RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES ,KARNATAKA
BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the Candidate and Address(in block letters) / DR. SIDDHARTH NIRWAN
ROOM 104,KIMS MEN’S HOSTEL,
BANASHANKARI II STAGE ,
BENGULURU-560070.
2 / Name of the Institute / KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES, BANASHANKARI 2ND STAGE,
BENGULURU - 560070.
3 / Course of Study and Subject / M.S. E.N.T.
4 / Date of Admission to the Course / 03 .MAY.2010.
5 / Title of the Topic / A STUDY OF HEARING IMPROVEMENT AFTER TYMPANOPLASTY BY MEANS OF PURE TONE AUDIOMETRY
6 / Brief resume of the intended work:
6.1. Need for the Study
Among the various causes of ear diseases, Chronic Suppurative Otitis
Media is the major disorder in our country and else where in the world.
Several therapeutic practices and regimen have evolved and tried out to treat
CSOM, but even the the surgical management –Tympanoplasty –has
remained the ultimate choice . To determine the degree of success or lack of
it , in restoration of hearing following Tympanoplasty , several
evaluationary techniques are in vogue to assess the hearing capabilities , both
pre & post operative hearing .
6.2. Review of Literature :
Chronic suppurative otitis media (CSOM) – is defined as chronic inflammation of mucoperiosteal lining of middle earcleft characterized by intermittent or persistent ,purulent discharge through a perforated tympanic membrane and can be associated with cholesteatoma1.
The most common bacterial isolate of CSOM is Pseudomonas aeruginosa . Other isolates include aerobic organisms ,such as enteric gram-negative
bacilli,Staphylococcus aureus,streptococci,Kleibsella pneumonia, and
Hemophilus influenza.Anaerobic isolates ,associated with a malodorous otorrhea ,include Peptostreptococcus and Bacteriodes species.
Clinically it is divided into two types :
1. Tubotymanic type – Also called safe or benign type ;it involves anteroinferior part of middleear cleft and is associated with a central perforation.There is no risk of complications.
2. Atticoantral type – Also called unsafe or dangerous type; it involves posterosuperior part of the cleft ,and is associated with an attic or a marginal perforation . the disease is often associated with cholesteatoma ,granulations or osteitis . Risk of complications is high in this variety.
The overall prevalence of CSOM is 4.1 percent(with 3.1 percent having unilateral and 1.0 percent having bilateral disease).In india studies report a prevalence ranging from 4.9 to 10.4 percent .It is the most important cause of deafness in india and occupies a considerable amount of clinic and operating time of otolaryngologists. Prevalence in rural areas is double that of in urban areas attributing it to unmanaged URI ,consequent upon the low level of literacy
& lack of health consciousness, along with contributing factors like malnutrition & swimming in dirty ponds.
Several therapeutic practices and regimen have evolved and tried out to treat CSOM, amongst the surgical management –Tympanoplasty –has remained the
ultimate choice.
The term Tympanoplasty has been defined by the American academy Of
Ophathamolgy And Otolaryngology committee on conservation of hearing
as ‘ A procedure to eradicate disease in the middle ear and to reconstruct the
hearing mechanism, with or without tympanic membrane grafting’.
Classification of Tympanoplasty by WullStein & Zollner is as follows :
Type 1 - Reconstruction of TM ( OC intact and mobile )
Type 2 – Malleus handle absent , reconstruction of TM over the malleus remnant
and long process of incus
Type 3 – Malleus and incus absent , , reconstruction of TM over an intact and mobile stapes ( Myringostapediopexy ) with stapes acting as a columella .
Type 4 – Mobile stapes foot plate , exteriorized with reconstructionof TM as a round window baffle .
Type 5 – Stapes fixed. Fenestration done in the lateral semicircularcanal and TM reconstructed over the fenestration
An audiometer is an electronic device which produces pure tones, the intensity of which can be increased or decreased in 5 dB steps. Usually air conduction thresholds are measured for tones of 125,250,500,1000,2000,4000 and 8000 Hz and bone conduction thresholds for 250,500,1000,2000 and 4000 Hz.The amount of intensity that has to be raised above the normal level is a measure of degree of hearing impairement at that frequency.It is plotted in the form of a graph called Audiogram.The threshold of bone conduction is a measure of cochlear function .The difference in thresholds of air and bone conduction (A-B gap) is a measure of degree of the degree of conductive deafness.
From the air conduction threshold levels the deafness can be graded into several categories like mild,moderate severe. the accepted grading is as follows –
0 to 25 dB – Normal hearing level
26 to 40 dB – mild deafness
41 to 55 dB – moderate deafness
56 to 70 dB –severe deafness
71 to 90 dB – very severe deafness
above 90 dB – profound deafness
The aims of performing pure tone audiometry are to ascertain –
1. Whether the subject has any definite auditory disorder.
2. Whether the hearing loss is conductive/sensory neuronal hearing loss/mixed.
3. If sensory neuronal hearing loss, then whether it is cochlear or retrocochlear.
4. The degree of hearing dysfunction.
6.3. Objectives of study:
1. Selection of patients of CSOM with conductive deafness to undergo
Tympanoplasty procedure.
2. The various Tympanoplasty methods used for the treatment of hearing
loss in cases of CSOM .
3. To document the hearing improvement after various types of
Tympanoplasty surgery in cases of CSOM.
7 / Materials and Methods:
7.1 Sources of Data:
Patients presenting to department of ENT,KIMS Hospital ,Benguluru
Study design : Prospective Interventional Study
Sample size : 50
Sample design : Purposive Sampling
Study place : Dept. of ENT, KIMS Hospital Benguluru.
Study period : December 2010 to May 2012
7.2. Method of collection of Data :
50 patients presenting to Department of ENT with CSOM to undergo tympanoplasty fulfilling the inclusion / exclusion criteria shall be selected for study.
Written informed consent shall be taken after explaining the merits / complications of tympanoplasty .All the necessary blood & radiological investigations shall be carried out for the purpose of surgery .Pre operative & Post operative audiogram 3 months following surgey shall be done & compared to assess the level of gain achieved after tympanoplasty.
7.3. Inclusion criteria:
1. All cases of CSOM –inactive type- unilateral and bilateral in either sexes- and of ages 15 to 50 years with documented hearing loss
7.4. Exclusion criteria:
1. Actively discharging ears
2.CSOM with complications
3. CSOM with Mixed/Sensory Neural Hearing Loss
4.Patient’s general condition not permitting surgery
7.5. Does the study require any investigations or intervention to be conducted on patients or other humans or animals? If so, describe briefly.
Pure tone audiometry to be done before and three months after
tympanoplsty
It does not require any animal studies.
7.6. Has ethical clearance obtained from your institution for this study and required investigations in this study.
Yes.
8 / List of References:
1. Slattery WH. Pathology and Clinical Course of Inflammatory Diseases of The Middle Ear. In : Glasscock ME, Gulya AJ, editors. Surgery of The Ear.5th Ed. ;2007 . p. 422 – 434.
2. Dhingra PL. Diseases of Ear,Nose and Throat.4th Ed. Elsevier:Noida(India);2007. p. 66 – 74.
3. Browning GS ,Merchant SN. Chronic otitis media . In :Michael Gleeson,editors. Scott and Brown’s Otorhinolaryngology Head and Neck Surgery. Volume 3,7th Ed. Hodder Arnold ;2008. p. 3395 – 3445.
4. Verma AK, Vohra A . Epidemiology of chronic suppurative otitis media and deafness in rural areas and developing an intervention strategy.Indian Journal of Pediatrics: 1995:62.p. 725 - 729 .
5. Biswas A.Clinical Audio- Vestibulometry For Otologists and Neurologists.3rd Ed. Bhalani Publishing House;2002.p. 1 – 23.
6. A,Tarique A.A Study of Surgical Management of CSOM With Cholesteatoma And Its Outcome. Indian Journal of Otolayngology and Head and Neck Surgery . Vol. 62 (5).April - June 2010 .p.171 – 176.
7. Tonni D,Barazizani MG.Single Stage Canal Wall Down Tympanoplasty -
Long Term Results and Prognostic Factors.Annals of Otology,Rhinology and Laryngology.Vol.119(5) –May 2010.p. 304 – 312
Signature of the candidate
10 / Remarks of the guide: The study shall be helpful in evaluating outcomes of tympanoplasty and in comparing results of various techniques to develop a better method of surgery.
11 / Name and Designation of:
11.1. Guide
11.2. Signature
11.3. Co-Guide
11.4. Signature
11.3. Head of Department
11.4. Signature / Dr.K.G. Somshekar,
Professor,
Department Of ENT,
Kempegowda Institute of Medical Sciences, Benguluru.
Dr B.V. Chandregowda
Professor & Head
Department of ENT
Kempegowda Institute of Medical Sciences,Benguluru.
12 / 12.1. Remarks of the chairman and principal
12.2. Signature