Thursday, December 24, 2020

How to disclose pin hole perforation in a discharging ear through valsal...

A person presents to you with a discharging ear but on otoscopic examination, No perforation is found despite meticulous suction cleaning. In such cases, applying Valsalva Maneuver (Forced expiration against closed Nose and mouth helps to pop middle ear with air), helps to disclose very tiny perforation ( like a pin hole). This technique is useful as this help us to distinguish Outer ear infection from middle ear infection and changes the whole scenario in diagnosis. Even in normal cases, seeing the ear drum moving outward in response to Valsalva maneuver help to establish normal Eustachian tube function Eustachian tube connects back of the nose to middle ear and that's how it equilibrizes middle ear pressure with atmospheric pressure. sometimes infection in middle ear lead to high pressure. Pus formation under pressure needs and outlet to come out of ear. This pus make very tiny temporary perforation which comes out only when middle ear pressure is high that typically happens during mid night. This tiny perforation or pin hole perforation closes as soon as pressure in middle down comes down. ENT Surgeon is in dilemna to distinguish between suppurative middle ear infection or Otomycosis of outer ear canal alone though both conditions may exist. If there is no middle ear infection, then treatment is lot easier and can only be managed with ear drops only. Middle ear infection means antibiotics and nose opening drops have to be continued for long. #Pinholeperforation #discharging ear #CSOM #ASOM #Valsalva Maneuvre #Suppurative otitis media Dr Ajay Jain, MS (PGI Chd), DNB ENT and Head & Neck Surgery ENT Clinic: Shop No:1,2,3 DDA Market-1, G-block, Preet Vihar, Delhi-92. Landmark: Enter G-block opposite Metro pillar 102 Appointments: 9871166370. Website: Map: Https:// Other Videos Care of discharging ears (CSOM)-बहते हुए कानों की देखभाल Must see video before ear surgery -कान के ऑपरेशन से पहले कम से कम एक बार इस वीडियो को देखें

Sunday, December 20, 2020

Which Ear drop should I put in ear? कान में कौन सी बूंदें डालनी चाहिए

Ear drops are often purchased without prescription to use in various condition of the ear like pain, infection, wax and fungus. कान की बूंदों को अक्सर कान की विभिन्न स्थिति जैसे दर्द, संक्रमण, मोम और कवक में उपयोग करने के लिए पर्चे के बिना खरीदा जाता है। This is not right way to approach. Ideally, it should be seen by Ear, Nose, Throat specialist and then prescribed. Still, If you don't have access to ENT doctor, then few ear drops can really help. Then how to choose ear drops? Dr. Ajay Jain, who is a senior ENT Surgeon practicing at New Delhi, India for last 20 years, explains about rational behind using ear drops in simple Hindi language. Wax is often the case for sudden ear blockage where person don't have any issue for long and especially develops after taking bath, swimming or after using ear buds or Q tips. It is essential in these cases to soften the wax first so that it can easily be removed by ENT specialist. In such cases over the counter drops which often has some kind of `wax` mentioned in trade name is the best. When water going from outside is an issue and there have not been any history of ear discharge or cold, then most likely, fungus in the ear or Otomycosis is an issue. then Clotrimazole based ear drops work best. If there is an issue with recurrent ear discharge, then combination of antibiotics, anti fungals and steroid based ear drops work best but the choice of antibiotics is tricky and few antibiotic ear drops can also cause Ototoxicity with decreased hearing.

Friday, December 4, 2020

What are those bumps behind tongue? जीभ के पीछे वे लाल दाने क्या हैं ?

People often visit ENT Doctors worrying about red bumps behind tongue? वे जीभ के पीछे लाल दाने की उत्पत्ति के बारे में पूछते हैं ? I wish to tell them the bumps lined in form of V shape are circumvallate papillae that is normal taste buds. They are useful normal thing. sometimes these buds become swollen because of local irritation from tongue cleaner or food allergy or smoking. The area behind these bumps is base of tongue which is blind area to most physician and only ENT doctors can see and reassure patients that there is nothing to fear about over tongue.

Wednesday, December 2, 2020

Ringing Sensation In Ear during Coronavirus Pandemic

It has been reported that tinnitus incidence has increased during Coronovirus pandemic ( read during lockdown or covid infections). This is true as we see tinnitus or ringing sounds in ear are felt more during silence. With more machine silent during Covid, more people are coming with these complaints. Most of the cases have some hearing loss at some of the frequencies and an audiometry test is must for work up of cases. High frequency hearing loss is often seen because of noise pollution.

Monday, November 9, 2020

Dr. Ajay Jain's ENT Clinic


Endoscopy Suite

Address : Shop number 1,2,3 DDA Market-1, G-block, Preet Vihar, Vikas Marg, Delhi-92. 

Landmark : Enter G-Block of Preet Vihar adjacent to Lajwab Banquet hall or Shree Rathnam.


Monday to Friday 9-1 PM
Saturday 5-8 PM
Sunday : off

(Prior appointment mandatory)

Fees : Valid for 3 days

Rs. 800 for first time new patients
Rs. 600 for returning old patients after long time.
Rs. 500 for follow up within a month.

For Appointments:

Call or Whatsapp on 9871166370


1. Parking- Usually not a issue.
2. Toilets- Available
3. Drinking water- Available 
4. Refreshments-Available in DDA Mkt.
5. ATM- 100m away
6. Metro station- Walking distance- 300 meters. 4 mins walk. 
7. Payments: Any UPI App or Paytm or Cash

Sunday, August 30, 2020

Speech Delay in Children

Prevalence: 13 to 27% of school children may have speech disorders.

( JIPMER and Trivendaram study)

In India, Autism has increased  to 8/1000 children.  and such Autistic child have often speech delay and speech therapy is not a option for such children.

Auditory stimulation (like anklets of mothers are missing and joint families are converting to nuclear family and lullabies from grand parents are missing) has become less.

Increased screen time has influence on speech development.

Speech is the motor act of communicating by articulating verbal expression.

Language is a system of symbols that individuals use for communication based on their culture.

Communication of ideas, information, thoughts and feelings between senders and receivers.

It could be verbal or non verbal.

Facial expression/ gesture/ postures/ eye contact/ head & body movement does not require speech or language.

Thursday, August 6, 2020

Water sounds in my ear

Water sound could be because of some fluid in outer or middle ear or because of a process known as Tinnitus happening due to inner ear perception of unknown sounds.

Let's put this way. If your outer ear has some fluid entered during swimming or bath or else because of discharge coming from middle ear from ear drum perforation, All this will give water sounds in ear.

Tinnitus happens usually when you have some hearing loss and in absence of external masking sounds, Cochlea picks up sounds of its own outer hair cells as some whistling or bird chirping or machine sounds especially in a quiet environment.

Dr. Ajay Jain

Consultant Otolaryngologist

Wednesday, June 17, 2020

Role of Zinc supplements during Coronavirus pandemic

There is no direct evidence for ZINC in COVID-19. All evidence is general.

1. Zinc has context dependent effects on NF-kB. It can inhibit NF-kB in some scenarios, and activate the same in other context. - Net effect in vivo on NF-kB – not clear.

2. Zinc is recommended in common colds, there are references that Zn reduces inflammatory cytokines. This could definitely help in controling cytokine storms.

3. Zinc supplementation of zinc increases NK cells.

4. Zinc deficiency decreases T lymphocyte number.

5. Zinc inhibits SHP, thus increasing signaling from TCR.

6. Zinc binds IKKB and reduces NF-kB activation, with beneficial effects in sepsis.

Relevant ref -

Self-Care for Common Colds: The Pivotal Role of Vitamin D, Vitamin C, Zinc, and Echinacea in Three Main Immune Interactive Clusters (Physical Barriers, Innate and Adaptive Immunity) Involved during an Episode of Common Colds-Practical Advice on Dosages and on the Time to Take These Nutrients/Botanicals in order to Prevent or Treat Common Colds.
Regulation of T cell receptor signaling by activation-induced zinc influx

In summary, Zinc deficiency can make Covid19 worse but supplementing it above and beyond the daily requirement is unlikely to do much.
Regular supplement doses cannot hurt.
(As posted by Dr. Ravi on our whatsapp group of PGIMER Alumni) 

No evidence about zinc. In Covid pandemic. I recall  Prof Mehra  talking about George shambough  that these days he is selling zinc for COM. This was during 1985 86.  No harm though cap zevit containing 22.5 mg zinc twice a day could not be an unsafe bet (Posted by my teacher n mentor Prof: Naresh Kumar Panda on our WhatsApp group) 

Sunday, April 5, 2020

Traumatic ear drum perforation

Ear drum injury is a very common event in my practice which is completely preventable. After injury, people do foolish things to complicate the matter.
ENT Surgeon describes simple Do and don'ts to facilitate natural healing of eardrum. The author also explains about medico-legal aspect of eardrum perforation. Slap by husband to wife is very common in the Indian scenario. Wife often hides this thing and this is also covered.

Tuesday, March 31, 2020

Masks and Respirators

In this era of Corona panic and fear, there are lot of confusion and misconceptions existing regarding the use of mask, not only amongst the laypersons but also among the health care providers.
On one hand masks are not available for the risk group while on the other hand, who are not at risk, spending unnecessary money and energy to procure these masks.
This provoke me to write this blog, hope this would improve the understanding of the various types of commonly used masks and clarify the proper indications of use.

Q1 ... What are the common types of masks
1 Cloth mask
2 Surgical mask

Q2... What are the Respirators
N- 95
N- 99
N- 100
are the respirators

Q3.. what is the difference between mask and respirator
Mask has a loose fit, it doesn't seal nose and mouth snugly.
During respiration air moves along the edges of the mask, while respirator has a tight seal and most of the time air passes only through its material after filtration.

Q4... Are all respirator masks are same
No, respirators are graded according to their filtration efficiency.
According to the used filter type
According to the type of materials used 
And additional features
They are of different types.

Q5... what is the efficiency grading
According to the efficiency of filtration these are usually graded as-
95, 99 and 100
This means these respirator masks are capable of traping 95%, 99% and 99.9% of particles, smaller up to the 0.3-micron size.
This grading can also be done as
P1 (FFP1) - 80%
P2 (FFP2) - 95%
P3 (FFP3) - 99.95%
Filtration efficiency.

Q.6.. what is the N, R or P meaning written over the mask
N - not oil-proof
R- oil resistant
P- oil-proof
(Eg. N 95 is not oil proof).

Q7. Few respirator masks have valve, what is that.
That valve is nothing but a simple exhalation port with one-way valve mechanism, it reduces the effort of expiration, reduce heat inside the mask, dissipate humidity and reduce co2 the amount of from the dead space of mask.

Q.8. When to use surgical masks.
Ans... Surgical mask or procedure mask is the most common mask used by health workers. 
It is not designed to protect the wearer from inhaling the air born bacteria and viruses.
 It is used to block only large-particle droplets, splashes, sprays or splatter.
It also reduces the exposure of the wearer's saliva and respiratory secretions to others. Surgical mask also reminds wearer not to touch their mouth/nose which could otherwise transfer virus/bacteria after having touched a contaminated surface.

Q9... what is the filtration capacity of surgical mask
Ans... It can vary between 10-90% according to the manufacturer.

Q..10.. how one can assure about the quality of the mask
Mask should be certified by the
NIOSH (National institute for occupational safety and health)
NPPTL (National personal protective technology laboratory)

Q.11... Does the cloth mask effective?
The cloth is a woven material thus pore size is bigger than a surgical mask which is made up of non-wooven polypropylene material thus cloth mask is less effective than surgical mask in terms of filtration efficiency.

Q..12 ... Does extra layer improve the efficacy of cloth mask
Ans.. No, it's not advisable. Each extra layer adds only 2% of extra protection on the cost of comfort.

Q.13... Can surgical/cloth mask be used routinely
Yes these can be used routinely. 
Few studies done on normal population concluded that the use of simple mask can decrease the incidence of flu up to 75%.
Few east asian countries following this practice of routine use of mask.

Q.14.. Can mask be reused?
Ans. -Cloth mask can be reused after washing
- Surgical mask should be discarded after single use or after soiled
- Respirator mask should be discarded when resistance of breathing get increased or get solied.
Viruses/bacterias can grow and flourish inside the reused mask.

Q..15.. what are the WHO recommendations for using masks?
- For the normal population, any type of mask is not required, maintaining the social distance and hand hygiene are the sufficient.
- Sick person should wear surgical mask
- Any person who is taking care of sick person should also wear the surgical mask.
- N 95 mask should be used by the person who is potential to get expose with the respiratory secretions of the infected patient eg. During the Endotracheal intubation, CPR, Ventilation, Bronchoscopy and Tracheostomy etc.

Please don't create panic and use this precious commodity judiciously. 

Stay safe...

Wednesday, March 25, 2020

Online ENT Consultation during Coronavirus Pandemic and Lockdown in Delhi.

We are in a situation we have never faced before. Though it looks like everything has been put on pause, we know that medical problems don't wait and we need help from the world we are trying to avoid. 

Few problems can be discussed with the doctor through phone or video consultation. Online consultation has it's own big limitations as clinical examination is not possible. Therefore, the relief from the clinical problem may not be as expected in some cases where clinical examination plays a major role in diagnosis. Nevertheless, we strive to achieve the best possible given the constraints imposed upon us.  

Keeping this idea in mind, Online consultation with Dr. Ajay Jain is offered 


The outcome of the online consultation has no bearing on the fees paid (Non-refundable).                    Please use your own discretion to understand the shortcomings of online consultation. 

Timings: 10-1 PM and 5-7 PM

Follow the steps.

1. Ask for an appointment by WhatsApp on 9871166370
2. Fees:  Rs. 500 

BHIM / UPI /Paytm



Bank Transfer

Account Number: 50200032402894
IFSC: HDFC0001561

3. You will receive a call at the appointed time from the doctor. If needed, face to face Video consultation can be done to see any visible finding. 

Wednesday, January 22, 2020

Preventive role of MMR and BCG vaccine against Nobel Coronavirus infection

Forward on many medical groups 👇. Just for your information.

Dr Ramesh Gulla, MS

The China born novel Corona virus is devastating the world by killing people in thousands and ruining the the world economies like never before. We still do not have an effective medicine nor do we have a novel vaccine. The medical world was not prepared for such an unprecedented attack on the global health when China announced its arrival on the last day of the last year to the unassuming world. Our own chloroquin unfortunately is far from of any help to stop the deaths. Quite a few new molecules invented by global pharma giants are falling short of expectation and novel corona vaccines are not expected before next year. Actually any new vaccine takes not less than 4 years to hit the market. Doctors are seen sitting helpless, afraid as they are, keeping themselves away from even mundane clinical practice and surgeries. Many large hospitals have shut down to an unimaginable misery of even non covid patients. Unfortunately there seems to be no end to the global pandemic. Amongst all this disheartening facts that we are witnessing there now appears a hope like a ray of light at the end of a tunnel.
The novel Corona virus causes the dreaded disease called Covid19. Out of every hundred infected patients about 7 require hospitalisation for treatment in ICU or to be on oxygen or, even worse, a ventilator. In all, a three of them may die adding to hundreds of deaths nationwide everyday. In this grim situation it appears now that an affordable and quick saviour is already in our hands! Unbelievable but true!

The new Corona virus that escaped from China to haunt the world actually shares its structural resemblance to rubella virus by upto 30% as found in the virology study at Cambridge University (1). The best thing is we already have a means of preventing this rubella disease. And that is the MMR, a combined vaccine for 3 childhood diseases Measles, Mumps and, the more important, Rubella. The antibodies that develop in response to MMR vaccine can also act against the new corona virus preventing a full blown Covid19 fatal stage of the disease. Though the similarity is not more than 30% between the two viruses, rubella and corona, the protective benefit can be near complete. Hence, when exposed to the new Corona virus the body will still get infected no doubt , in the form of a mild cold and fever or nothing at all, but the rubella antibodies prevent its progression into Covid19 disease and its severe complications and death. So the MMR can be a very effective vaccine against the new Covid 19 disease and it's benefits could be impressively lifesaving not less than any expected promises of newer corona vaccines still in pipe line.

Enough evidence is already there to corraborate for this unbelievable finding (2)

1. The death rate in corona pandemic for children is surprisingly very low world over as compared to adults. For, the children do receive MMR vaccine! The rubella antibodies they develop protect them.
2. Covid death rate is very high in older, 50+, people world over. Because, not surprisingly, this age group never received the vaccine. The MMR came into wide spread use only 50 yrs back.
3. Where adults also received the vaccine in their recent past the covid death rates are low in those parts of the world irrespective of any racial difference as seen in Hong Kong, South Korea, Madagascar and US sailors.
4. A country with 2.7 crore population, Madagascar witnessed just 16 covid deaths for having vaccinated about 70 lakh people last year over and above their routine childhood MMR vaccination schedule. This recent MMR dose of vaccine refreshed immune memory and helped battle out the Corona virus and avoided Covid deaths.
5. Hong Kong witnessed just 4 covid deaths as compared to about 30,000 deaths in New York with similar large, denser population. They have an extended MMR immunisation programme including many adults.
6. There are less than 300 covid deaths in South Korea as there is mandatory armed service for adults where they receive 2 MMR vaccines at recruitement.e
7. In American Samoa islands there are very few covid deaths as they recived MMR last year.
8. In the offshore American ship Roosewelt more than a thousamd became corona positive, but only 1 died of covid. For, all of them had received MMR vaccine at recruitment.
9. In contrast, in countries where covid deaths are at top 5, none had MMR programmes for adults in near past.
10. Iran did vaccinate the people with MMR extensively but with only single dose, as against the required two, and could not prevent covid deaths.
11. The novel Corona virus shares its structural similarities by 20% with Measles virus and 30% with Rubella virus.
12. The antibodies produced against novel Corona virus in the body are similar to that produced by MMR vaccine as seen in cross reactions at antibody tests.
13. The pattern of M and G type of antibodies produced in the body in the course of Covid19 disease is similar to that seen in a secondary rubella infection: mild M and very high G.
14. Because of these antibodies, a previous infection from the Corona virus could protect people from rubella, and vice versa.
15. Waning of MMR immunity over years after vaccination occurs because of decreasing levels of antibodies and interferons (3). This immunity needs to be tuned up by fresh vaccination.
16.Covid mortality is very low (0.05%) in children and adolescents because of MMR immunity. But a slightly higher(4.5%) mortality rate in adults below 50 suggests waning status of MMR immunity.
17. Another older vaccine BCG, used against tuberculosis (TB), also confers protection against Covid deaths as seen in countries such as Japan ( compared to other G7 countries), where it is part of universal vaccination (4). BCG is already a part of universal immunization programme in India since decades. This has kept our Covid death rates lower than the Western countries! BCG provides nonspecific but protective immunity against a variety of respiratory diseases.
The above body of corroborative evidence proves fairly convincingly that the good old MMR vaccine has prevented covid deaths in adults and of course in children world over.
After administration of MMR vaccine the body produces antibodies. The antigenicity of rubella virus is committed to the memory of body's immune apparatus. Later when novel Corona virus infects the body, enough antibodies are again produced early on to tame the virus preventing it's complications like respiratory or cardiac failure. There will be, therefore, no need for any scary ICU admissions or requirement of expensive ventilators. This way hundreds of thousands of deaths can be prevented and that too at a very low cost.
This wonderful solution for the dreaded new disease is not drawn from any rat-rabbit or for that matter man-monkey type laboratory research but by just corraborating widely available information to a desperately helpless global shame.
I resorted to injecting the wonder into myself in a show of my enormous confidence in my medical researh as an answer to fix an ultra-modern menacing challenge. I thought, I being a doctor myself, it drives home the point best. I have already vaccinated over a hundred willing adults in my practice at Athani, Karnataka, including many doctor colleagues, their families and their staff, and none, as expected, had any side effects.
MMR is the only scientific preventive tool to prevent Covid deaths apart from face mask, social distancing, hand washing and lock downs. MMR vaccine could be far more effective than other trivials like herbal drinks or homeopath's pills or even the yoga.
The cold chain maintained MMR vaccine is in an injection form of only half ml causing hardly any pain on administration. Two such doses are to be taken a month apart. All Children and adults can have it, dose being the same for both, half ml only.
In all only a quarter of our population needs to be vaccinated to bring down the reproduction rate (R) of the virus to below 1 when the chain of spread gets broken completely. We already have running mandatory MMR vaccination programme for children in India only since last 3 yrs and now it needs to include adults as well to reach one fourth of our total population. This will also prevent second and any later waves of the pandemic in coming years as is warned by the WHO.
The high placed agencies like the ICMR may happen to be misleading the government for being biased heavily towards clinical trials to establish proof. But I am sure this is not the time to be wasted on a very time consuming clinical trials which take months together to complete by which time we might have lost thousands of unimmunised lives. The ICMR may even advise to wait for the arrival of new brand proprietary corona vaccines under the mesmerising infuence of vaccine industrial sharks. I we stay away from such fast tracked inadequately tested for late side effects vaccines however efficacious they may be, from getting into our system before demonstrating absolutely sure of their safety profile over years of clinical observation. The vaccine industry seems to be happily in a hurry abetted by political compulsions. On the other hand MMR is a time tested vaccine in clinical use for over 5 decades and is quite reliable and is bereft of any late serious side effects.
In times of crisis, such as this pandemic, even a small piece of evidence is enough to be proactive and act with full commitment to save ourselves first.
In this endeavour I along with my wife Dr Prabha, a paediatrician herself, along with our 3 children received the MMR vaccine by ourselves in our own hospital in a press meet and thus became the world's first previleged family to ever have got vaccinated against the dreaded Covid19. In doing that I repurposed the MMR vaccine against Covid19 disease, a first in the world.
It is an off the shelf injection and does not even require any governmental or ICMR-like institutional recommendation. MMR is in Indian Pharmacopeia (IP) and can be administered by any registered medical practitioner. Those who have already received MMR, (very very unlikely in India, and not to be confused with DPT !) children including, must also get it now to boost immunity further to fight Covid19.    
 This does not require any fresh clinical trials. We know that during a pandemic a trial is not an absolute necessity. Hydroxychloroquin was advised by ICMR without backing from any clinical trials. Adult MMR vaccine programme is actually being practised in many armed forces like that of South Korea and the US and also in general populations in 25 other countries, from Bhutan to Belarus, to name a few. WHO recommends it for all adult health care workers as also international travellers.
All patients requiring indoor treatment, surgeries, procedures, chemotherapy, radiation therapy and dialyses as well as out door chronic cardiac and respiratory  patients should be manadated a compulsory vaccination.
There is no harm even if Covid positive person also receives it, as it only benefits him by boosting the native immunity. 
Let us kick start the idea with a slogan:
To kick Covid out, get 2 shots MMR.

Dr Ramesh Gulla, MS
2454, Gulla Hospital, Athani
Karnataka 591304
(1) Homologous protein domain in SARS-CoV-2 and measles, mumps and rubella viruses: preliminary evidence that MMR vaccine might provide protection  COVID-19. A Young, et al Preprint: https//
(2) MMR vaccine appears to confer strong protection from COVID-19: Few deaths from SARS-CoV-2 in highly vaccinated population. J E Gold et al :  posted on 29.3.2020 v7.3
(3). Characterization of humoral and cellular immunity to rubella vaccine for distinct cohorts. N Lembert et al: Immunol Res 2014; 58(1) 1-8.
(4) Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study. Aaron Miller, Mac Josh Reandelar,  Kimberly Fasciglione, Violeta Roumenova, Yan Li, Gonzalo H Otazu; doi:
(5) WHO : worldometre; accessed on 26th June, 20

Laser excision of Leukoplakia of the tongue

This case is doing well in follow up. She underwent Laser Excision of the tongue lesion. 
Laser is just a precise cutting tool. Tongue normally bleeds heavily so Laser sometimes creates problem as this alone is insufficient to control the bleeding. Laser is better for smaller lesions and conventional cautery is needed to control the bleeding. 

Message from Dr Ajay Jain

Dear Friends, I hope this message finds you in good health and high spirits. Welcome to my blog, a space dedicated to educating my patients ...