2015 - The year which lead me from a job to a career

There is a not of unrest amongst doctors these days.The growth of private corporate hospitals is  making it difficult for private practices to survive.Managers in these hospitals are looking for turnovers and quarterly growth. Doctors are stuck between good medical practices and economics of getting that paycheck.

This is beautifully sum up in an article http://www.forbes.com/sites/susanadams/2012/04/27/why-do-so-many-doctors-regret-their-job-choice/.Though it's in American context,some applies to us as well.
"The transformation of the field from independence and professionalism to being commoditized and feeling like you’re just another worker is disheartening to some,” says Howard Forman, a professor at the Yale School of Management who researches diagnostic radiology, health policy and healthcare leadership.

I myself had a successful job at a corporate hospital for ten years. My passion for pediatric ENT took me to Spastics Society of Karnataka and Indira Institute of Child Health,working as an Honarary.

I started doing ground work on pediatric deafness when I started the pilot of Universal hearing screening at K C General Hospital in 2013.I worked with NRHM .(National Rural Health Mission)

Finally the decision of leaving a corporate OPD practice came and it was not easy. I still need to go to a corporate to operate as I perform high end surgeries like Cochlear Implantation.I also perform Endoscopic Sinus surgery and do Base of skull work with Neurosurgeons.

Within 6 months of leaving corporate and starting our Anganwadi and government school screenings,we were rolling.We were the finalists in the prestigious BMJ South Asia Award in Healthcare Advocacy Category.

There is a long road ahead..

I want to see a day where Newborn hearing screening is made Mandatory in India nad every child is screened regularly till age 6 years.

Along with above,I wish to support as many under privileged hearing challenged children as I can and help them to be mainstreamed.

All of above is only possible with the support of my team and well wishers

Age appropriate Speech and Hearing in children

Hearing and speech together forms almost 40% of all disabilities in children, early diagnosis is the key for habilitating these children.

1-5:1000 children are born with some degree of hearing loss. 5-10% of pre-schoolers have speech problems. Hearing is critical for learning speech, language and communication. Apart from hearing loss, other causes of speech delay include learning disabilities, structural abnormalities like cleft palate, autism spectrum disorders, expressive speech delay to name a few.Early diagnosis for disabilities means diagnosis at birth or below three years.If the diagnosis is delayed,i.e. after 6-8 years,it is difficult to mainstream.

Below is the age appropriate hearing and speech chart from birth to 5 years. 

I must mention that if a child achieves about 70 % of these milestones, it is satisfactory. If any concerns, child should be assessed by a doctor immediately. Hearing screening should be done in all babies at birth. Hearing loss can be confirmed as early as 3 months of age and habilitation should be started as soon as the diagnosis is confirmed.

Hearing and language communication starts at birth

Hope we celebrated Diwali safely...

Sharing an article with views from our center in Deccan Herald

http://www.deccanherald.com/content/510898/dark-side-light.html

The dark side of the light - Deccan Herald

www.deccanherald.com › Supplements › Metrolife

Oct 9, 2015 - Dr Srinivas HV, medical director of Aditya Netralaya, sees around four to five ... Dr Sheelu Srinivas, Consultant ENT Surgeon and Director,Dr Sheelu’s ENT Centre and Deafness Habilitation Uni

Sound pollution also occurs during this season. Dr Sheelu Srinivas, Consultant ENT Surgeon and Director, Dr Sheelu’s ENT Centre and Deafness Habilitation Unit, says, “There is not much that one can do about this apart from staying away from crackers entirely or bursting the less noisy ones.” 

She adds, “If a cracker bursts very close to the ear, the person may experience a ringing sound in the ear or a tear in the eardrum. Any noise above 85 decibels can cause damage to the inner ear.” She advises people to burst crackers in larger spaces. “They can also use ear muffs as this dampens the sound out.

Listen.Speak.Educate...Compete

Anyone listening!

http://www.publishaletter.com/readletter.jsp?plid=61063#.VgaOlKedTTs.facebook

Lets raise awareness about deafness in children-Early diagnosis and habi...

We are shortlisted for BMJ South Asia 2015 Awards:Healthcare Advocacy

This is for our work on deafness:early diagnosis and intervention in the community.
It means a lot to my team of audiologists,speech pathologist,Pediatricians, immunisation nurses,ASHA workers,Anganwadi teachers,Parents,Volunteers and our supporters

http://southasiaawards.bmj.com/about-bmj-awards/

There is a long road ahead but early diagnosis and intervention is the key.We have been proposing pediatric hearing screening in immunisation OPD.As regarding rehabilitation,again early and we advocate speech,language and education for the young deaf (infant to 6 years).This will prepare them for mainstream or integration.
Deafness is a silent disability but not a mental disability,early habilitation can make them independent and a productive member of our society.

Discussing Cochlear Implants with Deaf Leader

Language Deprivation Syndrome Lecture

Though this lecture is for an hour,for professionals working with hearing impaired- its an eye opener.I am speechless..I should say..

I have learnt Hindi as my mother tongue L1 and went ahead to learn Marathi,English,Telugu,Kannada...now I want to learn Indian Sign Language.When I say learn and speak,I learnt grammar and vocabulary of these languages.
I can understand and speak few words of Malayalam,Tamil,Gujarati,Punjabi and Bengali being with friends.In our field,we say incidental learning of another language.

Presently,in my opinion- it's almost impossible to convince hearing parents about signing!I hope they educate themselves about the advantage of bilingualism.The best change to learn language for these children born to normal hearing parents is to diagnose them at birth and amplify by 6 months,at least with a hearing aid. 

Cochlear Implant Surgeon learns from Cochlear Implant Engineers:Sharing a wonderful talk by Prof. Rahul Sarpeshkar

Though we as Surgeons counsel patients for surgeries and read about implants,talks like these are very informative.This helps me to understand implants better and give proper information to patients or parents.
We have to remember that once inserted,Cochlear Implant is a lifetime commitment.

Hearing loss and deafness treatment-Role of Cochlear Implants

Hearing loss can be classified as conductive or Sensorineural or mixed.
It can also be temporary or permanent or progressive.

How do we hear?

The sounds are collected by outer ear pinna and carried through the ear canal.This vibrates the eardrum and the tiny bones of hearing in turn.These vibrations are carried to the inner ear or Cochlea where it is converted to electrical impulses and finally carried to brain through nerve of hearing.The auditory area of brain interprets the sound.


If there is a disease or problem in outer or middle ear,usually its conductive hearing loss.For example ear wax or middle ear fluid.
If the disease spreads from middle ear to inner ear,it causes mixed hearing loss.

Sensorineural hearing loss occurs if the infection involves inner ear or deafness from birth due to various causes.
Clinical examination and audiological tests helps us to diagnose.Sometimes we may need scans-HRCT/MRI.

Depending on the diagnosis,treatment is planned.
For infection-medical treatment.
Middle ear fluid may need drainage.Chronic ear  diseases may need surgery.

The treatment of Sensorineural hearing loss also depends on diagnosis.If its Sudden Sensorineural Hearing Loss,it may need oral steroids as the cause is usually Viral.

However manytimes an MRI Scan is ordered to rule out other pathology.

Finally Sensorineural Hearing loss-Progressive or from birth

This may need fitting of hearing aids with auditory,speech and language therapy.

Most of the times children welcome the world of sound.Few take time to keep the hearing aids on for the daytime.The therapist and mother work on auditory and language training.

Cochlear Implants are for those children who do not do well with hearing aids.There are various audiological,radiological and social criterias for Cochlear Implantation.

A cochlear implantee attending auditory verbal therapy with mother.

Newborn Hearing screening

Hearing tests in children

Hearing tests in children are usually ordered by pediatrician or ENT doctor if the child presents with ear problems like infections or hearing and speech concerns expressed by parent or teachers.

However we need to be aware that newborn hearing screening is mandatory by law in the developed part of the world.1:1000 babies are born with some hearing problem and this ratio increases if the baby is high risker i.e. icu stay at birth,jaundice etc at birth.

So lets start with newborn hearing screening.For this screening we do Oto acoustic emissions,referred as OAE.
In this test a soft probe is gently inserted in baby's outer ear canal and the test is recorded.

Here is a test done in NICU,nurse is gently holding the probe and audiologist is performing OAE.

The test takes 2-3 minutes for both ears.It can be done in natural sleep.Here is a video

The test report of OAE is given as Pass or Refer.The refer ones are retested in 2-3 weeks.

If a baby fails OAE ,then ABER (Auditory Brainstem Evoked Response) or BERA is done.

ABER can be done in natural sleep in very young babies.Most of the children need oral sedation for this test.None of these test are painful,its just that even a swallow movement can intefere with the results.

Here are pictures of BERA test ,electrodes are taped over forehead and behind the ear with probes on each side.

Above test are both objective.As the baby grows,we can also do subjective tests.

Subjective tests are also done in newborns and below 18 months of age,but are not confirmative.

There are other subjective tests in children like Visual Reinforcement Audiometry.

Conditioned Play Audiometry

The commonest test used in clinical practice is Impedence audiometry or Tympanometry to rule out fluid in the ear or glue ear as well as eustachian tube block.This test again involves inserting a probe in outer ear canal and takes few seconds to give a recording:graphs as below

So,in a nutshell all tests are safe.If any concerns,kindly meet your pediatrician and discuss.

Final word "›Tests are not infallible, they are only as good as those taking, administering and interpreting them …”

If in doubt,observe the child and repeat the test.

Role play between two hearing Habilitated siblings:Cochlear Implantee and Hearing aid user

https://www.youtube.com/watch?v=D--_CbrR6Ys&sns=fb

Removal of Adenoids and Tonsils:Which technique?How to take decision?

Removal of Adenoids and Tonsils/Adenotonsillectomy is commonly indicated in the following conditions:

1. Recurrent infections:more than 3-4/years for 2 consecutive years 
2. Upper airway obstruction due to enlarged tonsils and adenoids
3. Peritonsillar Abscess
4. Asymmetrical Size of Tonsils
5. Adenoidectomy especially if recurrent middle ear infections or sinusitis in children

Surgical Removal of adenoids and Tonsils can be done through following techniques:

in the order of older to newer techniques as they evolved.We shall discuss how we decide which technique to be used at the end of the article.

• Cold knife (steel) dissection:Gold old method using surgical dissection of tissues with bleeding controlled with taking ties.
• ElectrocauteryThermal Dissection
• Harmonic scalpelThis medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second.
• Radiofrequency ablationMonopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis. However, tonsils may re-grow after this procedure.
• Carbon dioxide laserHand-held CO2 or KTP laser to vaporize and remove tonsil tissue.  
• MicrodebriderThe microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery.  
• Bipolar Radiofrequency Ablation (Coblation):This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs.

I have personally been trained and used all above techniques.Harmonic Scalpel and Coblation while training in the U.K.I also learned Bipolar Tonsillectomy which if used carefully gives good outcomes.

As a Surgeon,my decision to use any particular technique depends on following factors :

• I have to first be familiar and learn each technique.
• Then go through medical literature about randomised controlled trails and their results about each technique.
• Availability of equipment in my setting
• One technique or combination of technique
• What has worked for my patients so far in terms of less bleeding and less pain
• Lastly..Do No Harm.

Tonsils can be examined in the opd on oral examination.

I must make a special mention about Adenoids here.Anatomically the adenoids sit at the back of the nose,behind and above soft palate.Here is a picture of nasoendoscopy done in the opd (picture 1) to look for the size of adenoid(picture 2)

The approach to adenoid has improved with endoscopes through the nose.There is a risk of incomplete removal of adenoids with traditional method.Newer techniques like Microdebrider and Coblater will ensure complete removal and avoid regrowth.

I am very comfortable to use dissection Technique for tonsillectomy with minimal bipolar for hemostasis with excellent outcomes in the last 9 years.For Adenoidectomy,I use Microdebridor or Coblator.

What medical literature says..these are articles from Medline Database

Laryngoscope. 2009 Jan;119(1):162-70. doi: 10.1002/lary.20024.
Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study.
Wilson YL1, Merer DM, Moscatello AL

Otolaryngol Head Neck Surg. 2003 Oct;129(4):360-4.
Hot versus cold tonsillectomy: a systematic review of the literature.
Leinbach RF1, Markwell SJ, Colliver JA, Lin SY

Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004619.
Coblation versus other surgical techniques for tonsillectomy.
Burton MJ1, Doree C

Dear Patient "Lets talk simple..not Google"...

 Particularly in 2014 ,I felt more & more patients have been expressing themselves in medical terms.
"Doc,I have sinus..I have bent nasal bone"..
"I have chest congestion"
This could have been expressed as headache,facial pain or nose block or a difficulty in breathing.

In medical school,we were taught to take a history which is asking symptoms like pain in ear/throat,block,discharge and so on..
Then we need to examine & look for signs of the disease.

A combination of signs, symptoms & clinical examination leads to a diagnosis.
This diagnosis can be final or provisional.
In provisional diagnosis ,we need further tests or another visit for a final diagnosis.

Patients should lead us to diagnosis rather than expressing the diagnosis themselves.

Another new in the passing year is the stress on time spent.This is not dependent on the successful diagnosis reached.
The same symptoms will be told by patients in various ways & it eventually means the same to me.Hence sometimes,I may have to stop them & come to the diagnosis & treatment.

Even a viral cold needs attention & empathy.However due to the pressure of seeing various patients,some having tumor or cancer or disability, I am hard pressed to spend less time with above patients. 

In the treatment- things like after food or before food tablet is necessary.If I miss it patients do ask repeatedly & its fine.

Look at following questions I have been repeatedly asked:

Salt warm water gargles is with common salt/iodised/rock salt?
How to take steam inhalation?
To apply ointment over skin before food or after food ?

Sometimes in practice these questions can be annoying.
Probably I am from old school of thought.
I do understand that except boiling water,there are various options for steaming available now like an electric steamer or sauna!

Lets stand together & hope even better relationship with patients in the coming year.... 

Google and internet searches are also required.Search Engine optimization is also there....Be careful on fully trusting all information on the net.