A study to determine factors influencing outcomes of paediatric cochlear implants

Background

Cochlear implantation is a powerful tool for helping children with severe to profound sensorineural hearing loss to gain the ability to hear, achieve age appropriate communication skills. However patient selection is of utmost importance to achieve optimum results.

Method

A cross sectional study was done on 75 children who had undergone unilateral cochlear implantation. Hearing was assessed by, The Meaningful Auditory Integration Scale (MAIS) and speech perception was assessed by the Meaningful Use of Speech Scale (MUSS) as a parent reported scale in an interview format.

Results

The cochlear implantation improved auditory skills and speech perception of the children who underwent cochlear implantation. Children who had less than 40 months auditory deprivation and those who had higher educated parents had better auditory skills and speech perception.

Conclusion

Early cochlear implantation and good auditory verbal therapy have better outcomes of hearing and speech.     

Effects of ageing on speed and temporal resolution of speech stimuli in older adults

Background

According to previous studies, most of the speech recognition disorders in older adults are theresults of deficits in audibility and auditory temporal resolution. In this paper, the effect of ageing on timecompressedspeech and auditory temporal resolution by word recognition in continuous and interrupted noisewas studied.

Methods

A time-compressed speech test (TCST) was conducted on 30 young and 32 older adults with normalhearing thresholds. Lists of monosyllabic words were used at three time compression ratios. Auditory temporalresolution was determined by measuring the monosyllabic word recognition score (WRS), in the presence ofcontinuous and interrupted noise, at three signal-to-noise ratios (S/Ns).

Results

There was a significant difference in TCST scores at the three compression ratios within and betweenyoung and older adult none (p< 0.001). Similar results were obtained in WRSs at the three S/Ns in the presenceof interrupted and continuous noise (p< 0.001), and in the degree of auditory temporal resolution(p=0.007). A significant correlation was found between the level of test difficulty of TCST with WRSs in bothyoung (r = 0.549, P=0.002) and older adults (r= 0.531, P=0.003).

Conclusion

Our results showed that ageing remarkably affects the processing of fast speech stimuli and temporalresolving ability. These results are more supportive of the effect of ageing on speech perception than onloss of hearing.     

Cochlear Implant : Anaesthesia Challenges

Background

Cochlear implants are now an acceptable therapeutic option for those patients with irreversible hearing loss and deaf-mutism. The surgery is time consuming and complicated. Hence, the technique of anaesthesia plays a crucial role in success of cochlear implant surgery. Cochlear implant patients have various types of syndromes which are important from anaesthetic as well as surgical point of view. Pre-implant preparation requires objective assessment of hearing, plain X-rays of skull and a CT scan of the temporal bone. Anaesthesia is required for objective assessment of hearing in children under five years of age, to obtain X-rays of skull, magnetic resonance imaging (MRI), CT scan, brain evoked response audiometry (BERA) testing and finally for cochlear implant surgery. Anaesthetic considerations include preoperative familiarisation with the patient and his family. Syndromal illnesses have specific anaesthetic significance such as presence of difficult airway or prolonged QT interval. Parental presence is highly desirable during induction of anaesthesia. Electro-surgical instruments especially monopolar ones, should not be used once the cochlear implant is in place.

Methods

In our institution, all cases (15 children) received their cochlear implants under general anaesthesia and formed the study group. Children were administered midazolam orally and inj ketamine during CT scan. Our techniques of general anaesthesia were modified to permit use of nerve stimulators during surgery. To minimise the incidence of vertigo particularly after cochleostomy, postoperative nausea and vomiting, all patients received glycopyrrolate and fentanyl citrate intravenously prior to induction. Other agents used were, thiopentone, suxamethonium and end-tidal 1.3 MAC halothane in 1:2 mixture of oxygen and nitrous oxide (O₂ and N₂O). Electro diathermy was switched off, before the cochlear device was implanted on the patient. Patients were allowed to breathe spontaneously whenever nerve stimulator was used to locate the facial nerve. Inj Ondansetron 0.1 mg/kg was used as anti-emetic agent. Postoperative pain relief was initially provided with fentanyl 1 μg/kg IV and later with syrup ibuprofen.

Results

There were no remarkable anaesthetic or surgical complication in our series except perilymph leakage in two cases.Key Words: Anaesthesia technique, Cochlear implantation, Deaf-mutism     

Use of Otoacoustic Emissions (OAE) to detect sub-clinical inner ear damage in divers of the Indian Navy

Background

Professional Divers are at a high risk of Sensorineural Hearing Impairment. Divers may sustain sub-clinical hearing loss that is not identified on pure tone audiometry (PTA). Otoacoustic Emissions (OAE) reflect the functional status of the Outer Hair Cells. OAE testing constitutes the only non-invasive means of objective cochlear investigation and may be a more sensitive measure than PTA in identifying sub-clinical hearing loss.

Methods

This cross-sectional study was performed to determine utility of Otoacoustic Emissions testing in detecting sub-clinical Inner Ear damage in divers of Indian Navy. Transient Evoked Otoacoustic Emissions (TEOAE) levels were measured in 50 audiologically asymptomatic ship divers of Indian Navy and compared with control group comprising of 50 normal hearing individuals.

Results

No statistically significant differences were observed between the study and control group. Also no correlation was observed between diving years and TEOAE levels. There was no correlation greater than −0.49 between diving years and TEOAE SNR.

Conclusions

We concluded that TEOAE levels are not a sensitive tool in identifying ships divers without any history of noise exposure at risk for developing hearing loss.     

A Survey of Deaf Mutes

Background

Detection of hearing loss at birth or early childhood is difficult. This bears on the rehabilitation of the child as the golden period of learning is lost. Reliable statistics relating the average age for detection of hearing loss and fitting of hearing aids in children are not available in our country. A survey of 52 deaf mutes was therefore conducted to ascertain the probable causes that lead to deafness.

Methods

The study subjects were 42 deaf mutes from the Government run school for deaf mutes and 10 from ASHA School run by the Army Wives Welfare Association. A questionnaire prepared in Hindi was filled by the parents and data analysed.

Results

The average age of detection of hearing loss was 2.8 years and the average age for receiving a hearing aid was 7.6 years. Thus due to the significant reduction of sensory input at the ‘golden period of learning’ only 50% of those fitted with a hearing aid found it useful. In 42.3% the cause of deafness could not be identified.

Conclusion

Greater emphasis is required on early diagnosis of childhood deafness and fitment of hearing aid.Key Words: Deaf mutes, Hearing aid     

Clinical Profile of Special Children at Asha Centre

Background

The care of special children suffering from cerebral palsy, deaf mutism, mental retardation (MR) and post encephalitic sequelae etc. is done in the armed forces at “ASHA” centre supported by Army Wives Welfare Association (AWWA).

Methods

The clinical profile and underlying etiological factors in these children were studied.

Result

Out of 30 children studied, majority were males. The commonest disability was cerebral palsy, seen in 13 (43%) cases followed by mental retardation in six (20%) and post encephalitic sequlae in four (13%) cases. Convulsions were noticed in 12 (40%) cases. The delayed speech was a significant handicap observed in 27 (90%) cases.

Conclusion

Among the etiological factors, natal causes and infections are leading factors in these children and there is an urgent need to strengthen the existing maternal and child health services in our country.Key Words: Cerebral palsy     

Furlow's Palatoplasty for Cleft Palate Repair

Background

The major drawbacks of standard procedures of palatoplasty have been inadequate palatal lengthening, velopharyngeal incompetence, impaired maxillary growth with mid-face retrusion and high fistula rates. The Furlow''s double opposing Z-plasty is accepted as one of the better procedures for treating cleft palates.

Methods

This paper compared Furlow''s procedure to Veau Kilner Wardill''s procedure performed on 63 patients from July 2000 till February 2005.

Results

The results were compared in terms of the fistula rates, palatal lengthening, nasal regurgitation, velopharyngeal incompetence, improvement in speech, hearing and maxillary growth.

Conclusions

The Furlow''s technique offered better results irrespective of the age, type and extent of the cleft in the palate.Key Words: Palatal lengthening, velopharyngeal incompetence, maxillary growth, fistula rates, Furlow''s palatoplasty     

Manual Small Incision Cataract Surgery: Experience at a Military Hospital

Background

Small incision cataract surgery came into practice with the advent of phacoemulsification. However, manual small incision cataract surgery (SICS) is a useful alternative for those who do not have access to phacoemulsification machine.

Method

A total of 69 cases of cataract were undertaken for manual incision cataract surgery and intra ocular lens (IOL) implantation using 6mm straight incision. The surgical technique and postoperative results are compared with the results of phacoemulsification and IOL implantation.

Result

Average postoperative astigmatism was ± 0.75 dioptres. Postoperative uncorrected visual acuity (UCVA) of 6/18 or better was observed in 51(71.9%) cases after first week of the surgery.

Conclusion

The study concludes that both phacoemulsification and small incision cataract surgery with intraocular lens (IOL) implantation are effective methods. However SICS with IOL implantation is a useful alternative in the absence of phacoemulsification machine.Key Words: Manual Small Incision Cataract Surgery (SICS), Extra Capsular Cataract Extraction (ECCE), Phacoemulsification, Intraocular lens implantation     

Resolution pattern of jaundice among children presenting with severe malaria in rural South-West Nigeria

Objective

To compare the pattern of jaundice resolution among children with severe malaria treated with quinine and artemether.

Methods

Thirty two children who fulfilled the inclusion criteria were recruited for the study from two hospitals with intensive care facilities. They were divided into two groups; ‘Q’ and ‘A’, receiving quinine and artemether, respectively. Jaundice was assessed by clinical examination.

Results

Sixteen out of 32 children recruited (representing 50%) presented with jaundice on the day of recruitment. The mean age was (7.00°C2.56) years. On day 3, four patients in ‘A’ and six patients in ‘Q’ had jaundice. By day 7, no child had jaundice.

Conclusion

The study has shown that both drugs resolve jaundice although artemether relatively resolves it faster by the third day.     

Laparoscopic Simulators : Are They Useful!

Background

Laparoscopic surgery has changed the face of medical care forever. The benefits of laparoscopic open surgery have been demonstrated in virtually all major abdominal surgical procedures. Laparoscopy has introduced a new skill set that must be mastered and requires dedicated training. The teaching of laparoscopic operative skills in the clinical setting is constrained by the complexity of procedures, medicolegal and ethical concerns, fiscal and time limitations. This has created the need for formal training outside the operating room. Simulator-based training holds great promise in enhancing surgical education and providing a safe, cost-effective means for practicing techniques prior to their use in the operating room.

Methods

The surgical residents of two batches were recruited for the study. The residents were randomized to either a group that received training on a simulator or a controlled group that did not receive the training or to a group that received training twice.

Result

The residents who received training on a simulator demonstrated better psychomotor skills in the operation theatre than those who did not. Training in simulator environment can contribute to the development of technical skills relevant to the performance of laparoscopic surgery in vivo. Training at regular intervals will benefit the residents in gaining significant improvement of their psychomotor skills.

Conclusion

Laparoscopic trainer is a promising tool for training in laparoscopic surgery.Key Words: Laparoscopic simulator, Endotrainer, Training, Laparoscopic surgery     

Auditory functionality and early use of speech in a group of pediatric cochlear implant users

This study examined auditory functionality and early use of speech in a group of paediatric cochlear implant users. Parents of 33 implanted children from the Universiti Kebangsaan Malaysia Cochlear Implant Program were interviewed using the Meaningful Auditory Integration Scale (MAIS) and the Meaningful Use of Speech Scale (MUSS). In general, higher MAIS scores post-implantation were significantly associated with higher MUSS scores suggesting that those with better functional hearing with the implant were also better in using spontaneous speech to communicate. Multiple regression analyses showed that several time factors significantly correlated with the MAIS scores post-implantation but not with the MUSS.     

Prevalence and Parental Awareness of Hearing Loss in Children with Down Syndrome

Background:

To establish the prevalence of hearing deficit in children with Down syndrome (DS) in Hong Kong as measured by brainstem auditory evoked potentials (BAEP). The secondary objective is to examine the agreement between BAEP and clinical questioning in detecting hearing deficit in DS.

Methods:

Consecutive DS patients attending the Down''s Clinic in a regional pediatric referral center were recruited into this cross-sectional study. BAEP data performed within 12 months were retrieved. The care-taker was interviewed with a structured questionnaire to detect any symptom of hearing impairment. BAEP findings and clinical questionings were compared in an agreement analysis using quadratic weighted kappa statistics.

Results:

Fifty DS patients (35 male, 15 female, mean age 11.70 years ± 5.74 standard deviation) were recruited. Eighteen patients (36.0%) were identified having hearing deficit by BAEP. Among patients with hearing impairment, 13 patients (72.2%) had a conductive deficit, and most have mild to moderate hearing loss. Five patients (27.8%) had sensorineural deficit and most have moderate to severe degree. Eight (44.4%) had bilateral hearing deficit. Care-takers of 13 patients (26.0%) reported symptoms of hearing impairment, with 9 (69.2%) having mild symptoms, 3 (23.1%) had moderate symptoms and 1 (7.7%) had severe symptoms. The weighted kappa was 0.045 (95.0% confidence interval − 0.138–0.229), indicating very poor strength of agreement between BAEP and clinical questioning. For patients with conductive hearing impairment, only 1 patients (7.7%) recalled history of otitis media.

Conclusions:

The estimated point prevalence of hearing impairment in Chinese DS children in Hong Kong is 36%. Our finding of poor strength of agreement between objective testing and symptom questioning reflects significant underestimation of hearing impairment by history taking alone. In view of the high prevalence and low parental awareness, continuous surveillance of hearing is mandatory for DS patients throughout childhood and adolescence.     

Terrorism,Trauma and Children

Background

Terrorist attacks, armed conflict and all forms of catastrophe, tax our ability to cope, understand and respond to the situation. Children are more vulnerable.

Material & Method

16 children, victims of a terrorist attack in an army residential camp were managed for their physical injuries and evaluated for psychological trauma.

Results

All patients recovered from physical injuries, except one baby of two months, who died due to severe chest trauma. 5 children presented with Acute Stress Reaction. 3 recovered well and two, showed persistent poor scholastic performance even after one year.

Conclusion

A terrorist attack, not only results in physiscal scars but also causes psychological trauma, which requires emotional support and needs to be followed up on a long term basis.Key Words: Terrorism, Trauma, Children, Gunshot injuries, Acute Stress Reaction     

Visualisation of the Bonebridge by means of CT and CBCT

Background

With the Bonebridge, a new bone-anchored hearing aid has been available since March 2012. The objective of the study was to analyse the visualisation of the implant itself as well as its impact on the representation of the bony structures of the petrosal bone in CT, MRI and cone beam CT (CBCT).

Methods

The Bonebridge was implanted unilaterally in two completely prepared human heads. The radiological imaging by means of CBCT, 64-slice CT, 1.5-T and 3.0-T MRI was conducted both preoperatively and postoperatively. The images were subsequently evaluated from both the ENT medical and nd radiological perspectives.

Results

As anticipated, no visualisation of the implant or of the petrosal bones could be realised on MRI because of the interactive technology and the magnet artefact. In contrast, an excellent evaluability of the implant itself as well as of the surrounding neurovascular structures (sinus sigmoideus, skull base, middle ear, inner ear, inner auditory canal) was exhibited in both the CT and in the CBCT.

Conclusion

The Bonebridge can be excellently imaged with the radiological imaging technologies of CT and CBCT. In the process, CBCT shows discrete advantages in comparison with CT. No relevant restrictions in image quality in the evaluation of the bony structures of the petrosal bones could be seen.     

Percutaneous Closure of Perimembranous Ventricular Septal Defect with Amplatzer Device

Background

The Amplatzer perimembranous ventricular septal occluder is an innovative device for percutaneous closure of perimembranous ventricular septal defects (PMVSD). In appropriately selected cases this procedure is safe and effective.

Methods

Fourteen patients with the mean age 10.53 years (range 18 months to 55 years) and mean body weight 20.64 kg (range 6 to 52 kg) underwent PMVSD closure.

Result

The PMVSD mean diameter was 5.28 mm (range from 4 to 9 mm). Implantation was successful in 92% of the cases and all patients had complete occlusion of the shunt within three months.

Conclusion

Device orientation was excellent in all cases. Device-related aortic insufficiency, tricuspid insufficiency or left ventricular dysfunction was not observed. One patient had embolisation of the device and another had complete heart block which required a permanent pacemaker implantation. The excellent short term results need to be confirmed over long-term follow-up.Key Words: Perimembranous ventricular septal defect, Arrhythmias, Percutaneous closure     

Delayed recognition of congenital heart disease

Objective

The aim of this prospective study was to evaluate the proportion of children with delayed recognition of congenital heart disease (CHD).

Methods

Of the 744 children with CHD primarily diagnosed during a 10 year period in one hospital, the patients were identified where the diagnosis of CHD was established with a significant delay.

Results

Sixty six patients (8.9%) had delayed diagnosis of CHD. Among patients with cyanotic CHD, 10.4% (7 of 67 cases) were referred after they had initially been discharged home from the birth clinic. Among patients with acyanotic CHD, 8.7% (59 of 677) of all children and 35.1% (59 of 168) of the children who required surgery or interventional catheterisation were referred at an age where elective repair should have already been performed or needed immediate treatment because of their haemodynamic status. Of the 66 patients with delayed diagnosis, one infant with cor triatriatum died at admission because of delayed referral and 10 children had severe complications: preoperative cardiogenic shock in seven cases of aortic coarctation and one case of endocardial fibroelastosis, pulmonary hypertensive crisis in one child after delayed repair of a ventricular septal defect, and infectious endocarditis after dental care in a teenager with undiagnosed moderate aortic stenosis, who required Ross operation a few months later.

Discussion and conclusion

A substantial proportion of CHD was detected with relevant delay. In all cases of late diagnosis, clinical cardiac findings were present that should have alerted the physician on the possible presence of underlying CHD.     

Comparison of Phaconit Rollable IOL with Acrylic Foldable IOL

Background

Phaconit or ultra micro incision phacoemulsification cataract surgery involves phacoemulsification through a 0.9 millimetre sleeveless phaco tip and irrigating chopper followed by implantation of a rollable intraocular lens. The procedure leads to negligible astigmatism and faster visual recovery as compared to phacoemulsification with a foldable intraocular lens.

Methods

This prospective study analysed 80 cases of sub millimetre phaconit surgery with implantation of rollable intraocular lenses(IOL) in 40 cases and acrylic foldable IOL in the remaining 40 cases. Evaluation of efficacy and adaptability of procedure, equipment settings, operative constraints, postoperative complications, keratometric and topographic evaluation of induced astigmatism with visual outcome and patient''s rehabilitation were studied.

Results

The intraoperative complications were surge/ chamber collapse in 16 (20%), iris chaffing in one and corneal burns in two cases. All cases had an induced astigmatism of less than or equal to ± 0.25 D in four to six weeks after rollable IOL and ± 0.5 D to ± 0.75 D after acrylic IOL implantation. All patients had best-corrected visual acuity of 6/6 by third post operative day.

Conclusion

Phaconit with rollable IOL is a perfect blend of surgical skill, application of technology and ultra thin IOL.Key Words: Phaconit, Ultra micro phaco, Submillimetre incision, Rollable IOL implantation     

Phacotrabeculectomy Versus Conventional Combined Technique in Coexisting Glaucoma and Cataract

Background

To evaluate and compare efficacy and outcome after single site phacotrabeculectomy and conventional combined surgery in cases of coexisting primary open angle glaucoma and cataract.

Methods

This prospective study on fifty patients of concurrent primary open angle glaucoma and cataract, who had undergone combined surgery as single site phacotrabeculectomy or conventional single site trabeculectomy with extracapsular lens extraction with IOL implantation in 25 cases each. Evaluation was based on operative and postoperative complications, control of IOP and visual outcome. The follow up period ranged between twelve months to eighteen months.

Results

The mean medically controlled preoperative intraocular pressure was 22 mm of Hg (Range 18 to 35 mm of Hg) by applanation method of tonometry. The range of postoperative intra-ocular pressure after one year was 11 to 22 mm of Hg in first and 14 to 26 mm Hg in second group. Failure to maintain optimum postoperative IOP without Beta-blocker was more frequent after conventional combined procedure. There was no significant difference in incidence and pattern of postoperative complications.

Conclusion

Phacotrabeculectomy provides effective and sustained visual recovery and adequate control of intraocular pressure as compare to conventional combined procedure.Key Words: Phacotrabeculectomy, Comparison with conventional combined procedure