out irritating background noise, but no hearing aid, digital or analogue is capable of only amplifying the sounds that you want to hear.

Implantable hearing devices

Cochlear implant

People who have such a severe deafness that they hardly derive any benefit from conventional hearing aids (i.e. those people with a profound sensorineural hearing loss) may benefit from a cochlear implant.
In this type of implantable hearing aid a wire electrode is surgically inserted into the inner ear (the cochlea). Intense speech and hearing therapy is required often for several years following this operation. Cochlear implants can be used for children and adults.

Bone-anchored hearing aid

For people with a conductive hearing loss, or for people who are unable to wear conventional hearing aids because of previous ear surgery or ear malformation, the bone-anchored hearing aid is proving to be an excellent alternative.

As mentioned above, bone conducting ‘Alice bands’ are bulky and can be quite sore to wear, because they have to press hard on the skin behind the ear to transmit vibrations to the skull. The BAHA consists of a small screw that is implanted in the bone behind the ear during a short operation (usually, but not always, under general anaesthetic).

After the area has healed, a small case containing all the electronic components of the hearing aid can be easily clipped on and off. The hearing aid gives excellent clarity of hearing and leaves the ear canal open so that patients who have been troubled by constant ear infections when using other types of hearing aids find they usually clear up very quickly.

Who can benefit from a hearing aid?

In theory, any person who has hearing loss irrespective of age or sex will benefit. However, you must have some residual hearing, however little, in order to benefit from a hearing aid. If no sound whatsoever is being heard, a cochlear implant may be indicated.

How can you obtain a hearing aid?

Hearing Aid will be provided by your Audiologist. Remember, Digital Hearing Aids are programmed based device and it needs to be adjusted according to your needs. So, the person from you are purchasing your hearing aid, should be the one, who is qualified to do so, who can give you services also later. Most of the Hearing Aid comes with Package in form of free service for first two or three years.

Tuesday, November 9, 2010

Septal hematoma, child

Bilateral enlarged submandibular glands-because of Tuberculosis

Pseudocyst of auricle


Profile: Diabetic, wearing helmet often
Pseudocyst of auricle in a diabetic patient and wearing helmet often.



The layers of pinna gets separated because of wear and tear and a fluid comes in.
Since this has no true capsule, so this is known as psuedocyst.
Various treatments have been described for this condition
  1. Surgical excision-which is technically challenging but can be attempted.
  2. Repeated aspiration and bandage. (Too slow and may not be rewarding)
  3. Wide bore needle aspiration and quilting suturing for 10 days under antibiotic coverage (my preferred technique)
after aspiration of cyst, the cyst is made to remain collapsed by applying buttons on both sides fixed by trans pinna suturing.

Add caption


Feel free to ask questions or put any comments.


Removing maggots from a 4 yr girl's ear

This come as bolt from blue. The thing I hated most removing Maggots from a human body as I have done from tracheostomy stoma in my residency days came as surprise when I removed them from discharging ear. I was stunned when I saw teeming head of maggots in Otoscope. I love ENT but these things were difficult for me to remove. 




Monday, November 1, 2010

Microlaryngoscopy-Surgery of vocal cords for hoarseness of voice

CONSENT INFORMATION – MICROLARYNGOSCOPY




PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Microlaryngoscopy. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

 What is “Microlaryngoscopy”?

Laryngoscopy is a procedure that allows your physician to look at your larynx (voice box) using a laryngoscope. "Micro" refers to getting a very close (magnified) view of the area to see every tiny detail. This can be done with a special telescope or operating microscope.


What are the indications for Microlaryngoscopy?

Microlaryngoscopy is especially useful for conditions in which evaluation or treatment of the vocal cords or immediate surrounding airway needs to be performed.

Nerve or structural injury
Voice problems, such as a hoarse voice, weak voice or no voice
Throat pain
Bloodstained saliva or sputum
Difficulty in swallowing
A sensation of a lump in the throat
Injuries to the throat
Narrowing of the throat
Obstructions or masses in the throat
 
We can perform some surgical procedures during the microlaryngoscopy, these include:
 
Removing foreign objects
Taking a biopsy, which is a small tissue sample
Removing polyps from the vocal cords
Performing laser treatment, which uses a tiny intense, focused beam of light to cut tissue.
What happens before the procedure?
When microlaryngoscopy is performed in the operating room, it is usually done with the patient asleep (general anesthesia). You should tell your anesthesiologists of any problems you have had in the past or any concerns you have about having anesthesia. In particular, if you have had trouble with nausea or vomiting in the past, your anesthesiologist may be able to adjust your medications to decrease the chance of stomach acid irritating your vocal folds as it comes back up.


What is involved with Microlaryngoscopy?

With the head tilted back (to make the airway as straight as possible), a laryngoscope is placed in the mouth to look at the larynx (voice box). It also pushes the tongue out of the way. If the patient is old enough to have upper teeth, they are protected with a tooth guard. The involved area is then visualized and the view is magnified (enlarged) using an endoscope (telescope). This is usually attached to a small video camera.
Procedures that may be performed during microlaryngoscopy are numerous, and include removal of polyps or masses on or around the vocal cords or to correct deformities of the vocal cords themselves. These procedures involve the use of special tools and techniques, and may include use of the CO2 laser.
The length of surgery depends on the reason the procedure is being performed (to simply evaluate the area, or to actually remove bumps or masses). The procedure usually does not last more than an hour.

How will I feel after the operation?

After microlaryngoscopy you may find that your throat hurts. This is because of the metal tubes that are passed through your throat to examine the voice box. Any discomfort settles quickly with simple painkillers and usually only lasts a day or two.

Some patients feel their neck is slightly stiff after the operation. If you have a history of neck problems, you should inform the surgeon about this before your operation.
You can usually eat and drink later the same day. You should be able to use your voice as normal after the procedure. However, if the surgeon has taken a biopsy from your voice box, he may advise you to rest your voice for a short period.

When can I go home?

Often you can go home the same day as the operation, as long as you have someone with you. Depending on how you feel afterwards, you may need to stay overnight for observation.
You may be advised to stay off work for a few days to rest your throat, depending on your job.
General Risks of having the procedure:

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure?

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:

(a) Injury to the lips, teeth, gums or tongue. Dental injury may result in teeth being chipped, broken or dislodged. Crowns may also be dislodged.
(b) Swelling of the tissues of the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth and support with breathing until the swelling resolves. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(c) Bleeding into the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth, until the bleeding is controlled. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(d) Collapsed lung (Pneumothorax). A small hole in the surface of the lung. Air then leaks from the lung, causing the lung to collapse. The lung may come back up itself, or a tube may need to be put into the chest through the skin to remove the air from around the lung. This may need a longer hospital stay.
(e) Voice change. The larynx (voice box) or the nerves controlling the larynx may be injured by the instruments used for the microlaryngoscopy. Voice change may also result from excision or biopsy of the abnormal tissue in the larynx. The voice change may be persistent and not respond to further treatment.
(f) Persistence or recurrence of the original disease may occur.
(g) Undiagnosed neck/spinal problems.

Consent Acknowledgement:

The doctor has explained my medical condition and the proposed surgical procedure.
I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
I have been given an Anesthesia Informed Consent Form.
I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
My questions and concerns have been discussed and answered to my satisfaction.
I understand that the procedure may include a blood / blood product transfusion.
I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements,

I REQUEST TO HAVE THE PROCEDURE.

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………

Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………




INFORMED CONSENT: MICROLARYNGOSCOPY

A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
 
See patient information sheet- “Microlaryngoscopy” for more

C.ANAESTHETIC

Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE

While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:

(a) Injury to the lips, teeth, gums or tongue. Dental injury may result in teeth being chipped, broken or dislodged. Crowns may also be dislodged.
(b) Swelling of the tissues of the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth and support with breathing until the swelling resolves. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(c) Bleeding into the airway. This may lead to difficulty breathing requiring the insertion of a breathing tube through the mouth, until the bleeding is controlled. Rarely, a tracheostomy (insertion of a breathing tube through the neck) may be required.
(d) Collapsed lung (Pneumothorax). A small hole in the surface of the lung. Air then leaks from the lung, causing the lung to collapse. The lung may come back up itself, or a tube may need to be put into the chest through the skin to remove the air from around the lung. This may need a longer hospital stay.
(e) Voice change. The larynx (voice box) or the nerves controlling the larynx may be injured by the instruments used for the microlaryngoscopy. Voice change may also result from excision or biopsy of the abnormal tissue in the larynx. The voice change may be persistent and not respond to further treatment.
(f) Persistence or recurrence of the original disease may occur.
(g) Undiagnosed neck/spinal problems.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND

The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.

The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT

I acknowledge that:
 
The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
I have been given a Patient Information Sheet on Anesthesia.
I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
I understand that the procedure may include a blood transfusion.
I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.
On the basis of the above statements,

I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….
Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES

INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
The patient ‘s condition
Need for treatment
The procedure and the risks
Relevant treatment options and their risks
Likely consequences if those risks occur
The significant risks and problems specific to this patient
I have given the Patient/ Guardian an opportunity to:
Ask questions about any of the above matters
Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.
Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………

Areas near the clinic

The areas which are within 2 km of clinic

IP Extension
Mandawali
Madhu Vihar
Chander Vihar
Vinod Nagar
Hasanpur
Patparganj Industrial area
Preet Vihar
Swasthya Vihar
Nirman Vihar
Laxmi Nagar
Shakarpur
Guru Angad Nagar
Arjun Nagar
Chander Nagar
Krishna Nagar
Hargobind enclave
New Defence Enclave
Narwana Road
Jagat Puri
Madhuban


The areas which are within 5 km of clinic

Mayur Vihar
Khichripur
Mother Dairy
Ganesh Nagar
Pandav Nagar
Preet Vihar
Madhuban
Shakarpur
Laxmi Nagar,
Kaushambhi
Vaishali
Gagan vihar
Hargobind Enclave
Anand Vihar
Pushpanjali enclave
Yojana Vihar
Krishna Nagar
Shahdara
Vishwas Nagar
Patparganj
Kondli
Kalyanpuri
Trilokpuri
Akshardham
Swasthya vihar
shankar vihar
karkardooma
Indirapuram
Jagriti Enclave
Vasundhara
Surajmal Vihar
Vigyan Vihar
Gandhi Nagar
Geeta colony
Noida
Khora Colony
Ghazipur
 Bahubali Enclave
Shastri Park