Clinical proceedings of panel discussion on Discharging Ear, Facial Palsy, hearing rehabilitation after cochlear implants

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24th National ENT Conference
Clinical proceedings of panel discussion on
Discharging Ear, Facial Palsy, hearing
rehabilitation after cochlear implants

KARACHI: Dr. Ausaf Ahmad moderated the panel discussion on discharging ear during the recently held 24THnATIOAL ENT conference at Karachi. Members of the expert’s panel were Dr. Iftikhar Salahuddin, Raesuddin Siddiqui, Manzoor Ahmad, Shamim Ahmad, Dr.Hafeez Sheikh and Zubair Ahmad. In the introductory remarks it was stated that discharging ear is a very common problem and thirty to thirty-five patients are seen in an OPD of which 50% are in the paediatric age group. SCOM remains the main focus. He then presented a few case histories and the panelists were invited to give their comments on their management.
The first case was a 24 years old male with bilateral recurrent ear discharge for the last 10-12 years. He had no headache, no vertigo; he had used lot of antibiotics. He already had tonsil and septum surgery and there was no evidence of cholesteatoma. He was diagnosed as bilateral mixed deafness. Dr. Iftikhar Salahuddin opined that this patient can be prepared for ear surgery. I do not operate on any ear unless I examine these patients under microscope. I do not want to see surprises, if there is some other pathology, I would like to see it. Dr. Shamim said that since the patient has had lot of antibiotics already, one must consider how to control the infection, ask for CS report and examine under microscope. Dr. Manzoor said that such ears do not get dry with oral and systemic antibiotics. There could be some fungal infection; hence it will be advisable to add some antifungal as well. Is it necessary to have a dry ear before surgery, he asked? One should not ignore focusing on nose and throat. Patients living in poor localities with discharging ears, it may be difficult to dry such ears. Oto endoscopy can help it provide better illumination, it helps but it is not mandatory.

Prof. M. Amjad Councilor of CPSP presenting a memento to Mr. Atif
Jameelur Rehman from Optical Palace at the recently held ENT
Conferencein Karachi. Picture also shows Dr. Sameer Qureshi,
Prof. Saleem Marfani and Dr. Salman Mutiullah Shaikh.

Dr. Hafeez Sheikh was of the view that it is essential to find out for how long one should go for conservative management and wait for surgery? One should discourage use of liquids; instead powder should be used for good clinical examination after suction and clearance. Send swab for culture examination and discourage use of topical antibiotic drops. As regards use of pre operative CT Scan, Dr. Iftikhar Salahuddin said he won’t use it unless he suspects any pathology. One should not use CT scan of ear for routine test. Indications for cholestetectomy should be clear. Tympanoplasty and mastroidectomy have different indications. Dr. Rais said that in certain cases, prophylactic antibiotics should be used.
Talking about cholesteatoma surgery, Dr.Manzoor said that it is difficult to educate the patient for two stage operation; he won’t accept second operation and will go to another doctor. We have successfully treated lot of patients with too much infection in single surgery. There are a very few conditions wherein cholesteatoma will be left and will require surgery later if the patient comes back with aggressive disease. Dr. Iftikhar Salahuddin said that he prefers inside out technique in cholesteatoma. One does not open the whole mastroid that is why he prefers it. First chance is the only chance one gets to eradicate the disease as patients do not want to come back again and again. We also lack resources to put in prosthesis which are quite expensive. It was also stated that one should try to have a dry ear before surgery. Participating in the discussion Dr. Iqbal from UK remarked that you need to have National Guidelines on management of discharging ears. For how long the ear should be dry before one goes for surgery. One finds lot of difference of opinion among the panel members. Efforts should be made to give perfectly functioning ear to the patient. Dr.Manzoor remarked that making the ear dry is one thing but rehabilitation is the other important problem in such patients.

Facial Palsy Session

Panelists in this session included Dr.Naveed Aslam, Prof.Iqbal Butt, Dr.Shaukat Malik, Prof.M.Jalisi and Prof. Mohibullah Khan. It was pointed out that treatment of bells palsy is conservative but I will go for decompression if the patient fails to respond in two to three months said Prof.M. Jalisi. Prof.Mohibullah Khan said that 80% of patients recover from bells palsy whether you treat it or not. There are numerous cases in USA and the surgical treatment is decompression but with no good results. Post surgical or nerve palsy, three months is not enough for conservative treatment. Go for MRI and other investigations after six to eight weeks. We do underuse EMG; the idea is to have regeneration even if it takes one year. One should never do decompression or opt for reconstructive procedures unless one has given enough time. Dr. Shaukat Malik opined that we should give patient life otherwise it will be dull. Do electromyography, if regeneration has taken place, one should wait for one year and then go for decompression. Prof.M.Jalisi said that late Prof. A.U. Lone went for decompression; we used to do it and always got good results.
The second case which was presented was about high resolution CT scan in child after trauma. It was suggested that one should see if there is a hairline fracture, track the facial nerve. Dr.Shaukat Malik said that such patients develop immediate palsy, their referral to ICU is delayed and they take more time to recover. He suggested high resolution CT and EMG.
The third case was a female who developed facial palsy six weeks after surgery for mastroidectomy. Prof.Iqbal Butt said that one should do mastoids on cadavers and make sure that you do not cut the facial nerve. Some surgeons cut it and then learn. Counseling of these patients was also emphasized. One should talk to them about the surgery, talk to the surgeon who had done the operation earlier and have more information about the disease. If possible invite him to be around when you operate on that patient Dr.Naveed Aslam remarked. Then reassure the patient that he they will get better. Talk to the surgeon. Remember it is difficult surgery. Such things do happen and they are very well documented.

Hearing Rehabilitation after Cochlear Implant

Members of the expert panel in this discussion included Dr.Naveed Aslam, Dr. Iqbal, Ms.Tahira Aleem and Dr.Shakil Razi. Dr. Iqbal Kiyani was the moderator. It was pointed out that implant does not bring back the hearing to normal. There are single chamber and double chamber implants. Dr.Fasihulalh Mir started doing cochlear implants in Karachi in the private sector and has so far done about half a dozen cases with good results. Lahore has taken the lead and cochlear implant team there has done a large number of cases with good results. It is not the surgery alone which matters but it is also important as to which type of cochlear implant was being used. Minimum requirements for cochlear implants should be monitored as it is a long process. The staff doing cochlear implant at DIMC had two years special intensive training for rehabilitation. Success rate even in best centers of the world is between 45-60%. Be careful not to overstate the results. One has to be ethical. Success rate will improve with the passage of time. Overseas experience is there but one needs to diagnose what is best for you keeping in view the local circumstances and facilities available. In Pakistan the government is not at all interested in cochlear implants programme as it has too many other priorities in health sector. In UK, it was a charity programme which we did it, remarked Dr.Iqbal. We got no support from the government. The trend was set in UK thirty years ago and now things are moving in positive directions.
It is the surgeon who comes and selects the patient for cochlear implant and it is done by a team. Wrong patient, wrong time and wrong implant will give the worse results. Audiological assessment is a must and most important. High resolution MRI should be done to identify the cochlear nerve. It is still under debate whether in CSOM one should remove all the mucosa and then do the cochlear implant. CSOM is not a contra indication. If the patient is prone to infection, be careful with cochlear implant as you are at risk of losing this implant. Specific conditions will require specific implants and expertise of audiologist is also extremely important.
Talking about the difficulty faced while doing cochlear implants, Dr.Aslam said that we do CT and MRI both. There is lot of information which one can get on CT like normal cochlea. If the device fails, the manufacturer provides a new one but if there is infection, one will have to pay for the device. Ms. Tahira Aleem highlighted the advantages of per operation NTR. In case of bilateral implant, electrodes are connected to the other cochlea at the same time. One can use one implant with two electrodes in adults but not in children as their scalp is growing. Bilateral implant is available and is being done routinely. Responding to questions from the audience, it was stated that it is the surgeon who decides the switch on time whether it will be after two to three days or more. After one years time, one gets the full fledged sound and it does take time.