Alexander Graham Bell Association’s Recommended Protocol for Audiological Assessment, Hearing Aid and Cochlear Implant Evaluation, and Follow-up | Listening and Spoken Language Knowledge Center | AGBell

Alexander Graham Bell Association’s Recommended Protocol for Audiological Assessment, Hearing Aid and Cochlear Implant Evaluation, and Follow-up | Listening and Spoken Language Knowledge Center | AGBell

Status of DRDO's Indigenous Cochlear Implant & my interview with MINT

I was interviewed recently by MINT (Mint is India's second largest business newspaper published by HT Media Ltd, the Delhi-based media group which also publishes the Hindustan Times) 
Kindly read the third article in the link attached..DRDO is hopefully ready with indigenous cochlear implant for trails.Thanks to the efforts of Prof.Abdul Kalam & recent push by Prime Minister Narendra Modi.
Once it is commercially available ,so many kids will benefit..eagerly waiting. 

just a little correction as you read the article.. you will read..hearing aids are only useful in mild hearing loss..this is not correct.During interview I have mentioned every child with hearing loss mild,moderate,severe & profound is first given hearing aids & speech therapy.
Its the severe to profound one who do not develop language & communication with hearing aids need cochlear implant.

here is the article copied..

DRDO TO SEEK APPROVAL FOR CLINICAL TRIALS FOR BIONIC EAR

New Delhi: Bionic ears, or artificial hearing devices that are partly implanted under the scalp, could be made in India in the near future, bringing down their prices by nearly a sixth and benefiting thousands of people suffering from significant hearing loss.

India’s Defence Research and Development Organisation (DRDO), which developed these devices, has completed two-year-long tests to ensure the human body does not reject these implants. It will seek approval from the Drug Controller General of India (DCGI) this month to carry out clinical trials, before starting commercial production.

The bionic ear, or cochlear implant, picks up sound, converts it into electrical energy and feeds it to the auditory nerve which goes to the brain, which perceives it as sound. The cochlea is the auditory part of the internal ear.Though the first cochlear implant was approved by the US Food and Drug Administration in 1985, the prosthesis is still not affordable for most, especially in developing countries.

“DRDO will produce a bionic ear which will not cost more than `1-1.5 lakh, and will be the world’s cheapest cochlear implant,” said Bhujanga Rao, director general (naval systems and materials), DRDO. “With the help of philanthropists and governments, the prices can come down further,” he added. More than 3,00,000 people across the world are already using such implants, as against 5,000 in India, according to Rao.

“The final results will be out after eight months to one year, after which production can begin. The observation will take time as a person needs to be given time to heal after the surgery for implantation of the device,” Rao said.

He added that it has been decided that 50 people will be part of the clinical trials, five in 10 centres, overseen by ethical committees. The final details are still being worked out.

“A doctor once told me, for every implant that he is doing, he is turning away 100 patients. That is the gap in demand in India,” said Rao. More than 90% of the market for cochlear implants is cornered by three companies from Australia, Austria and the US, and the implants sold by them cost `6 lakh and above, said Rao.

Cochlear implant surgeries are state funded for children in European Union countries and the US because of the high cost. In India, there have been a few attempts by some state governments to make these expensive surgeries free for the poor or be financed through insurance schemes in designated government hospitals. In 2009, the health ministry had issued a notice saying that it would reimburse as much as `5,35,000 for cochlear implant surgeries of children, but only after it is approved by a standing committee of experts.

Lack of awareness, even among people who can afford the expensive procedure, is also a hindrance, experts say.

“The problem, however, is not restricted to affordability, but lack of awareness, lack of early diagnosis and groundwork. Even parents who can afford these implants for these children often do not know about the available options, or they are too late in getting the implant,” says Sheelu Srinivas, a surgeon with Fortis Hospital in Bangalore. “Statistically most of the children in India get cochlear implants after they turn five years old by which time most of the cerebral growth is over, but cochlear implants can only be effective if they are implanted in a child till she turns two.”

The device is usually implanted before a child turns two, as the brain has a tendency to slowly disable the audio cortex from functioning in the absence of sound stimulus. Conventional hearing aids can only help those suffering from mild hearing loss.

“Cochlear implants also involve a lot of signal processing, irrespective of the language. The brain has to understand all languages. We have to make a common brain language using signal processing,” said Rao, who is also a distinguished scientist. “This implant can enable a person to hear frequencies ranging from 100Hz to 8kHz, which can include telephonic conversation, normal speech to loud music,” he explained.

The cochlear implant developed by DRDO will be manufactured by Pacetronix, an Indore-based firm that makes pacemakers. So far, 50 bionic ears have been made for DRDO’s biocompatibility tests.

“There are some materials the body can accept; we have to use medically graded materials only. There are also some processes, such as welding and joining, through which we introduce foreign materials inside the head. These have to be accepted by the body,” said Rao, explaining these tests.

“This month, we are submitting the documentation for biocompatibility tests, design, advice to doctors and reliability studies to the DCGI. We will seek approval for multi-centric clinical trials, and if we get approval, clinical trials can start in the next three to four months,” Rao said.

The DRDO’s unit which developed the device has done much work in the area of signal processing. Two years ago, former President A.P.J. Abdul Kalam had announced that the cochlear implants would enter clinical trials that year, but was delayed due to biocompatibility tests.

On 20 August, Prime Minister Narendra Modi had criticized DRDO and asked it to complete its projects sooner to put India ahead in the world,  Press Trust of India had reported. India is left behind in defence research because products which are “two steps ahead” come into the market even before India conceptualises a system, PTI quoted Modi as saying.

(Source: Mint August 27, 2014)

 http://beta.thearabianpost.com/govt-nails-finmeccanica-protects-current-contracts/

Robotics in ENT

ENT Surgery had a revolution with introduction of nasal endoscopes in the late 80's.Since then, ENT Surgeons have expanded their horizon from nasal cavity to the base of skull.Presently endoscopes are also used for ear surgeries.

As surgeons we need to update ourselves with the latest techniques available & above all learn to use them.

Before adapting any technique in practice ,we go through rigorous training on cadavers.I remember attending 3-4 dissection courses per year for mastering the nasal endoscopic surgery & the hands on training still continues every year.Training & learning never stops as we expand our horizons.

Robotic in surgery has been there for a while now. The da Vinci Surgical System is a robotic surgical system made by the American company Intuitive Surgical. Approved by the Food and Drug Administration (FDA) in 2000, it is designed to facilitate complex surgery using a minimally invasive approach, and is controlled by a surgeon from a console.  

The main applications for Robotic surgery have been  in Urology,Gynecology & General surgery.The first Robotic set up came to India in January 2011. Vattikuti Technologies are the distributors in India for the da Vinci® surgical systems.  

Above picture depicts the latest Model. da Vinci Si HD. The surgeons at the console,the Robot at the patient table,scrubbed nurse for helping with instruments & the display tower

Recently I had the opportunity to a attend a training on the da Vinci Simulator organised by Vattikutti Technologies.It was a humble experience.The Vattikutti technologies are based in Bangalore & they offer these training sessions for surgeons.It starts with introductory videos & interactive session with their engineers.Then hands on with the robot stationed there.

There is a learning curve for this technology as with any new gadget.The most impressive things for me was the amazing "Endowrist" intrumentation (180 degree articulation & 540 degree rotation) The latest model in the first picture has two consoles ,useful for training as well TilePro is another plus as the surgeon can see  multisource videos in the same screen.

The application in ENT Surgeries has been mainly in oral cavity & neck.Procedures like  lingual tonsil excisions, tongue base resections & supraglottic resections have been performed so far. Case selection is very important.

Though it comes with set of instruments & forceps as ENT surgeons use it more ,we can modify instruments suitable for ENT use.For Pediatric ENT ,surgeons are working on smaller & flexible scopes.

The use of Robotics in ENT Surgery is new & indications are expanding.Cost effectiveness is a challenge at the moment.

I must finally thank Vattikutti Technologies & their team for the excellent insight in to robot handling and their hospitality.

New techniques or gadgets for disease management : How do patients decide ?

Thanks to www....& Google,patients have access to so much of information...how do they decide?
Of course you may say "patients depend on their doctors or surgeon to decide what's best for them".Its the doctors responsibility not only to critically study the new technology but also to train themselves to handle it.
It's not unusual to get a patient who demands for a surgery using a particular technique.For example ,I recently had a young boy who wanted tonsillectomy using a particular technique.He aspires to be a singer & his teacher in the U.S.advised this new technique.How much ever I spent time explaining that I was actually involved in a nationwide study in the NHS in the U.K. & shared the outcomes,he was fixed on his idea.He went ahead at another center with this surgery & surprise comes back with all the possible risks explained!!
I have seen patients having similar faith in lasers.I fail to understand from where it's come but they think everything can be operated with laser & it's all bloodless & painless!! Ofcourse lasers are useful for selected conditions & the results are excellent if a particular type of laser is used.
Every new gadget may not be suitable for every patient.It depends on the stage of disease & also patient as well as doctor factors.
I recently came across this article about cancer advertisements in a reputed medical journal.Especially in cancer treatment, there are standard staging systems & treatment is offered according to classification or stage.Few other diseases have such protocol.
Sharing it....

The full report is titled “What Are Cancer Centers Advertising to the Public? A Content Analysis.” It is in the 17 June 2014 issue of Annals of Internal Medicine (volume 160, pages 813-820). The authors are L.B. Vater,
J.M. Donohue, R. Arnold, D.B. White, E. Chu,
and Y. Schenker. 

Summaries for Patients
Understanding Cancer Center Advertisements
What is the problem and what is known about it so far?
A new diagnosis of cancer can be frightening. Many decisions need to be made, the first of which is usually where to receive care. Throughout the United States, cancer centers are increasingly purchasing magazine and television advertisements aimed directly at patients with the intent of informing them about their centers.
Why did the researchers do this particular study?
To examine television and magazine advertisements placed by cancer centers for information provided about clinical services and the use of emotional advertising appeals and patient testimonials.
What was studied?
Advertisements in the top 269 consumer magazines and in 44 television markets that reached more than 1 million viewers in the United States. However, the researchers could not be sure whether television advertisements were local or national in their distribution.
What did the researchers find?
The advertisements tended to focus on the newest or most innovative treatments offered for particular types of cancer. They often included patient testimonials but did not indicate whether the experience of that patient was typical. In general, the advertisements appealed to a person’s emotions but did not provide more concrete information about benefits and risks of therapy, what other therapies a patient may use, or whether the centers accepted all types of insurance.
What were the limitations of the study?
The study analyzed the advertisements but did not study people watching the advertisements to see how they were affected.
What are the implications of the study?
Although it is natural for patients with a new diagnosis of cancer to look for the best news possible, they should try to view cancer center advertisements as critically as they view any other advertisements. They should not believe that the patient experiences portrayed in such advertisements are typical or that their own experience will be the same. They should choose where they receive cancer care on the basis of all issues important to them, including benefits, risks, and costs
 This article was published online first at www.annals.org on

27 May 2014. 

Dizziness Part III :Management

Dizziness...like fever or pain is just the symptom of an underlying pathology.Hence for effective treatment ,we need to diagnose the underlying cause.As I have already mentioned,sometimes appropriate diagnosis needs few visits.

The treatment of vestibular or inner ear related vertigo is divided into immediate symptomatic relief & to promote vestibular compensation.

Medications for vertigo mainly provide symptomatic relief.Drugs like antiemetic (for nausea & vomiting ) & anti vertigo drugs are given for short duration (3-5 days).In Meneire's disease Histamine agonists drugs are used for longer duration.

The mainstay of management is to promote vestibular compensation.Vestibular compensation is a natural process that allows the brain to regain balance, and minimise dizziness when there is damage to the inner ear.These include various exercise manuvers specific to a diagnosis.For example in BPPV, we usually perform Semont's Manuver or Epleys Manuver. There are also certain eye movements,neck & head exercises.I am not describing them here as I do not want any patient to perform them without doctors advice.

Appropriate referrals to neurologists,cardiologists,endocrinologists or other specialities if suspected cause is not the inner ear.

Finally lot of reassurance & regular follow up.Also concentrate on the concomitant psychological & cognitive impairment for a holistic recovery.

Picture of a rainbow over a volcanic eruption in Tanzania.....courtesy National Geographic

Dizziness Part II: Evaluation & finding the cause of Dizziness

Dizziness evaluation is a time consuming task.Sometimes the assessment process may take few visits.

The cause of dizziness could range from peripheral vestibular disorders (related to the ear & it's structures) to Central disorders(related to other pathways connecting the balance systems including brain).

The doctors also has to rule out other causes like low blood pressure,some heart conditions to thyroid dysfunction.

The most important step towards reaching a diagnosis is history i.e.patients story.I usually encourage the patients to describe their symptoms in words other than "dizzy".

Narrate your story & if possible write it before visiting your doctor.

Important information to write down will be :

-What is the feeling during the attack ?is it rotation or unsteadiness or black out,associated with nausea or vomiting 

-How long does it lasts?seconds,minutes or hours & days.Frequency in a week,month or year.

-What are the triggers?does change of position have an effect?Is it related to viral fever,cold,noise,social situations etc

-Are there associated symptoms like ringing sound in the ear,ear fullness or deafness

-other symptoms like double vision or weakness of limbs or gait problems

-Medical history of self & family

-Treatment you have received so far & carry your medical records

I also ask patients some direct questions to complete the history.

Dr Micheal Strupp,one of the pioneers in vertigo & dizziness says 90% of the diagnosis is clinical especially good history taking.All common causes like BPPV,Meneire's disease,Vestibular neuronitis & Vestibular migraine are diagnosed by good history alone.I had to opportunity not just to meet him but also attend his masterclass on this topic.

Clinical examination:

I as a doctor need to come to two main conclusions

1.Is there a deficit?

2.Is it peripheral or central?

Bedside examination includes examination of vestibular & oculomotor system 

I am just naming them as complete description is beyond the preview of this blog meant for patients education.However just to prepare you for the doctors visit ,I must say this will involve the doctor asking you to follow the instructions to move eyes in different directions(nystagmus & saccades).It will also involve shaking your head in either direction (head tilt).The doctor will also hold your head & bring you down on the couch from sitting to lying down on each side.Finally gait or your walk will be tested with eyes open & closed.

These clinical tests are namely

1.Ocular tilt

2. Nystagmus -peripheral versus central

3. Vestibulo Ocular Reflex / head impulse test

4. Central oculomotor,vestibular or cervical reflex

5. Gait

As already mentioned 90% of diagnosis of common presentations of dizziness is clinical.Rare presentations like Multiple Sclerosis,Brain stem encephalitis or infarction will need radiology imaging like MRI.Some conditions like Meneire's an audiogram is advised.

Some Causes of Dizziness and Vertigo

1.Benign paroxysmal positional vertigo

Severe, brief (< 1 min) spinning triggered by moving head in a specific direction

2.Meniere disease

Recurrent episodes of unilateral tinnitus, hearing loss, ear fullness

3.Vestibular neuronitis (viral cause suspected)

Sudden, incapacitating, severe vertigo with no hearing loss or other findings

Lasts up to 1 wk, with gradual lessening of symptoms

4.Trauma (eg, tympanic membrane rupture, labyrinthine contusion, perilymphatic fistula, temporal bone fracture, post concussion)

5. Ototoxic drugs

Treatment with aminoglycoside drugs recently instituted, usually with bilateral hearing loss and vestibular loss

6. Chronic motion sickness 

Persistent symptoms after acute motion sickness

7.Central vestibular system disorders

-Acoustic neuroma

Slowly progressive unilateral hearing loss, tinnitus, dizziness, dysequilibrium

-Brain stem hemorrhage or infarction

Sudden onset

-Cerebellar hemorrhage or infarction

Sudden onset, with ataxia and other cerebellar findings, often headache

8. Migraine

Episodic, recurrent vertigo, usually without unilateral auditory symptoms (may have tinnitus that is usually bilateral)

Possibly headache, but often personal or family history of migraine

Photophobia, phonophobia, visual or other auras possible, helping make diagnosis

9. Multiple sclerosis

Varied CNS motor and sensory deficits, with remissions and recurring exacerbations

10. CNS-active drugs' (not ototoxic)

Drug recently instituted or dose increased; multiple drugs, particularly in an elderly patient

11. Hypoglycemia (usually caused by drugs for diabetes)

12. Hypotension (caused by cardiac disorders, antihypertensives, blood loss, dehydration, or orthostatic hypotension syndromes including postural orthostatic tachycardia syndrome and other dysautonomias)

13. Other causese

Psychiatric 

Syphilis

Thyroid disorders

List is in rough order of frequency of occurrence.

Note: drugs, including aminoglycosides, chloroquine ,Lasix  including most antianxiety, anticonvulsant, antidepressant, antipsychotic, and sedative drugs. Drugs used to treat vertigo are also included.

Dizziness Series-Part I "What is dizziness or vertigo?"

Dizziness forms about 15 - 20 % of my practice.Dizzy patients are given symptomatic treatment by general practitioners & usually they are referred to specialists like Physicians,ENT's,Neurologists,Neurosurgeons,Cardiologists and to Psychiatrists.

I thought of dividing the topic into 3 parts

1. Introduction & brief anatomy

2. Clinical Approach:Good history & targeted neurotological examination

3. Management 

"What is dizziness or vertigo?"

The term Dizziness or vertigo is synonymously used.

The term dizziness tends to be used by patients to include a wide spectrum of sensation from dizziness or disequilibrium through spatial disorientation to simple faintness,blackouts  or light headedness.Some of the patients simply refer their symptoms to Meneire's or Positional vertigo.

Literally the word vertigo has come from Latin word "Vertere" which means whirling ie to turn.Other effective definitions are "a subjective sense of imbalance "which may or may not include sense of rotation"(Kerr) & "illusionary sense of unidirectional environment and/or bodily rotational movement "(Daroff).

Balance is maintained by visual apparatus (eyes & it's neural connections ),vestibular system (includes inner ear structures -3 semicircular canals & 2 otoliths) & the proprioceptive organs (proprioceptors sensory receptors in muscles, joint capsules and surrounding tissues, that signal information to the central nervous system about position and movement of body parts).

Above chart courtesy vestibular disorder association who have a very informative website vestibular.org

Though we have three organs as mentioned above to maintain balance,two are sufficient to maintain balance.Brain decodes the signal send by these organs through respective nerves.

Disclaimer :Kindly note the above information is over simplified for a lay man to understand & in no way depicts exact neuro anatomy which is not the intention of this blog)

Patients evaluating Doctors - Just dial is enough or mouthshut.com will do?

"To observe without evaluation is the highest form of human intelligence."

- J. Krishnamurti


But we are all not non violent communicators.We are all very busy people & are very good at evaluation,labeling & commenting.We mix evaluations with observations & if someone does not come up to our expectations - we are upset.

Some examples of patient feed backs -'The doctor seemed uninterested in my illness"
'The doctor is rude" "The doctors is not fit to practice"
If you go through the above survey sites even the most respectable doctors with whom I have worked & personally know that will do no harm-get such remarks!

My immediate impulsive reply to the person who brought above feedback can be -'The patients illness probably was really not interesting.What I mean is the patient may have some common cold or viral fever."

I have all empathy for any one who is sick however when I am seeing opd in an tertiary care hospital-there are so many serious things happening around.

There should be an issue if a doctor has not treated the patient properly or poor bedside manners.

In the era of "Patient is always right" -doctors opinion or feedback are never taken.
In order to please patients doctors may be overacting or reacting i.e. to satisfy patient they may over test or over-prescribe. 

Customer satisfaction has been applied to anything & everything nowadays,but can it be applied to the practice of medicine just like in supermarkets?

In Medical practice-there are various factors to be taken into consideration.

Following applies to most of the doctors who are seeing outpatients

1.May be having a sick patient in ward/ ICU
2.May have operated early morning & the patients relatives are wanting to see. (In spite of meeting a close relative post surgery).
3.Ward patients may be in a hurry to go home & the nurse is constantly ringing to give orders
4.Phone calls either about appointment or drug or a new symptom.
5.Emergency department calls to attend a patient
6.Reports to be followed up or collected
.....so on & so forth.....Not to forget ....doctor also needs a coffee break or food.

The patients should know that the doctor needs them as well.The doctors concentrate on keeping them healthy & not "satisfied" as most of the feedback ask.

Eventually the system i.e. feedback form is designed to keep them satisfied first & healthy next.

What makes a patient most “satisfied”.. isn’t what is best for their health.

The reasons for a patient being dissatisfied with a particular healthcare encounter can be very complex.  It’s not so simple as to just include a line in a survey such as, “Were you satisfied with your doctor?

I see children & some mothers are excessively worried..sometimes I do tell them to find other ways of occupying themselves than just their child.Its for their childs wellbeing-It cannot be rude.
Some Google educated patients ask irrelevant questions-I can answer only so much in 10 minutes & sometimes stop entertaining their queries.

Not to mention just like I have many things to handle even the patient may have work stress ,an ill relative or various physical/ mental causes for being anxious or "a bad experience at a previous hospital"
There is so much going on in media that everyone comes influenced & charged.
The feedback form should be designed to take above patient factor in to consideration.

For good patient care & doctor patient relationship-not just patient satisfaction but doctors satisfaction should also be considered.

But giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.

To summarize -I personally am not against feed back.However encourage patients to describe the situation by just what they saw or heard not what they think should be.

Make your observations free from your judgments, criticism and interpretations. 

Dr. Sheelu Srinivas - The Hindu

Dr. Sheelu Srinivas - The Hindu

Being the change, they want to see - The Hindu

Being the change, they want to see - The Hindu



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