Otolaryngology Pg Guide Book 45p3a

OTOLARYNGOLOGY P.G GUIDE BOOK

Balasubramanian Thiagarajan

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About the Author

Professor Balasubramanian Thiagarajan is currently Professor of Otolaryngology Stanley Medical College Chennai

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About the Book This e book was authored to serve as a guide to post graduate students pursuing otolaryngology degree / diploma under The Tamilnadu Dr MGR Medical University. This e book describes what a student of otolaryngology should do to complete the course and come out with flying colors. This book helps the fresh student of otolaryngology to understand the Tamilnadu MGR Medical University regulations, syllabus, examination pattern etc. This book discusses the various aspects of dissertation preparation. Documentation is one of the neglected aspect as far as our country is concerned. This book stresses the importance of documentation of medical records. This book discusses the various documentation procedures which can be followed by a post graduate student during the course.

This book is the first of its kind authored with an intention of helping the postgraduate student in taking those baby steps, which is important before the actual sprint.

Comment any can be mailed to the author at: [email protected]

Otolaryngology PG guide book by Otolaryngology online is licensed under a Creative Commons Attribution-Non Commercial-No Derivs 3.0 Unported License.

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Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Introduction - 4 Duties and Responsibilities – 6 Syllabus – 9 Clinical examination pattern – 14 Theory examination pattern for post graduate degree – 16 Theory examination pattern for post graduate diploma – 18 Outpatient instruments – 19 Books and journals – 24 Online resources – 25 Soft skills development for post graduates – 26 Clinical examination techniques in otolaryngology - 27 Dissertation – 54 Art of choosing dissertation topic – 56 Aims of dissertation – 60 Documentation - 69

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Introduction

Changing face of otolaryngology: Otolaryngology as a specialty has under gone tremendous changes during the past 20 years. Lots of innovative equipment have been added to the armamentarium of the otolaryngologist. This has emboldened of the specialty to walk through unchartered territories. Adjacent anatomical areas like orbit and skull base are no more rigid boundaries for the otolaryngologist. Now more and more head and neck oncological surgeries are being performed by otolaryngologists. Skull base has successfully been breached. Studies reveal more and more otolaryngologists are taking up thyroid surgeries. In a nutshell this is no more a specialty confined only to tonsil / nasal septal surgeries. Boundaries cease to exist.

Equipment have played a vital role in changing the profile of an otolaryngologist. The advent of nasal endoscope should be considered to be a milestone of sorts. This tool has taken an otolaryngologist to the next level. Gone are the days of blind antral lavage. Now every individual para nasal sinus ostium can be visualized. Nasal endoscope has forced anatomists to revisit the topic "Anatomy of the lateral nasal wall". A large volume of literature has been generated on this very topic. Hither to unheard like "Mucociliary clearance mechanism" is being used more and more these days.

High definition Endoscopes and Angled Endoscopes provide the a clear image and has the ability to look around corners. It is not an understatement to say that every nook and corner of the nasal cavity is within the reach of Rhinologist now.

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Image showing a nasal endoscope

Major advantage the present generation otolaryngologists have is the falling price of nasal endoscopes. With the mandatory Royalty period with Hopkin's University over, the manufacturers don’t have to pay royalty money to the university and they readily on the concession to the customer. As with any other surgical specialty it is a steep learning curve to climb for the budding otolaryngologist. With practice and diligence nothing is impossible. This book is meant to give insight on various aspects of otolaryngology to the incoming post graduate student. Even though otolaryngology is an undergraduate subject, getting oriented in examination of ear / nose / throat takes some time for the student. According to the author's rough estimate it takes about a month for a student to get trained in using head mirror and Bull's lamp to examine a patient. A post graduate student during the period of study should acquire skills in managing patients with various otolaryngological problems. In Indian scenario there are no simulated exercises for otolaryngology students. They are simply pushed into the sea with instructions on how to swim. More over the standard of training also varies from institution to institution. Now is the time for the MCI to standardize post graduate training so that all our students will get uniform training where ever they study.

The following surgeries which were not part of otolaryngologist's domain some years back is very much in their domain now. They are:

1. 2. 3. 4.

Endoscopic dacryocysto rhinostomy Endoscopic orbital decompression Optic nerve decompression Endoscopic Hypophysectomy Drtbalu’s otolaryngology online

6 5. Thyroid surgeries

Usually it takes some time for an otolaryngologist to master all the skills of the trade. During the post graduate period they should strive to achieve competence in basic otolaryngological surgical procedures which include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Cold blade tonsillectomy and adenoidectomy Tracheostomy Diagnostic nasal endoscopy Nasal septal surgical procedures Endoscopic sinus surgeries Mastoidectomy Tympanoplasty Caldwel Luc procedure Excision of benign lesions from nasal cavity Endoscopic dacryocystorhinostomy Removal of foreign body from ears / nose / throat Bronchoscopy Oesophagoscopy Microlaryngeal surgical procedures Laryngofissure surgery

Even though this list is no means complete but every postgraduate student should attempt to master these procedures during their training period. Usually they have 2 / 3 years of study period at their disposal depending on whether they pursue Masters degree / Diploma in otolaryngology.

Duties and Responsibilities During the first year of study a post graduate student is posted as Junior Resident in otolaryngology. During the 2nd and 3rd year of their course they are posted as senior Residents. Duties and responsibilities of Junior Residents:

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7 1. They are primarily responsible for patient care under guidance from senior residents, Assistant Professors and Professor. 2. They should serve as first point of whenever queries are raised pertaining to patient care. 3. In the face of persistence of symptoms / non alleviation of symptoms Assistant Professors and Professors come into the picture 4. Junior Residents should render outpatient care, In patient care and emergency care.

During the first 6 months of their Junior Resident period a post graduate student is under direct supervision of senior resident. When they are adequately trained they will go to a stage of indirect supervision with help available if necessary immediately. Every Junior Resident is expected to reach the stage of working under indirect supervision from the 7th month of their post graduate training period.

Duties and responsibilities of Senior Residents: 1. Guiding Junior residents in patient care 2. Direct supervision of Junior Resident 3. Performing otolaryngological surgical procedures under the guidance of consultant 4. Active and direct involvement in patient care

Post graduate student pursuing masters degree in otolaryngology will be trained as per Tamilnadu Dr MGR Medical University Guidelines in: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Basics of General Surgery Basics of Plastic surgery Basics of Neuro surgery Audiological Medicine Neuro otology Paediatric otolaryngology Otolaryngology Head and neck surgery Bronchology Oesophagology

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They will be posted in various departments for training purposes as given below:

For MS (ENT): First year:

E.N.T. …..

6 Months

General Surgery …..

1 Month

Anaesthesia …..

1 Month

Plastic Surgery …..

1 Month

Cardio Thoracic Surgery …..

1 Month

Neuro Surgery …..

1 Month

Oral Facio Maxillary Surgery …..

1 Month --------------

Total

12 Months

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9 Second Year:

Audiology and Neurotology …..

2 Months

Paediatric Otolaryngology …..

2 Months

Anaesthesia …..

1 Month

Radiology and Radiotherapy …..

1 Month

ENT including upper aerodigestice tract endoscopy …..

6 Months -------------

Total

12 Months

Third Year:

Entire period in otolaryngology

At the end of the First year of post graduation students of both diploma and masters in otolaryngology will have to take up Applied basic sciences and audiology examination (Theory).

Syllabus for Basic sciences Examination for Diploma and MS (ENT) Students:

Anatomy, Physiology, Biochemistry, Pathology and Bacteriology related to E.N.T. Specialty: Anatomy: 1. Pre-natal and Post-natal development of the ear: Internal ear Drtbalu’s otolaryngology online

10 Fistula ante fenestrum Air spaces and lining membrane The Ossicles Stapes External Ear Pneumatisation of the Mastoid Process 2. Anatomy of temporal bone: Squamous portion Mastoid portion Petrous portion Tympanic portion 3. Anatomy of the ear: External ear Middle ear Internal ear 4. Anatomy of cranial nerves: with particular reference to facial and auditory nerves 5. Osteology of the cranial bones: Venous sinuses The brain Anatomy of nose and paranasal sinuses: Prenatal and post – natal The external nose The nasal cavity The paranasal sinuses Nasal Mucous membrane Blood supply and nerve supply Anatomy of the Pharynx and Nose: Drtbalu’s otolaryngology online

11 Development The tonsil Lymphoid tissue Functions Anatomy of the larynx: Prenatal and postnatal development of the larynx Difference between child and adult larynx Muscles and cartilages of larynx Anatomy of trachea, bronchi and Oesophagus The long and Broncho-pulmonary segments The Mediastinum The visceral arches, their derivatives developmental defects Development of face Bacteriology Syllabus 1. Elementary Bacteriology pertaining to: 1. Cornye Bacterium Diphtheria 2. Staphylo, Strepto, Pneumococci 3. Neisseria group 4. Proteus group 5. Vincents and Fusiform Bacillus 2. Fungus: Aspergillus group Rhinosporidiosis etc. 3. Viruses: Adeno virus, Cosake virus 4. Immunology Biochemistry syllabus: 1. Biochemistry of body fluids and C.S.F 2. Electrolyte balance and maintenance of PH of Blood 3. Biochemical changes in upper airway obstruction and after tracheostomy. Drtbalu’s otolaryngology online

12 4. Biochemistry of labyrinthine fluids and its variations in diseases. Pharmacology syllabus: 1. Pharmacology of sympathomimetic and their uses in Otolaryngology 2. Local anaesthetics and analgesics: Merits and Demerits 3. Chemotherapy of malignant conditions 4. Cortico Steroids and its usage in Otolaryngology 5. Antibiotics – recent trends Pathology Syllabus: General Pathology – Inflammations, Necrosis, Gangrene Repair of wounds. Shock – Pathology Granulomas including midline granulomas Thrombosis and Embolism Tumors – Aetiology, Classification, Pathology & Histopathology Special Pathology: Surgical pathology of Mouth, Jaw, Neck Salivary glands and Oesophagus. Ear: Pathology of the external ear. Histopathology of the drum membrane Inflammations of the middle ear Inflammation of Mastoid Inflammation of the Petrous bone Histopathology of the inner ear Chronic inflammatory changes in the temporal bone Neoplasms of the ear Nose: Pathology of the Nose. Chronic specific infections of the Nose and paranasal sinuses Drtbalu’s otolaryngology online

13 (Pre Nasal). Cysts and tumours of the nose and accessary sinuses. Pharynx and Larynx: Oral and Pharyngeal pathology as manifestations of Constitutional diseases. Pathology of the Nasopharynx larynx. Lungs swellings of tumefactions of the neck. Clinical Pathology in its relationship to otolaryngology. Physiology Syllabus: Regulation of water balance and composition of body fluids by the kidney. Coagulation of blood. Physiology of special senses: Taste. Smell. Heating. Physiology of respiration including its mechanism and regulation. Physiology of deglutition. Maintenance of balance of body. Physiology of nose and paranasal sinuses. Carriage of Oxygen by the blood. Carbon dioxide transport in the body

Audiology syllabus: Physiology of hearing and balance: Hearing including physics of sound. Sound production. Physics of sound. Drtbalu’s otolaryngology online

14 The vibration. The decibel. The material source. Wave motion in a material medium. Propagation. Complex sound various and phase difference. Sound conduction. Vestibular function. Semicircular canals. The otolith organs.

Clinical Examination pattern for Masters degree in otolaryngology of Tamilnadu Dr MGR Medical University POST GRADUATE M.S. DEGREE COURSE IN E.N.T. - BRANCH IV SCHEME OF EXAMINATION CLINICAL EXAMINATION Total Marks: 200 No. of Cases Marks 1. Long Case One =

80

2. Short Case Three = 120 (3x40 marks) ----------Total

200 -----------

VIVA VOCE EXAMINATIONS Total Marks: 100 1. OSCE

=

50

2. Log Book (Evaluation & Questioning) = 20 Drtbalu’s otolaryngology online

15 3. Orals on Recent Advances =

30 ------------

Total

100 ------------

1. OSCE (Objective Structural Clinical Examination) Based on Objective Structured Exam Stations: --------------------------------------------------------------------------------------------------S.No. Stations Marks --------------------------------------------------------------------------------------------------1. Pathology

05

2. Microbiology 05 3. Specimen – Dry – 5 (numbers) 05 4. Specimen – Wet – 5(numbers) 05 5. Operative Surgery 05 6. Instruments – 5 (numbers) 05 7. X-ray – 5 / Laptop video 05 8. CT/MRI – 5 (numbers) 05 9. Audiogram 05 10. Recent advances in ENT 05 (BERA/OAE/VEMP/CHAMP/ IMPEDENCE) Drtbalu’s otolaryngology online

16 ----------50 ----------Note: Serial No. 1 to 10 should be common to all the candidates appearing on that day. 2. Log Book (Evaluation and Questioning) Marks : 20 3. Oral on Recent Advances Marks : 30 THESIS Marks : 100 Minimum for : Clinical Examination

VIVA

Thesis

Maximum

200

100

100

Minimum

100

50

50

Candidate must each component separately. Even if a candidate fails in one component, the candidate is deemed to fail in the whole examination.

Theory Examination pattern for students pursuing Masters degree in otolaryngology

At the end of first year of their course they need to sit for an university examination which will be on applied basic sciences and Basic General Surgery. This theory paper will be for 100 marks totally out of which securing 50 marks is a must for ing the examination.

Paper I: Question paper pattern for basic sciences examination:

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17 Entire paper will be in short notes pattern. Questions will be from: Anatomy = 4 questions x 5 = 20 marks Physiology = 4 questions x 5 = 20 marks Biochemistry = 3 questions x 5 = 15 marks Pharmacology = 3 questions x 5 = 15 marks Pathology = 3 questions x 5 = 15 marks Microbiology = 3 questions x 5 = 15 marks

Total = 100 marks

At the end of the course a post graduate student will take up 4 papers in theory examination.

Paper II: ENT including audiology and Neuro otology Paper III: ENT including head and neck Oncology Paper IV: Recent advances in ENT Medicine and surgery as applied to ENT Paper V: Rhinology, Laryngology and recent advances in ENT

Each of these question papers will be of 3 hours duration and 100 marks maximum. A student will have to secure 50% in each of these papers for securing in the theory examination.

Question paper blue print: Essay questions = 2 Marks = 15 each

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18 Short notes = 10 Marks = 7 each Total = 100 marks

Theory exam pattern for students taking up diploma course in otolaryngology. At the end of I year of the diploma program a student will have to take up a theory exam covering basic topics in otolaryngology. This paper will be for 100 marks out of which a candidate will have to secure 50 to the examination.

On completion of second year of diploma program a student will have to appear for theory examination comprising of two papers.

Paper II - This includes otolaryngology including audiology and neuro-otology

Paper III - This paper includes otolaryngology including head and neck oncology and Endoscopy

Each of these papers is for 100 marks out of which a candidate will have to separately score 50% in each paper to the examination.

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s a Post graduate student is supposed to maintain Log book: All post graduate students are expected to maintain a log book. This is nothing but a daily journal written by them. These log books need to be signed by Assistant professors and Professors periodically. Log book will have to be submitted by the student during their examination for evaluation as separate marks are awarded for it.

A log book should ideally contain: Details of patients seen by the student, with neat illustrations. Details of surgeries performed / assisted by the student including follow up records. Case discussion if any participated by the student should also be recorded in this .

Records pertaining to Dissertation:

Case record - for recording case details pertaining to the approved dissertation topic. Dissertation evaluation record - this contains records of periodic evaluation of dissertation topic by the guide concerned. A diary for collecting and archiving references.

A to document interesting and rare case records.

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Instruments a Post graduate student is expected to possess

1. 2. 3. 4. 5. 6. 7. 8. 9.

Clair head light Otoscope Thudicum's nasal speculum Tilley's nasal dressing forceps Hartman's forceps Grubber aural speculum Aural syringe Jobson Horne probe Tracheal dilator

Image showing an otoscope

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Image showing Thudicum's nasal speculum

Image showing Tilley's nasal dressing forceps

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Image showing Hartmann's forceps

Image showing Grubber's aural speculum of varying sizes

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Image showing aural syringe

Image showing Jobson Horne probe

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Image showing Trausseu's tracheal dilator

These instruments are necessary and will save them lots of trouble when they are on duty. All these are specialized instruments which may not be available in all wards.

Study resources suggested for post graduate students

Books:

1. Scott Brown's text book of otolaryngology (7th edition) 2. Glasscock-Shambaugh's Surgery of the Ear, 6th edition 3. Mawson's diseases of the ear 4. Stell & Maran's Textbook of Head and Neck Surgery and Oncology 5. Otolaryngology Michael M. Paparella

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25 Journals:

1. 2. 3. 4.

Laryngoscope Archives of otolaryngology North American Clinics of Otolaryngology JLO

Online resources:

1. http://drtbalu.co.in/ 2. http://drtbalu.com 3. http://otolaryngology.wikidot.com/ 4. http://www.idoub.com/drtbalu 5. http://entscholar.net 6. http://enttutorials.com/ 7. http://tonsil.entresources.net/ 8. https://sites.google.com/site/drtbalusotolaryngology/ 9. http://oscenotesent.wikidot.com 10. http://entslides.wikidot.com/

All these sites are free to access.

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Soft skill a post graduate student is expected to possess Present day post graduate student should be adept at modern communication skills and computer skills. They should be conversant with:

1. Word processing - This will help them immensely in their publication efforts and dissertation work 2. Presentation software - They should be conversant with currently available presentation software like power point, Libre impress etc. This will help them during preparation for case presentations and conference participation.

The Tamilnadu Dr MGR University encourages post graduate students to attend conferences and workshops. Every post graduate student should have compulsory CME credit points for them to become eligible to sit for their examination.

For Post graduate degree courses = 50 credit points For Post graduate diploma courses = 40 credit points

All post graduate degree students are expected to submit one paper to Online journal published by the University. This is again mandatory for the student in order to become eligible for appearing for the examination.

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Clinical Examination Techniques in otolaryngology

Examination of Ear Nose and Throat needs specialized illumination and instruments. Since these are cavities proper illumination, focusing of illumination special instruments are necessary.

Two types of illumination is used in otolaryngological examination:

1. Semi mobile illumination like the Bull's lamp

2. Mobile illumination like the Clair's head light, or cold light based head bands.

Bull's lamp: is a semi mobile source of illumination. It has a 100 watts milk white bulb which provide the source of illumination. This light is focused with the plano convex lens placed in front of the bulb. Ideally the Bulls lamp is placed 6 inches above and behind the left shoulder of the patient, at the level of left ear of the patient.

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28 The examiner and the patient must be conveniently be seated on adjustable stools. While using a Bull's lamp the examiner must focus the light using a head mirror to illuminate the patient.

The head mirror is a concave mirror. It has a hole in the center. The approximate focal length of the mirror is about 10 inches. It has a plastic head band with a lever with 2 ball and socket ts. The ts are at right angles to each other.

Focusing the light with head mirror: The art of focusing the light to the desired spot comes only with practice. But there are certain basic steps which must be followed.

1. The patient sitting on the stool must be at the same level as the doctor.

2. The patient's legs must be placed to one side of the examiner.

3. The distance between the doctor and the patient must not be more than 8 inches (i.e. the focal length of the head mirror).

4. The mirror is fixed over the right eye in such a way part of the mirror touches the nose.

5. The mirror is adjusted in such a way that the right eye sees through the hole in the mirror. The mirror is adjusted while keeping the left eye closed and the right eye is kept open. Then both eyes are opened.

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29 Clair's head light provides mobile illumination. The source of light is from a small 9 volt bulb. It is placed in front of an adjustable concave mirror. The mirror and the bulb are held via a plastic adjustable head band. The power supply to the bulb is from a 9 volt transformer. The major advantage of this illumination is that it is freely mobile and the patient may be examined in various positions. This illumination is highly useful while performing operative procedures inside the theatre.

Examination of throat:

Throat consists of oral cavity and oro pharynx.

The term oral cavity include

1. Lips

2. Teeth

3. Gums

4. Tongue

5. Palate - both hard and soft

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6. Floor of the mouth

7. Cheeks

The oropharynx include

1. Uvula

2. Soft palate

3. Anterior and posterior tonsillar pillars

4. Tonsils

5. Posterior pharyngeal wall

Lips are common site for

1. Malignancy

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2. Herpes

3. Primary syphilis

Teeth and gums must be carefully examined for evidence of focal sepsis. Bleeding gums are commonly seen in vitamin c deficiencies.

Tongue should be carefully examined. The patient's ability to protrude the tongue is also ascertained. If the patient has tongue tie then full protrusion of tongue is not possible. Size of the tongue must also be seen. Macroglossia is seen in acromegaly / Down's syndrome.

In hypoglossal nerve palsy the tongue deviates to the side of the lesion. The tongue on the paralyzed side may show wasting of lingual musculature. Fasciculation of tongue is seen in motor neuron disease.

Loss of papilla is seen in patient's with vitamin deficiency, in those patients who have under gone irradiation of that area.

Malignancy of tongue is common over its lateral surface. Any suspicious swelling of tongue must be palpated for signs of induration, which is a characteristic feature of malignant lesions of tongue.

Tongue coating is seen in cases of oral thrush and in patients with febrile illness. Drtbalu’s otolaryngology online

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Opening of the wharton's duct can be seen under the tongue. If there is swelling in this area then it must be palpated to rule out submandibular gland calculus.

Image showing a patient being examined using Bull's lamp

The opening of the parotid duct can be examined after gently retracting the cheek. It lies opposite to the upper second molar.

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33 Palate is examined for ulcers, clefts, perforations or presence of masses.

The position of the uvula must be seen. Normally uvula is in the midline. In cases of palatal paralysis uvula deviates to the opposite side.

Tonsillar pillars must be clearly seen. It is commonly congested in chronic tonsillar infections. Tonsils must be examined. Its size must be noticed. Tonsillar enlargement can be classified under the following heads:

Grade 0 - Tonsils are found confined to the space between the anterior and posterior pillars

Grade 1 - Tonsils are enlarged and is just seen coming out of the anterior pillar.

Grade 2 - The enlarged tonsil reaches to about half the distance of uvula.

Grade 3 - The enlarged tonsil comes into with the uvula.

Grade 4 - The enlargement of tonsil is so much that both tonsils lie virtually in with each other i.e. kissing tonsils.

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Image showing Grade III tonsillar enlargement

Hypopharynx include:

1. Posterior pharyngeal wall

2. Pyriform fossa

3. Post cricoid region

Examination of this area is done by

1. Indirect laryngoscopy Drtbalu’s otolaryngology online

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2. Flexible and rigid endoscopy

3. Imaging

Indirect laryngoscopy:

1. The mirror used is plane mirror with a long handle.

2. It is held like a pen in the dominant hand with the mirror pointing downwards.

3. The mirror is warmed with a spirit lamp, the temperature is tested on the back of the hand

4. The patient is asked to protrude the tongue and it is held with a gauze.

5. The mirror is introduced into the mouth and gently slide under the uvula.

6. The mirror is tilted to get good view of the larynx.

7. The patient is asked to say eee. Drtbalu’s otolaryngology online

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8. The mobility of the vocal cord can be tested.

Otological examination:

Before proceeding with clinical examination perse a good history taking is a must. Without proper history taking it is not possible to come to a reasonably correct diagnosis by clinical examination alone.

History should include: Previous ear surgery Previous head injury Systemic diseases like diabetes / hypertension Use of ototoxic drugs Exposure to noise during work Family h/o deafness H/O atopy / allergy

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37 The classic symptoms of ear disease are as follows:

1. Deafness

2. Discharge

3. Tinnitus

4. Pain

5 Vertigo

Deafness: The patient must be asked whether deafness was sudden in onset, or gradual in onset. If deafness is sudden in onset the triggering event if any must be sought for. For example, deafness following head injury may be caused by a fracture of petrous portion of temporal bone. If the damage occurs to the auditory nerve the patient may have sensori neural hearing loss. Damage to 8th nerve is common following transverse fractures of temporal bone. Sometimes acute trauma may lead to dislocation of the ossicles causing conductive hearing loss. Of the 3 ossicles incus is the most commonly dislocated bone following trauma.

Conductive deafness can be differentiated from sensori neural deafness in a conscious patient easily by doing a tuning fork test. Commonly used tuning fork tests are 1. Rinne, 2. Weber, and 3. Absolute bone conduction test.

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38 Transient deafness after head injury may be commonly caused by a haematoma in the middle ear cavity. Following head injury the other common triggering event for deafness is viral infections. Common among them are mumps, measles etc. Deafness following viral infections are purely sensorineural in nature. The presence of wax is sufficient to cause fluctuating hearing loss which is conductive in nature.

Causes of fluctuating hearing loss are:

1. Presence of wax (conductive deafness) - Patient will c/o severe itching in the affected ear

2. Meniere's disease (sensorineural deafness)

3. Peri lymph fistula (sensorineural deafness)

In patients with deafness associated with ear discharge the presence of perforation in the ear drum could be the cause.

In all patients with c/o deafness a proper drug history is a must. Ototoxic drugs like streptomycin, gentamycin and aspirin may cause irreversible damage to the hair cells of the cochlea causing sensori neural hearing loss. These drugs also sensitizes the hair cells of the cochlea to damage due to noise exposure, hence occupational history of these patients is a must. H/O exposure to loud noise must be sought.

Discharge: Ear discharge is one of the common problems that brings the patient to the doctor. Before examining the patient a detailed history regarding

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1. Duration of the discharge

2. Quantity of discharge

3. Quality of discharge

4. Aggravating & relieving factors must be sought for.

If the duration of discharge is short then acute conditions must be borne in mind. Common acute conditions which can lead to ear discharge are

1. A.S.O.M. - here the discharge is Serosanguinous in nature (blood tinged), preceded by an episode of severe ear pain, pain subsides as soon as discharge starts, preceding episode of upper respiratory infection.

2. Otomycosis - common fungi affecting the external canal are candida and aspergillus fumigatus. Candida gives a curdy appearance in the external ear canal. In a dried up state it could appear like a cotton wool. Aspergillus fumigatus appears as a black color patches in the external auditory canal. These patients have ear discharge mostly just wetness, not profuse in nature, associated with intense itching.

3. C.S.F. Otorrhoea - The discharge is watery in nature, there is absolutely no mucoid elements in the discharge. This clear discharge starts when the affected ear assumes Drtbalu’s otolaryngology online

40 a dependent position. Biochemical analysis of this discharge will show that it contains glucose which is normally absent in purulent ear discharges.

Bedside test - One useful bedside test for CSF otorrhoea is Handkerchief test. If the secretion is mopped with a handkerchief and allowed to dry, there will be stiffening of the handkerchief if the discharge is from the middle ear because of the presence of mucous, if the discharge is csf there is no stiffening seen.

Most sensitive diagnostic test is estimation of Beta 2 transferrin in the secretions. Beta 2 transferrin is seen only in the CSF and is absent in other types of discharges.

Another important factor in the history taking is asking for the quantity of discharge. If the discharge is profuse the following conditions must be borne in mind: chronic mastoiditis, mastoid reservoir, extra dural abscess. Of these three in extra dural abscess the discharge is so profuse the external canal fills up with pus immediately after mopping. The presence of mastoiditis or mastoid reservoir can be ruled out by looking out for tenderness in the mastoid tip area. In children with well pneumatised mastoids the pus may cause erosion of the outer cortex and present as a collection just under the mastoid periosteum. This condition is known as sub periosteal abscess. If the ear discharge is scanty and foul smelling osteitic reaction due to infection must be suspected. This is frequently caused by the presence of cholesteatoma in the middle ear cavity associated with bone erosion.

The quality of discharge may range from:

Mucoid - common in CSOM

Mucopurulent - common in CSOM associated with mastoiditis

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Serous - Common in ASOM

Serosanguinous - ASOM and otitis externa

Watery - CSF otorrhoea

Tinnitus

Tinnitus is defined as hearing abnormal sounds in the ear. It can be classified into objective tinnitus and subjective tinnitus. Objective tinnitus is the one which is heard by both the examiner and the patient eg palatal myoclonus. Subjective tinnitus is heard only by the patient. Even a simple problem like impacted wax can cause subjective tinnitus by the process of amplification of endogenous sound (internal milieu sounds of the body like the sound of circulating blood, contraction of muscle etc) Commonly tinnitus (subjective) in the absence of impacted cerumen indicates early sensori neural hearing loss. This is caused by damage to hair cells of the cochlea. The damage could be due to the adverse effects of medicines like those belonging to the group of antibiotics, diuretics or cytotoxic drugs. Tinnitus associated with hearing loss is commonly a manifestation of Meniere’s syndrome. Tinnitus in this syndrome is roaring in nature and resolves within a day. It is also associated with giddiness.

Tinnitus in a patient with otosclerosis is an indication of active disease. These patients have active foci of otosclerosis. A separate term is used to identify these patients i.e. otospongiosis. Surgery if performed during this phase carries an immense risk of sensorineural hearing loss.

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42 Pain: is one of the common complaints in patients with ear problem. Pain in the ear can arise from 2 sources, pain due to problems confined to the ear, and referred otalgia i.e. pain that is referred to the ear from a problem arising from other areas, i.e. pain associated with tonsillar infection has a propensity to radiate to the ear due to common nerve supply i.e. glossopharyngeal nerve. Pain due to inflammation in the external ear is intense and is associated with swelling of the external auditory canal. This can be differentiated from pain arising from middle ear inflammation by the presence of tenderness on pressing the tragus. This sign is known as the tragal sign. Tragal sign is negative in otalgia due to middle ear causes. Pain due to mastoiditis (inflammation of mastoid air cells) can be differentiated from pain due to otitis externa by the presence of three point tenderness. Three point tenderness is elicited by using the middle finger to apply pressure over the well of the concha, index finger is applied over the mastoid process, and the thumb is used over the mastoid tip. The pressure over the well of the concha indicates tenderness over the antral area, tenderness over the mastoid process indicates the presence of mastoiditis, and tenderness over the tip of the mastoid process indicate inflammation and thrombosis of mastoid emissary vein.

Vertigo: is defined as a sensation of unsteadiness / rotation. The commonest peripheral causes for vertigo are the diseases affecting the inner ear. It is always associated with tinnitus/ blocking sensation in the ear. Peripheral vertigo can be differentiated by central vertigo by its fatigability. In peripheral vertigo the vertigo tends to diminish with time because the higher center learns to adjust with the problem. It is always positional. The patient will have to assume the provoking position for vertigo to manifest. Vertigo due to Meniere’s disease is self-limiting and short lived. It never lasts for more than a day after which the patient gradually improves. Peripheral vertigo is always associated with horizontal nystagmus, which is again fatiguing, whereas central nystagmus due to cerebellar pathology manifests with rotatory / vertical nystagmus. They also show other positive cerebellar signs like past pointing, dysdiadokokinesis etc.

Inspection:

The external ear is inspected with the following in mind:

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Size & shape of the pinna Presence of tags / preauricular sinuses / pits Evidence of trauma to pinna Skin condition of pinna & external auditory canal Evidence of previous surgery / presence of scars in the post aural / end aural region Discharge from the external canal Neoplastic lesions of pinna The ear drum can be examined using an otoscope. The pinna should be grasped between the index finger and thumb and is pulled postero superiorly. This maneuver straightens the external canal bringing the ear drum into full view. This maneuver should be done only in adults. In infants the pinna must be pulled posteriorly and downwards in an effort to straighten the external canal. This is because of the fact the bony portion of the external canal is not fully developed in infants. The use of Grubber's aural speculum itself is sufficient to straighten the external canal. The status of the canal skin / presence or absence of discharge is noted. The whole of the ear drum is visualized by tilting and moving the otoscope in various directions.

The ear drum is roughly oval in shape and about 1 cm in diameter. Normal ear drum is pearly white in color. The following structures of ear drum are visualized:

1. Attic area

2. Pars tensa

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44 3. Cone of light

4. Handle / lateral process of malleus

Rarely the following structures also can be seen:

Long process of incus

Head of stapes

Promontory

Eustachian tube orifice

Perforations any must be identified, its position clearly documented. Through the perforation the status of the middle ear mucosa must be observed and documented. Presence of tympanosclerotic plaque (chalky mass over the ear drum) is an indicator of previous ear disease.

The cone of light must be observed for any distortion. Cone of light is absent in perforated ear drums, is distorted in retracted ear drums. It is also distorted when the ear drum is bulging as in the case of Acute otitis media.

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45 The color of the ear drum must also be noted:

Red drum - is seen in acute otitis media, glomus jugulare

Blue drum - is seen in haemotympanum, secretory otitis media

Flamingo drum - is seen in otospongiosis

Mobility of the ear drum must be tested using a pneumatic otoscope, or a Siegel’s speculum. The mobility of the ear drum is restricted in adhesive otitis media. A Siegel’s pneumatic speculum has an eye piece which has a magnification of 2.5 times. It is a convex lens. The eye piece is connected to a aural speculum. A bulb with a rubber tube is provided to insufflate air via the aural speculum. The advantages of this aural speculum is that it provides a magnified view of the ear drum, the pressure of the external canal can be varied by pressing the bulb thereby the mobility of ear drum can be tested. Since it provides adequate suction effect, it can be used to suck out middle ear secretions in patients with CSOM. Ear drops can be applied into the middle ear by using this speculum. Ear is first filled with ear drops and a snugly fitting siegel's speculum is applied to the external canal. Pressure in the external canal is varied by pressing and releasing the rubber bulb, this displaces the ear drops into the middle ear cavity.

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Image showing Siegel's pneumatic speculum

Tests for hearing:

Useful bedside test for hearing is performed using a tuning fork. Ideally 3 frequencies are used 256 Hz, 512 Hz, and 1024 Hz. These three frequencies are used because they fall within speech frequency range. An ideal tuning fork should have the following features:

It should be made of a good alloy.

It should vibrate for one full minute.

It should not produce any over tones.

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47 Tuning fork tests are performed to identify whether the patient is suffering from conductive deafness, sensor neural deafness, or mixed deafness. Three tests are performed towards this end. They are 1. Rinnes test, 2. webers test, 3. Absolute bone conduction test / ABC.

Rinnes test: Ideally 512 tuning fork is used. It should be struck against the elbow or knee of the patient to vibrate. While striking care must be taken that the strike is made at the junction of the upper 1/3 and lower 2/3 of the fork. This is the maximum vibratory area of the tuning fork. It should not be struck against metallic object because it can cause overtones. As soon as the fork starts to vibrate it is placed at the mastoid process of the patient. The patient is advised to signal when he stops hearing the sound. As soon as the patient signals that he is unable to hear the fork anymore the vibrating fork is transferred immediately just close to the external auditory canal and is held in such a way that the vibratory prongs vibrate parallel to the acoustic axis. In patients with normal hearing he should be able to hear the fork as soon as it is transferred to the front of the ear. This result is known as Positive rinne test. (Air conduction is better than bone conduction). In case of conductive deafness the patient will not be able to hear the fork as soon as it is transferred to the front of the ear (Bone conduction is better than air conduction). This is known as negative Rinne. It occurs in conductive deafness. This test is performed in both the ears.

If the patient is suffering from profound unilateral deafness then the sound will still be heard through the opposite ear this condition leads to a false positive rinne.

Weber's test:

Here again 512 Hz tuning fork is used. The vibrating fork is placed over the forehead of the patient and he is asked to indicate on which side he is hearing the sound. Normally when hearing level is equal in both the ears, it is heard in the middle, in patients with conductive deafness the sound is heard in the left ear. This is known as lateralization of Weber test. If the patient is suffering from sensorineural hearing loss then the sound is lateralized to the normal ear or the better ear. Hence weber's

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48 test must always be interpreted along with the Rinne's test. Weber's test is a sensitive test, it can pin point even a 10 dB hearing difference between the ears.

Absolute bone conduction test:

This test is performed to identify sensorineural hearing loss. In this test the hearing level of the patient is compared to that of the examiner. The examiner's hearing is assumed to be normal. In this test the vibrating fork is placed over the mastoid process of the patient after occluding the external auditory canal. As soon as the patient indicates that he is unable to hear the sound anymore, the fork is transferred to the mastoid process of the examiner after occluding the external canal. In cases of normal hearing the examiner must not be able to hear the fork, but in cases of sensori neural hearing loss the examiner will be able to hear the sound, then the test is interpreted as ABC reduced. It is not reduced in cases with normal hearing.

Basic tests for hearing:

For making a basic assessment of patient's hearing the ear opposite to the one tested is masked by occluding it. The patient is asked to repeat random numbers uttered by the examiner. Ideally patient is blind folded to prevent lip reading. The numbers are uttered at various intensities, quiet whisper, loud whisper, quite voice, loud voice and shout.

Rough estimation of hearing loss would be:

Quite whisper - normal

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49 Loud whisper - 20 - 30 dB

Quite voice - 30 - 45 dB

Loud voice - 45 - 60 dB

Shout - 60 - 80 dB

Image showing the technique of straightening the external auditory canal

Examination of Nose

In addition to the illuminating instruments described under the heading examination of patient in otolaryngology, certain other unique instruments are necessary in the examination of the nose. Drtbalu’s otolaryngology online

50 They are 1. Thudichum's nasal speculum 2. Lac's tongue depressor 3. St. Claire Thompson post nasal mirror 4. Tilley's nasal dressing forceps 5. Spirit lamp to warm the post nasal mirror

The steps that must be followed while examining a nose is 1. Examination of external nose 2. Anterior rhinoscopy 3. Posterior rhinoscopy

Examination of external nose: On inspection the following things should be looked for

In this step the following aspects must be diligently looked for 1. Change in shape / contour of the nose 2. Deformities congenital / acquired if any 3. Presence of clefts and sinuses 4. Presence of swelling: inflammatory, cysts, or tumors 5. Presence of ulceration: trauma / infective / neoplastic

On palpation the following must be sought after

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51 1. Tenderness - If it is present over the nasal bone area then # nasal bone must be suspected. If it is present over the tip of the nose, it could be due to vestibulitis, if tenderness is present over the dorsum of the nose the septal hematoma, of septal abscess must be strongly suspected. 2. Crepitus - when present over the nasal bone area then # nasal bone is a surety. 3. Deformity - The presence of deformity is one of the features of trauma to the nose. Nose being the most prominent area of the face, it is susceptible to various injuries. Any blow to the dorsum of the nose can cause buckling of the cartilagenous nasal septum. This buckling may lead to bleeding under the perichondrium of the nasal septum. This bleeding in fact lifts the perichondrium away from the nasal septum. If this happens on both sides of the nasal septum the nutrition to the nasal septum which is dependent on the intact perichondrium suffers. The cartilage in fact under goes liquefaction necrosis within 48 hours, depriving dorsal to the nose causing pig snout deformity. 4. The nasal septal area must be palpated to ascertain the presence or absence of septal cartilage.

Anterior rhinoscopy:

In anterior rhinosopy the following steps must be performed in the given order. 1. Examination of the vestibule (i.e. the skin lined cavity of the nares). 2. Examination of nasal cavity using thudichum's nasal speculum. 3. Patency test. 4. Probe test if examination of nasal cavity reveals a mass. This test is done to ascertain the site of origin of the mass. 5. Examination of the nasal cavity after vasoconstriction. This is done after packing the nasal cavity with cotton plegets dipped in oxymetazoline or xylometazoline nasal drops.

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52 Examination of vestibule: This is carried out by tilting the tip of the nose. The vestibule is lined with skin and has all the dermal appendages. All the diseases which affect the adnexia of the skin can occur in the vestibule. Boils i.e. vestibulitis can cause swelling of the roof and lateral wall. Ulcerations in this area can be infective or neoplastic. Excoriation of skin lining the vestibule can also occur due to persistent nasal discharge.

Examination of nasal cavity using a nasal speculum:

A Thudichum's nasal speculum is utilised for this purpose. The speculum is held in the non-dominant hand. The speculum is hooked with the index finger, while the middle and ring fingers are utilized to press and release the speculum blade. The axis of the anterior nares is upwards and backwards, while that of posterior nares is backwards. The tip of the nose is lifted and the blades of thudichum's speculum is introduced getting these two axis in a straight line. The speculum is always introduced with the blade closed. The speculum is always introduced in a upwards and backwards direction. Once inside the nose the blades are gradually opened to avoid discomfort to the patient. The roof, floor, lateral and medial walls of the nasal cavity are systematically examined.

Nasal septum is visualized with a special eye for the presence of spurs, deviations, or perforations. The lateral wall displays the inferior and middle turbinates. Their color, size and the quality of the mucosal lining is assessed. Discharge if any from the middle meatus is also looked for. Since the middle meatus is situated backwards the head is tilted upwards and backwards up to an angle of 45 degrees. This maneuver brings the middle meatus into clear vision. If polyp or neoplasm is visualized within the nasal cavity a probe test is done to confirm its attachment.

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Probe test: Is done using Jobson’s Horne probe. The nose is anaesthetized with 4% xylocaine. Cotton is wound tightly over the probe end of Jobson's Horne probe. The probe is used to assess the site of attachment of the nasal mass, its consistency, mobility etc.

Nasal patency test: Is performed using a cold tongue depressor just under the nose of the patient and comparing the amount of mist formation between both sides. A wisp of cotton can also be used to ascertain the patency of the nose. Patency is compared with both sides.

Posterior Rhinoscopy: It can be done using 1. Post nasal mirror 2. Flexible nasopharyngoscope 3. 30 degrees nasal endoscope 4. Examination under general anaesthesia after retracting the soft palate. Digital palpation is possible only in this method.

Examination using post nasal mirror: The post nasal mirror is warmed using a sprit lamp. The throat of the patient is anesthetized using 4% xylocaine spray. The tongue depressor is held in the non-dominant hand, and the tongue is depressed. The already warmed post nasal mirror is gently is ed under the

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54 uvula visualizing the post nasal space. The mirror is tilted to visualize the various portions of the naso pharynx. Examination of nasopharynx using post nasal mirror is a difficult procedure to master. It may be difficult to perform in all individuals. If it cannot be performed then a flexible nasopharyngoscope, or a nasal endoscope must be used. If a suspected lesion needs to be palpated it can be done after retracting the soft palate under general anaesthesia.

Image showing the process of examination of nasal vestibule

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Dissertation

It is mandatory for a post graduate student undergoing training for Master's degree to complete dissertation during the study period. This enables the student to be trained in research methodology and thesis writing. Since this must be completed and submitted during the course of study period, time management becomes all the more important. By definition dissertation is an inquiry made into some aspect of physical, natural or social world. Students should also that their work will be subjected to public scrutiny and peer review before being accepted. Every dissertation should be accompanied by a meticulous analysis of the results documented.

Points to ponder:

1. Dissertation is just one of the hurdle in the pursuit of the Master's degree 2. Non submission of dissertation will be considered more worse than exam failure and will show the faculty in poor light 3. Dissertation is actually a compromise between what is desirable and what is actually possible 4. A delicate balance should be maintained between academics / clinical duties / family

Tips for successful completion of a good dissertation:

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56 1. Incisive thinking 2. Ideas should be jotted down in the log book. Human brain is always cluttered with unwanted details. To stay in focus it is always better to note down ideas and thought process on dissertation in a log book maintained for this purpose. 3. Never be too much influenced by other's research on the same topic 4. The set goal should be realistic and easy to achieve 5. The time line set should always be feasible 6. It is always prudent to conduct a preliminary survey / study before embarking on the actual one. This effort is worth because it could forewarn the researcher about the pitfalls that lie ahead.

Problems faced by a guide while guiding a student through with the thesis:

Guide is confronted with varying types of students. Some of them could be young, energetic and enthusiastic, while the other group could be old and mature. Problems faced by these groups are also highly varied. There is actually a divide between these two groups. This divide is more acutely felt in the field of medicine than in others. The older and mature students are more egoistic, and find it difficult to adjust with more dynamic young colleagues. The older and more mature students have the advantage of handling problems better. It calls for lots of tact to handle these two groups on the part of the guide.

Self-assessment: Every post graduate student should ruthlessly assess oneself. Only a person who is capable of good and candid self-assessment could survive in this competitive environment. Self-assessment should be on the following lines:

1. 2. 3. 4. 5.

Motivation levels (Am I really motivated?) Coping up with the demands of course and family Reading and writing skills (Are they really up to the mark?) Response to deadlines Whether comfortable working alone or as a member of a group

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57 Current day postgraduate training schedule is really rigorous. One has to be really motivated in order to come out successful. This course is not only challenging, but it is also demanding. A delicate balance will have to be struck between the demands of the course and that of the family.

The art of choosing a dissertation topic

Before actually choosing a dissertation topic the following points should be considered:

The actual date of submission of dissertation. Any intermediate deadlines to meet. Type of Institutional one can get towards completion of the dissertation. Library facilities available in the institution. A thorough review of pervious years dissertations. Draw up a list of probable topics and seek advice from faculty.

Expenditure involved: Another factor that should be taken into consideration while choosing the topic is the expenditure involved. Whether the candidate can afford to incur that expenditure is an important criteria. Dissertation topics usually don’t receive any funding from institutions.

Institutional : The type of Institution can provide is an important criteria in deciding a topic. For successful completion of the dissertation active Institutional is a must. Availability of literature / references:

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58 The topic chosen for dissertation should have been well researched and documented elsewhere. All such references and documents should be available to the student.

Will the topic be approved by the Institutional ethical committee? This is another aspect that should be taken into consideration while choosing a dissertation topic. All research projects will have to be approved by the ethical committee constituted for this purpose. A detailed proposal listing the various aspects of the study along with references will have to be submitted to the ethical committee. A specially designed consent form in vernacular language for getting consent from the patient to participate In the study should also be included in the proposal submitted to the ethical committee.

Proposal submitted to the ethical committee should contain:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Name of the topic (In block letters) Name of the researcher (PG student) Name of the guide Aim and scope of the study References Review of literature Patient consent letter in local language (specimen) Permission letter from the guide Permission letter from the Head of the Department

Care should be taken while choosing a topic. Topics like those shown below can be rejected.

1. Study of JNA – Too broad & vague 2. Survey of ASOM – Vague & nonspecific 3. Study of interesting cases – Not dissertation at all 4. Study of discharging ear – Too vague to pursue Drtbalu’s otolaryngology online

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Ethical issues that should be considered while choosing a topic:

The following ethical issues should always be taken into consideration while choosing a topic for dissertation: 1. The participants of the research project should not suffer any harm either physically, mentally or socially as a result of participating in the project. 2. Children, elderly and physically challenged should not be exploited hence should be excluded from the study. 3. The research project should not cause any environmental / physical damage 4. Privacy of the participant should be protected at all costs 5. The project should not cause disrepute to the institution

Planning the dissertation realistically: While planning a dissertation the following factors should be considered: 1. 2. 3. 4. 5. 6.

Allot time for illness Allot time for family problems Take into holidays Allot time in the event of computer failures Take into consideration for typing and manuscript binding delays Last but not the least be prepared to face manuscript rejection

Role of computing and word processing skills in completing dissertation:

Computing and word processing skills are rather important in successful completion of dissertation. Gone are the days when students used to sit behind typists and oversaw their work being typed. Possession of computing skills which include word processing and image manipulation will help a lot. Lack of this skill is going to cost time and money. Students lacking this skill need to add an extra week / 10 days to their dissertation schedule because it needs involvement of other people in the completion of work. It is always better to keep back up copies in removable media Drtbalu’s otolaryngology online

60 like CD-ROMs, pen drives and also printed copies are desirable. Computers can fail at the most crucial time and it is necessary to safe guard the data.

Time allotment for various aspects of dissertation work: (Approximate only)

Introduction = 5% Review of literature = 35% Research methodology = 10% Data collection = 20% Data analysis = 15% Conclusion = 10% Bibliography = 5%

Before really diving into the actual work a blue print need to be drawn. This will help the candidate to stay focused and complete the dissertation work on time.

The first step is the question:

What do you want to know?

Step II

How are you going to find the answers?

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61 Step III

What are you going to do with the answers?

Aims of Dissertation:

Dissertation should always have an aim. The possible aims of dissertation are given below:

1. 2. 3. 4. 5.

To develop a theory To a hypothesis To evaluate critically a practice To increase the understanding of a topic If possible to recommend policies

Hypothesis is the most crucial part of a dissertation. In fact it constitutes the kernel in all dissertations. Usually hypothesis is based on observation or belief. A valid dissertation topic should endeavor to prove or disprove a hypothesis. It is very rare for a dissertation topic to exist without valid hypothesis.

Check list: A student will have to draw up a check list before exactly starting the dissertation work. The check list include: 1. 2. 3. 4. 5. 6.

Understanding the general requirements Whether the chosen project has been refined and focused Feasibility of study Selection of title (tentative at least) Chartered the time schedule Discussion with guide and peers

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62 A student should not develop fondness to any page authored. Dissertation needs to be ruthlessly edited to fulfill the page limitations specified by the University. Initial write up should be considered as draft. It is advisable to spend a few hours each week on dissertation issues. This will help the motivation levels of the student to stay high.

Tips for dissertation writing:

Writing should begin as soon as data collection is completed. Corrections made to the written material should be catalogued.

Dissertation work will start in right earnest during the final year of Master's program. Total duration available to complete dissertation is roughly 12 months. This 12 month period can be divided as shown below to organize work in a better way. 1. Reading / note taking / planning / writing introduction – 3 months 2. Writing review of literature – 2 months 3. Writing of research methodology – 1 month 4. Carrying out work / recording findings – 1 month

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63 5. Data analysis – 1 month 6. Preparing conclusions / Bibliography – 1 month 7. Typing / proof reading / corrections / binding – 1 month 8. Grace time – 2 months

Common conventions used in dissertation: 1. Use white A4 paper for dissertation typing 2. All main texts to be typed in double space 3. Single spacing can be used for quotations 4. Use plain standard fonts 5. Margins – 1.5 inches in the left and 1 inch on other sides

Types of research projects that could be taken up for dissertation

Given below are some of the types of research projects that can be taken up as dissertation topics.

1. Action research 2. Surveys 3. Experimental methods 4. Ethnographic research 5. Case studies 6. Historical research 7. Correlational research 8. Evaluative research Drtbalu’s otolaryngology online

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Action research: This is also known as participatory research. In this type of research project a researcher tackles a real problem, intervenes if necessary, makes changes and monitors results. Participating subjects are supposed to implement the suggested changes by the researcher. This is more or less similar to real life problem solving. This type of research will be scrutinized thoroughly by the ethical committee because of the risks involved. The term "Action research" was coined by Kurt Lewin a Professor at MIT in 1944. Performing an action research is the same as performing an experiment.

Surveys: Survey type research is designed to gather information. Usually information for this type of research is gathered through questionnaires / interview. Success of this type of research is totally dependent on the question designed to gather information. Questions should be structured in such a way that maximum information should be gleaned from minimum number of questions. This type of research needs compliance on the part of the participant. If they give false data then the entire study will lose its accuracy. The possibility of the participant withholding information or providing false information should always be considered while analyzing the results. Major advantage of this type of research is that it is easy to get approval from ethical committee for survey based research.

Ethnographic research: This term is derived from the Greek word "ethnos" which means people, and "graphy" to write. This is in fact a qualitative and descriptive type of research which takes a long time to complete. In this type of research the study group is integrated into the society, and the researcher studies the behavior and customs of that group. Since this is a time consuming research modality it is not advisable to take this up as a dissertation work which has to completed within the specified time frame

Case study:

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65 This is the commonest approach taken for dissertation topic. Student before taking up the case study need to understand that the institution should get at least 50 cases belonging to the study category during the course of study to make this topic a successful one. In this type of study both qualitative and quantitative data can be harvested and interpreted. One word of caution is that the temptation to formulate a universal theory out of trivia should be avoided.

Historical research: Before embarking on this type of research, it should be checked with the University whether this type of research can be taken up as dissertation topic. This is actually a grey area. Availability of adequate historical literature and other archives is a must. All historical documents used for this study should be checked for authenticity. Statistical variables should always be ed for.

Correlational research: This research in nutshell is a study of variables. Attempt should be made to study the variables for possible relationship without manipulating them. Mathematical tools should be used to study variables and their possible causal relationship.

Evaluative research: “The systematic assessment of the operation and/or the outcomes of a program or policy, compared to a set of explicit or implicit standards, as a means of contributing to the improvement of the program or policy” Weiss.

This research methodology deals with a possible set of questions. This work needs to be highly structured. While attempting to seek answer to the questions the researcher should against personal vagaries and variables. This is another protocol commonly used for dissertation topics.

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Duties and responsibilities of a researcher during dissertation data collection:

1. 2. 3. 4.

Should behave professionally and politely with s / participants Should dress formally during field visits Should be very professional while speaking to subjects All communications should be typed / word processed and be of very high standards

Sampling: This is actually a mine field for researchers. Even though it is easy to obtain samples in the physical world, the size of the sample is rather important. Sample size should be at least 1% of the population studied. The procedure of sampling should be opportunistic / random. In opportunistic sampling, sample is collected when opportunity presents itself. In random sample collection computer randomizes and tells the researcher from whom to collect samples from.

A dissertation should be written with the following headings:

1. 2. 3. 4. 5. 6. 7. 8.

Aims and objective Introduction Review of literature Methodology Data analysis Conclusion Bibliography Appendix

Aims and objective: Drtbalu’s otolaryngology online

67 Aim and objective of the topic taken up for dissertation should be clearly stated under this heading.

Introduction: One need to ensure the following points when authoring this chapter. In the introduction chapter the author tries answering these questions: 1. What is going to be done? 2. Why is it being done? 3. Who is likely to be interested in the work? 4. What is the hypothesis / problem the author attempting to test? 5. What is the use of performing this study? 6. What is the focus / location of the study? 7. Writing an introduction chapter helps the author to break ice

Review of literature:

1. Should include what others have written on the topic 2. Discussion on the theories used to illuminate the topic 3. Literature relationship with the research questions 4. Considerable time should be spent compiling this chapter 5. This shows that the author has read widely the subject 6. The author acknowledges work of others here

Methodology: 1. The author narrates what procedure is followed in the research

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68 2. A detailed discussion of the style and technique chosen for the Research should be enumerated with proper justification 3. The tests author intends to perform, inclusion & exclusion criteria if any, a discussion on data observation and recording should find a place under this head

Data analysis:

1. Data recording 2. Interpretation of the recorded data 3. A discussion on whether the collected data proves or refutes a hypothesis

Conclusion: 1. Should contain a summary of the complete work 2. It should contain a discussion on the results of your study 3. Recommendations if any the author makes after the study should be incorporated here

Bibliography: This is nothing but a list of journals, reference materials, text book materials and other resources you relied on to complete your work. References which are more than 5 years old should not be included unless it is completely unavoidable. It is ideal to index and number them for easy reference.

Appendix: Tables, master chart and additional material if any should be incorporated under this heading

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69 Plagiarism: The Tamilnadu Dr MGR Medical University routines conducts plagiarism check on all submitted dissertation manuscripts. Before submission, the author of the dissertation is encouraged to submit the manuscript for online plagiarism check. Many sites offer free plagiarism check facilities. It can also be done via the university website.

Documentation

Introduction: Documentation is an important job of a post graduate student. This helps in improving patient care. The patient is provided with a recorded version of the ailment as well as the details of treatment given. By carefully documenting patient records a student can publish papers. Documentation is a must for settling insurance claims. Currently health insurance is really catching up in our country. State Governments also provide health insurance cover of people living below poverty line. Documentation also helps the planners to plan for future health care requirement of the country. An exclusive department “Medical Records Department” is available in all medical colleges. This department is headed by a medical statistician qualified in medical statistics. Patient records are coded and assigned ICD numbers and archived.

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71 Photo documentation: Every post graduate student is expected to possess a digital camera. Currently excellent cameras are available at reasonable cost. Currently available cameras shoot digitally and do not use film, hence it proves to be cost effective in the long run. Choice of digital camera:

Picture resolution: In order to ensure good picture quality, the camera should have good resolution. Picture resolution depends on the number of dots within the picture. More the number of dots better becomes the picture quality. In lay the resolution of digital camera is specified in megapixels. An ideal digital camera should have at least 6 megapixels resolution.

Zoom quality: This is another feature one should look for in a digital camera. Two types of zoom is possible in a digital camera i.e. digital zoom and optical zoom. Digital zoom actually attempts to enlarge each recorded pixel electronically whereas in optical zoom the camera lens digitally magnifies the object. One should look for optical zoom values when purchasing a digital camera. Buyers are usually confused with the term digital and optical zoom. It is prudent to , the functions of digital zoom can be done by any desk top computer with its installed program. At very high digital zoom values the picture has a tendency to become fuzzy. A high optical zoom value is the one a buyer will have to look out for in a digital camera. At high optical zoom levels the camera provides the best results. Less expensive cameras have lower optical zoom levels, and do not offer best results.

LCD screen: Good digital camera should have an excellent color LCD screen. This is actually a must for all digital cameras. Drtbalu’s otolaryngology online

72 Image storage system: A digital camera with adequate storage space in the form of memory cards / hard disk drives.

Image showing a digital camera

Modern day digital cameras have taken the uncertainties out of the art of photography. The preview screen helps in composing excellent images.

Digital still cameras can be used to take clinical photographs of patient for purposes of documentation.

To compose excellent photographs using a digital camera, the aspect ratio is important. In simple aspect ratio deals with ratio between width and height. It is the ratio of width: height. It should also be noted that width comes before height. Ideally speaking a 35 mm frame is the best for excellent image composition and the ideal aspect ratio for a 35 mm frame is 3: 2. Drtbalu’s otolaryngology online

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Use of half press feature in focusing digital camera: In contrast to manual cameras of yester years which needed manual settings to be configured for excellent results. These settings could be adjusted only with many years of experience. In present day digital camera era these settings are automatically adjusted by the camera itself. After composing the image to be captured using the image preview screen the capture button should be pressed up to the half way. This half press brings a small square in the center of the view finder. This center square should be used to focus the area of interest in the image and the capture button is pressed all the way down to capture the image.

Image format: It is ideal to choose a camera which would save images captured in raw format. A raw image can be manipulated by image manipulation program and converted into any image format. The following are the various image formats.

1. JPEG (t photographic experts group). This image format is compressed format and is used for displaying images in a website. Image in this format is compressed with very little deterioration in quality 2. BMP (windows bitmap file system). This format is commonly used to display images in windows operating system. This image is in uncompressed format. 3. GIF (Graphic interchange format). This format is limited to 256 colors. This is useful in creating logos, diagrams, images of various shapes and cartoon style images 4. PNG (portable network graphics). This is an open source file format designed to be a successor of GIF format. This format is best for images containing large uniform colored areas 5. TIFF (Tagged image file format). This image is large in size. This image format is still the preferred format when images need to be printed.

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To document intra oral pathologies it is best to have a camera with ring flash. Ring flash throws uniform light into the cavity and helps in capturing well illuminated shadow less images.

These captured images can be archived in a removable media like CDROMs, Pen drives, or online storage services like SkyDrive, Picasa, and Flickr etc.

Video recording: This helps to record surgical procedures. Fortunately all otolaryngological surgeries except neck surgery are camera based surgical procedures. Surgery video output can be taken out of the TV monitor and captured using video capture card connected to a laptop. These captured videos can be edited using video editing software like:

1. Windows movie maker 2. Pinnacle studio

For web based projection of videos the best on line platform is YouTube videos. Edited video can be saved in MPEG 4 format. This format is highly compressed and streaming via internet. After ing to YouTube these videos can easily be called by embedding to a website.

Surgical videos captured using Handy cam device can be recorded using fire wire cord. Currently available hand cam cameras record in hard disk / memory cards. These videos can easily be ed to a computer by simply mounting the storage devices where these videos are stored.

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