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By B. Ateras. New England Conservatory of Music. 2019.

Urgent liver drug-induced function tests and Health personnel can prevent some drug-induced acute liver failure) prothrombin Visual Ethambutol Stop ethambutol order 15gr differin free shipping, side effects buy 15gr differin mastercard, for example isoniazid-induced impairment (other seek further advice causes excluded) peripheral neuropathy cheap differin 15gr visa. The public heath priority of a National These patients should receive preventive treatment Tuberculosis Programme is to cure smear-positive with pyridoxine 10 mg daily along with their anti- cases, while avoiding drug resistance. In many countries, a significant proportion usually at the same dose but sometimes at a reduced of patients stop treatment before the end, for dose. For these patients, the supervisor right drugs, in the right doses, at the right intervals. Directly observed treatment is also Preventative measures to decrease the duration applicable in out-patient settings. The supervisor of treatment interruption may be a health worker or a trained an supervised At the time of registration of a tuberculosis patient community member. There may be an incentive starting treatment, it is important to set aside of some sort for community members to be enough time to meet with the patient, and supervisors of directly observed treatment. It is partner/spouse, parents, work place, or place of important to ensure confidentiality and that study, in order to contact the patient. Also, it is directly observed treatment is acceptable to the important to identify potential problems which patient. Directly observed therapy is always recommended in the following cases: Recommendations to help prevent the patient • two months initial phase of treatment for all new from stopping treatment too early smear-positive cases; • Be kind, friendly and patient. Contacts are • Tell the patient about local arrangements for usually limited to household contacts and to friends supervision of treatment: for example, admission sharing a similar level of contact to that of to a ward or hostel, or daily attendance at a centre household contacts. Close or household contacts near home for first 2 months, or supervision by can be generally considered to have had at least four volunteers or other persons in his village. If there is a local calendar different from the standard Managing close contacts international calendar, give the patient the date in Figures 1, 2, and 3 on the next page show how the local calendar. This will help in determining the right advice to provide about continuing the full treatment. Aspects of prevention to be discussed include: • contact tracing; • management of close contacts; and • immunization. Contact tracing Studies in the United Kingdom show that up to 10% of tuberculosis cases are diagnosed by contact tracing. Here tuberculin testing is less useful, as many adults will be tuberculin positive (especially if previously immunised). It is important to examine all adults living in the family home, particularly the grandparents, one of whom may be the infector. Controlled trials in several Western Heaf head will be released and protrude 2mm into countries, where most children are well nourished, the skin. Discrete induration of three or The tuberculin skin test 0 fewer needle sites is acceptable. Heaf test (or multiple puncture test), and Induration around each needle site merging with 2. Heaf gun, disposable Heaf heads (paediatric and Individuals who have not previously received standard). The immunised there is no evidence of the characteristic vaccine must be given strictly intradermally with scar. If the skin is visibly dirty it should be swabbed with spirit Those individuals with a Heaf grade 2, or Mantoux and allowed to dry. The Heaf grades 3 or 4, and Mantoux tests of 15 mm needle can usually be seen through the epidermis. If little resistance is felt when injecting, (For a further guide on skin testing and screening the needle is too deep – stop injecting, withdraw of high-risk groups such as new immigrants and and recommence at the correct depth. In Since chemotherapy treatment of tuberculosis has some specialized hospitals, a negative pressure already been discussed, this section will concentrate ventilation system may be available for nursing mainly on infection control issues. The negative psychological effects of isolation can be minimized by careful planning prior to Respiratory precautions prevent the spread of admitting the patient. Isolation of the patient is usually should be given to providing some recreation: recommended for a minimum of two weeks after radios and books or magazines the patient would commencing chemoprophylaxis. Three negative sputum smear toys from any patient in an isolation room as there specimens at a minimum of 24 hours apart and is a low, theoretical risk of cross-infection. Papers resolution of the cough are required before allowing should be discarded as household rubbish and toys the patient home. It is not necessary to heat treat books Out-patient clinics following use by a known infected patient. The coordinated to minimize cross infection to other mattress and pillows should be protected by patients. Any therapeutic overlay or potentially infectious or known infectious patients pressure relieving equipment must also be washable attend other departments, for example X-ray. When sputum samples are obtained in the clinic A comfortable washable chair and footstool to this should be done in a well ventilated area away allow the patient to sit out of bed should be from other vulnerable patients (see further notes provided, as should a washable chair for visitors. The movement of furniture in and out of the room during the isolation period should be minimised Page 185 In-patient treatment because everything in the room may be considered Isolation potentially infected until cleaned and disinfected. Equipment for monitoring the patient’s clinical Module 6 Page 185 condition should be available in each room and to be disposed of as contaminated and potentially kept there until he is discharged. Ideally, the patient should have his own en suite Patient clothing should be washed at normal toilet or a commode within the isolation room to temperatures. If soiled, place in a water soluble or reduce the cross infection risks in communal toilets water-soluble membrane bag to protect care staff or bathrooms. This should have hot and cold or bin with a lid to place soiled items in and do running water, liquid soap for staff use and paper not open them until reaching the laundry - lift the hand towels for staff use. If there is no washbasin clothes directly into the washing machine taking within the room a second member of staff will care not to shake the items out. Clothing should have to bring a basin of water to the door when be dried and ironed at the recommended the first one leaves. The wash wash programme to allow extra water to cloths may be disposable or changed daily and mechanically reduce the soiling. Remember that sunlight aids disinfection, and then steam iron to Now carry out Learning Activity 9. Alternatively, the items could be tumble-dried and ironed at a lower Care of bedclothes, clothing, and other linen temperature. Staff and caregivers should wear disposable gloves and plastic aprons when removing any used Coughing and obtaining sputum samples bedclothes from the bed.

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Keratosis of the feet Blackfoot disease What happens to arsenic when it enters the environment? There are tests to measure the level of arsenic in blood generic differin 15 gr mastercard, urine order 15 gr differin fast delivery, hair cheap differin 15 gr overnight delivery, or fingernails. The urine test is the most reliable test for arsenic exposure within the last few days. Tests on hair and fingernails can measure exposure to high levels or arsenic over the past 6-12 months. Methemoglobinemia can be an inherited disorder, but it also can be acquired through exposure to chemicals such as nitrates (nitrate-contaminated water), aniline dyes, and potassium chlorate. The other inheritable type, called hemoglobin M disease (Type I), is an autosomal dominant condition (you only need one affected parent to inherit it) characterized by an inability to convert methemoglobin back to hemoglobin. Acquired by Drinking Water and Other Causes Exposure to certain chemicals may also cause an increase in the production of methemoglobin. These chemicals include nitrites (used commonly to prevent spoilage of meat), xylocaine, and benzene. Nitrates and nitrites are nitrogen-oxygen chemical units which combine with various organic and inorganic compounds. Primary sources of organic nitrates include human sewage and livestock manure, especially from feedlots. Since they are very soluble and do not bind to soils, nitrates have a high potential to migrate to ground water. Because they do not evaporate, nitrates/nitrites are likely to remain in water until consumed by plants or other organisms. Short-term Excessive levels of nitrate in drinking water have caused serious illness and sometimes death. This can be an acute condition in which health deteriorates rapidly over a period of days. Nitrate levels greater than 5 mg/L indicate the possibility that agricultural chemicals may be reaching the water source, and pesticide testing is recommended. Nitrate specific resin should be used with anion exchange systems to prevent the possibility of a maladjusted or malfunctioning anion exchange system from increasing the nitrate level due to sulfate exchange. We recommend that persons shopping for nitrate removal systems shop carefully and purchase only from a dealer experienced in nitrate removal. Drinking water; national primary drinking water regulations; filtration, disinfection; turbidity, Giardia lamblia, viruses, Legionella, and heterotrophic bacteria; final rule. Drinking water; national primary drinking water regulations; total coliforms (including fecal coliforms and E. Drinking water; national primary drinking water regulations; total coliforms; corrections and technical amendments; final rule. National primary drinking water regulations: interim enhanced surface water treatment; final rule. National primary drinking water regulations: long term 1 enhanced surface water treatment rule; final rule. National primary drinking water regulations: long term 1 enhanced surface water treatment and filter backwash rule; proposed rule. Underground injection control regulations for class V injection wells, revision; final rule. National primary drinking water regulations: monitoring requirements for public drinking water supplies; final rule. Protracted outbreaks of cryptosporidiosis associated with swimming pool use---Ohio and Nebraska, 2000. Outbreak of gastroenteritis associated with an interactive water fountain at a beachside park---Florida, 1999. Pseudomonas dermatitis/folliculitis associated with pools and hot tubs--- Colorado and Maine, 1999--2000. Methemoglobinemia attributable to nitrite contamination of potable water through boiler fluid additives---New Jersey, 1992 and 1996. Drinking water: information on the quality of water found at community water systems and private wells. Outbreak of severe Pseudomonas aeruginosa infections caused by a contaminated drain in a whirlpool bathtub. Legionnaires disease associated with a whirlpool spa display---Virginia, September--October, 1996. The affected person may also have headache, fever, and abdominal cramps ("stomach ache"). In general, the symptoms begin 1 to 2 days following infection with a virus that causes gastroenteritis and may last for 1 to 10 days, depending on which virus causes the illness. The term abiotic is also used to denote a process which is not facilitated by living organisms. The absorption spectrum is studied to evaluate the function of photosynthetic pigments. Because accessory pigments have different absorption optima than chlorophylls, presence of accessory pigments allows photosynthetic systems to absorb light more efficiently than would be possible otherwise. These compounds are not dangerous to health but can make the water unpleasant to drink. Carbon filtration comes in several forms, from small filters that attach to sink faucets to large 149 Bacteriological Diseases ©11/1/2017 (866) 557-1746 tanks that contain removable cartridges. Activated carbon filters require regular maintenance or they can become a health hazard. It is composed of an outer cortex, and a central medulla, each involved in different hormone: mediated phenomena. This technology uses an up-flow clarifier with low-density plastic bead media, usually held in place by a screen. This adsorption media is designed to enhance the sedimentation/clarification process by combining flocculation and sedimentation into one step. In this step, turbidity is reduced by adsorption of the coagulated and flocculated solids onto the adsorption media and onto the solids already adsorbed onto the media. Cleaning of this type of clarifier is initiated more often than filter backwashing because the clarifier removes more solids.

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Clinical features The disease presents with an acute onset of fever order 15 gr differin with mastercard, sore throat purchase differin 15 gr without prescription, dysphagia buy discount differin 15gr on line, headache, and malaise, followed by diffuse ery- thema and vesicles. The vesicles are small and numerous, and rupture rapidly, leaving painful ulcers that heal within 7–10 days (Fig. Characteristically, the lesions appear on the soft palate and uvula, ton- sillar pillars, and posterior pharyngeal wall. The disease has a peak incidence during summer and autumn, and frequently affects children and young adults. Usage subject to terms and conditions of license 108 Vesiculobullous Lesions Hand-Foot-and-Mouth Disease Definition Hand-foot-and-mouth disease is an acute self-limiting con- tagious viral infection transmitted from one individual to another. Clinical features The disease usually affects children and young adults, and often occurs in epidemics. Oral manifestations are always present, and are characterized by small vesicles (5–30 in number) that rapidly rupture, leaving painful, shallow ulcers (2–6 mm in diameter) sur- rounded by a red halo (Fig. The buccal mucosa, tongue, and labial mucosa are the most commonly affected sites. Skin lesions are not constant, and present as small vesicles with a narrow red halo. The lateral borders and the dorsal surfaces of the fingers and toes are the most common areas involved. Erythema Multiforme Definition Erythema multiforme is an acute or subacute self-limiting disease that involves the skin and mucous membranes. However, an immunologically medi- ated process triggered by herpes simplex or Mycoplasma pneumoniae, drugs, radiation, or malignancies, is probable. Clinical features The disease more frequently affects young men be- tween the ages of 20 and 30 years. The oral lesions present as coalescing small vesicles that rupture within two or three days, leaving irregular, painful erosions covered by a necrotic pseudomembrane (Fig. The lips, buccal mucosa, tongue, soft palate, and floor of the mouth are most commonly involved. The skin manifestations consist of erythematous, flat, round macules, papules, or plaques, usually in a symmetrical pat- Laskaris, Pocket Atlas of Oral Diseases © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license 110 Vesiculobullous Lesions tern. Conjunctivitis, balanitis, vulvitis, and prodromal symptoms such as headache, malaise, arthral- gias, and fever, may also be present. Differential diagnosis Primary herpetic gingivostomatitis, aphthous ulcers, erosive lichen planus, pemphigus vulgaris, pemphigoid. Stevens–Johnson Syndrome Definition Stevens–Johnson syndrome, or erythema multiforme ma- jor, is a severe form of erythema multiforme that predominantly affects the mucous membranes. Clinical features The oral lesions are always present, and are charac- terized by extensive vesicle formation, followed by painful erosions covered by grayish-white or hemorrhagic pseudomembranes (Fig. The ocular lesions consist of conjunctivitis, uveitis, symblepharon, or even panophthalmitis. Differential diagnosis Behçet disease, pemphigus, pemphigoid, pri- mary herpes simplex. Treatment Systemic steroids; antibiotics, if considered necessary in severe cases. Usage subject to terms and conditions of license 112 Vesiculobullous Lesions Toxic Epidermal Necrolysis Definition Toxic epidermal necrolysis, or Lyell disease, is a severe skin and mucous membrane disease with a severe prognosis. Clinical features The disease usually begins with low-grade fever, malaise, arthralgias, conjunctival burning sensation, skin tenderness, and erythema. After 24 hours, blisters appear, and the skin is lifted up so that the whole body surface appears scalded. The oral manifestations consist of diffuse erythema, vesicles and painful erosions primarily on the lips and periorally, as well as on the buccal mucosa, tongue, and palate (Fig. Differential diagnosis Stevens–Johnson syndrome, pemphigus vul- garis, severe and extensive burns. Usage subject to terms and conditions of license 114 Vesiculobullous Lesions Pemphigus Definition Pemphigus is a severe chronic bullous autoimmune muco- cutaneous disease. Clinical features Four classical varieties of pemphigus are recognized: vulgaris, vegetans, foliaceus, and erythematosus. Recently, two additional forms of the disease have been described: drug-induced pemphigus and paraneoplastic pemphigus, which usually affect patients with lympho- reticular malignancies. Oral lesions are characterized by the formation of bullae, which rapidly rupture, leaving painful erosions with a tendency to extend peripherally (Figs. The buccal mucosa, labial mucosa, palate, tongue, floor of the mouth, and gingiva are often involved. The skin lesions present as flaccid bullae that rupture quickly, leaving persistent eroded areas (Fig. Any skin area may be involved, although the intertriginous regions, umbi- licus, trunk, and scalp are the most common sites affected. Lesions may develop on other mucosae (conjunctivae, nose, larynx, pharynx, genitals, anus) (Fig. Usage subject to terms and conditions of license 116 Vesiculobullous Lesions Laboratory tests Histopathological and cytological examination, direct and indirect immunofluorescence. Differential diagnosis Cicatricial pemphigoid, bullous pemphigoid, linear IgA disease, epidermolysis bullosa acquisita, toxic epidermal nec- rolysis, primary herpetic gingivostomatitis, erythema multiforme, ero- sive lichen planus, aphthous ulcers. Ciclosporin, azathioprine, and mycophe- nolate mofetil may also be used, always in association with steroids. Usage subject to terms and conditions of license 118 Vesiculobullous Lesions Cicatricial Pemphigoid Definition Cicatricial pemphigoid, or mucous membrane pemphigoid, is a chronic bullous mucocutaneous disease that primarily affects mu- cous membranes, and results in atrophy or scarring. Oral manifes- tations are seen in almost all patients, but other mucosae and rarely the skin may be involved. The oral lesions are characterized by recurrent vesicles or bullae that rupture, leaving large, superficial painful ulcer- ations (Fig. Gingival involvement is common, producing a spe- cific clinical pattern of desquamative gingivitis.

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These coupled with life style changes have led to increase in incidence discount 15gr differin amex, prevalence and mortality due to non- communicable diseases notable cardiovascular diseases differin 15gr generic, diabetes buy discount differin 15 gr line, renal diseases, cancers and other degenerative diseases. Most of these diseases can be altered by health lifestyles for which continuous multisectoral approach is required for promoting health and changing behaviours. Health Promotion focuses primarily on the social, physical, economical and political factors that affect health and include such activities as the promotion of physical activity, healthy living, good nutrition, healthy environment and control of tobacco and alcohol consumption etc. The goal of Health Promotion is to improve the quality of life of individuals and communities. This goal can be achieved by mitigating the impact of risk factors associated with the broad determinants of health as they lead to illness and premature death. The main focus of the programmes is to bring behavioural change in the life style of the community by various health promotional measures. The institute would also provide need based technical assistance to other communicable and non communicable disease programmes. Aim &Objectives To be the centre of excellence in India, for promoting health by changing lifestyle of the people through developing personal skills, strengthening community action, reorienting health services and creating supportive environment, backed by healthy public policies. To review and analyze existing sectoral policies to develop healthy public policies, carry out advocacy with allied sectors in order to incorporate requisite health components in respective policies & plan for health promotion strategies that: • Involve community in planning, policy-making, delivery and evaluation of health promotion strategies. To conduct, facilitate and build the capacity for conducting research in areas of: • Health Behavior. To build a competent health promotion work force comprising specialists, practitioners and functionaries at different levels and in different sectors aiming at : • Developing knowledge and skills for advocacy and mediation with people’s representatives; policy makers, managers, implementers in Govt. To develop communication strategies based on the life patterns, culture and languages of communities using lifecycle approach to enable : • individuals, families and communities to perceive the threat of environment and risk factors to health • Change in behavior to adopt healthy and avoid risky practices. To empower specific vulnerable and high-risk groups by formulating setting-specific strategies to enable them to promote their health: • Through ideal setting and infrastructure to support the promotion of health of a large audience by influencing "physical, mental, economic and social well-being"; • By formulating “workplace wellness programs”. Administrative & Finance Division Details of each Division are given hereunder: 270 1. Policies, Planning Strategy Development and Co-ordination Division Objectives Activities • To plan and develop evidence based 1. Identifying Policy needs to take care of the changing disease profile of India health promotion strategies among especially emerging Non-communicable Diseases 2. Review of existing policies (both health &non-health) which have a bearing on different population groups and health e. To prepare, strengthen and re-orient the existing health systemsfor health promotion work in terms of Governance (to improve access to health), country. Identify priority areas for action for the next five years in respect of Health of their policies on the health of the promotion in the existing Policies and programmes especially for non- people and to develop and implement communicable diseases. Formulating new Policies based on the data generated by the Health Promotion address determinants of health. State consultations, meetings/advocacy workshops :Development of New to create enabling environments in Policies as well as review of existing policies will require State consultations, different settings (Schools, work meeting/advocacy workshops with different stakeholders (administrators, places, industries, hospitals etc. Planning for development of Health promotion Infrastructure- alcohol and responsible sexual Improvement/up gradation of old/ existing buildings for Health Promotion ; behaviour etc. Area Specific/population-based/settings- based/problem specific Health Promotion units at different levels i. Networking, Partnerships and Inter-sectoral Coordination:To develop improving/upgrading existing necessary linkages, networks and Partnerships in the priority areas for action institutions to build strong health with both National and International organizations promotion infrastructure and its 10. Coordination with the sectors within and outside the health system to institutionalization in the country. To plan, design and conduct research studies on the Policy Research determinants of health as well as health related behaviour, Policy research will include studies which provide attitudes, beliefs & knowledge among members of the evidence for policy-makers to develop and implement community with regard to desirable health practices in public policy for improving the health of the order to feed and support the policy makers / planners and population. To coordinate, develop & strengthen the capacity at the attitudes, beliefs & knowledge of the community and central & state levels as well as South East Asia region to Assessment of Health Promotion Needs gather evidence through research on health promotion in Programme Development & Evaluation order to support policy, advocacy and programmes of Generate data for for evaluating ongoing health interventions pertaining to health promotion. To plan, design and conduct research studies on various interventions in collaboration with practitioners, health promotional initiatives focussed on different settings policymakers & local communities in the identified for health promotion (schools, workplaces, hospitals areas as listed under the ingredients. To conduct evaluation studies on various healths’ particular focus on equity of access. To collect, review and analyse the information on health stakeholders promotion research in order to document and disseminate to Documentation and dissemination of information all stakeholders including practitioners, funders, related to health promotional research to all policymakers, researchers and the general public and allied. To collaborate with universities, research and training related components of various National institutions to promote research studies on various issues Programmes for chronic diseases. Human Resource Development Division Objectives Activities • Prepare and standardize training curriculum 1. Identify Human Resource needed for Health for the training of various categories of promotion and develop training programmes personnel from health and allied fields and accordingly e. Experts in Policy areas, Social peoples representatives Scientist Strategies development, Research, Bio- • Sensitize the govt. Curriculum development for Training for at national and state level to the need of various stakeholders in the focus areas as coordinating the efforts of various mentioned under Ingredients. Conduct In service training programs for • provide training in health promotion medical and paramedical professionals, teachers through long and short term training and other stakeholders programmes for both technocrats and 4. Conduct Need based Orientation and bureaucrats to equip them with knowledge Sensitization courses for different stakeholders on various health promoting aspects including Schools, Panchayati Raj Institutions and requiring policy level decision Community members. Conducting seminars; symposiums conferences services to the selected field area etc throughout the year 8. To identify health promotion needs in respect of different health settings • To help formulate healthy public 2. School Schools/ Adolescent Health Interpersonal communication colleges, workplaces, health colleges/ Healthy behaviour Organizing Declamations, seminar, workshops, facilities village’s cities etc. Nehru Yuva • To help build appropriate Educating specially Kendra, Campaigns, Provision of special infrastructure and partnership challenged children schools and educators for specially challenged mechanisms for implementation of children health promotion Hospitals Health Patient Safety and Hand Hygiene Promotion, Safe Waste programmes/policies for different centres Infection Control Disposal, Safe Surgeries, Green buildings, settings. Healthy and Safe Landscaping , Solar Energy, Horticulture, Hospital environment Water Harvesting, Disabled friendly, Disaster • To provide orientation and training preparedness to various stakeholders to ensure Workplaces Healthy environment Executive Health programmes, fitness and yoga their broadest possible and healthy centres, De-Stress workshops. Settings child health, nutrition communication in local dialects etc Market place Healthy environment Clean toilets, General Sanitaion, Disabled • To formulate interventions aimed Friendly, Safe products, Fire prevention, at improving the access to essential Zoning, Safe food, Display information on health and nutrition care food products, Waste disposal, Safe water Fairs and Mela Crowd Management, Sanitation • To identify the social determinants Chlorination of water etc.

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The intensifies with increase in deafness and tympanic membrane shows bulging and looks profuse discharge continues to drain from the more congested cheap differin 15 gr free shipping. The Ear discharge cheap differin 15 gr with mastercard, usually profuse cheap differin 15gr on line, purulent or mucosa of the middle ear if seen through the creamy, for more than 2 weeks duration perforation is much congested and thickened. It is The mucosa of the middle ear through a to be differentiated from furunculosis of central perforation of the tympanic memb- posterior meatal wall as it pushes pinna rane, if visible, shows marked congestion and forwards to downwards and obliterates thickening. Postaural abscess This is most common appears in front of and above the pinna form presenting over mastoid. There may be associated Acute Suppurative Otitis Media and Acute Mastoiditis 61 iii. Bezold’s abscess Here swelling is present in the upper part of neck and it forms because of pus going through the tip of mastoid into the sheath of sternocleido- mastoid muscle or via the digastric muscle to the chin. Citelli’s abscess The abscess is found in the digastric triangle of neck, as pus goes through the inner table of mastoid tip along posterior belly of digastric muscle. Retromastoid abscess It is formed behind the mastoid along mastoid emissary vein, on the occipitotemporal suture. Constitutional symptoms like fever, body- ache, malaise and loss of appetite are the other accompanying features of the acute mastoid Fig. Radio- logical examination of the mastoid in the coalescent stage shows clouding of the air cells with destruction of all cell partitions, thus there occurs loss of clarity and distinctiveness of the air cells. Treatment Acute suppurative otitis media In the initial stages of the disease, nasal decongestants, antihistaminics, analgesics and antibiotics like Fig. Myringotomy provides drainage to the pent- up secretions and relieves the pain without the tissue necrosis of the tympanic membrane. Besides the systemic antibiotics (preferably following a culture sensitivity test of the ear discharge), the external canal should be cleaned of the discharge by suction or dry mopping and local antibiotic drops instilled. Mastoid surgery is reserved for those who start to develop a subperiosteal abscess, any Fig. There Indications are two types of incisions—posterior myringo- tomy and anterior myringotomy incisions The common indications of this procedure are (Fig. Acute suppurative otitis media, parti- Posterior myringotomy A J-shaped incision is made in posteroinferior quadrant of the cularly during exudative stage when the tympanic membrane as this is most accessible drum is bulging or the patient has severe area, is relatively less vascular and there are pain. In cases where deafness persists even after In acute otitis media a small 3-4 mm incision apparent control of acute suppurative is generally all that is required. In secretory otitis media, for aeration of the Anterior myringotomy This is done for the inser- middle ear (grommet insertion) and tion of grommets and for facilitating aspira- removal of secretions. In Ménière’s disease, myringotomy some- times gives dramatic relief though the exact In cases of purulent discharge drainage is mechanism is not known. This includes mastoid exploration and If a grommet has been introduced the exenteration of the cell tracts leading to patient is warned against getting water into petrous apex. Masked Mastoiditis Complications Those cases of acute mastoiditis which do not present with the typical symptoms and signs These include incudostapedial joint disloca- are grouped under the term masked or latent tion, injury to the chorda tympani nerve, and mastoiditis. This is usually the result of injury to the jugular bulb which may be pro- inadequate treatment with antibiotics, which jecting into the middle ear due to a dehiscence slow the process but do not completely check in its floor. There is a Gradenigo’s Syndrome dull aching pain with some amount of deaf- This symptom complex occurs when the ness and low grade fever. On examination, the process of acute mastoiditis involves the cell tympanic membrane shows an inflammatory tracts leading to petrous apex and causing thickening and congestion of the tympanic petrositis. Some amount of postaural otorrhoea, trigeminal neuralgia (headache, periosteal thickening with mastoid tenderness retro-orbital pain) and sixth nerve palsy. Radiological examination reveals is probably due to oedema involving the sixth the coalescent process of the mastoid. Persistent mucosal disease: Infection reaches the middle ear either through the eustachian tube or through a perforated tympanic membrane. These hyperplastic mucosal proliferations trap the infection which is responsible for its chronicity. In some cases especially in sclerotic mastoids, mucosal proliferation leads to polyp formation (Figs 10. Cholesterol granuloma: The middle ear gets ventilated through the eustachian tube. When there is mucosal hypertrophy it may block the posterior portion of the tympanum, thus creating vacuum which Figs 10. This provokes a foreign body reaction resulting in the formation of cho- lesterol granuloma. There is also an extremely vascular granulation tissue containing numerous cholesterol crystals, blood pigments, and giant cells. Tubal type: In this variety the infection The Ascaris had crawled up from upper respi- ascendes through the eustachian tube and ratory tract (Fig. Clinical Features This type is usually seen in children from the low socioeconomic strata and often 1. Tympanic type: In this variety the infection On examination, the external auditory reaches the middle ear through a defect in canal is seen full of mucopurulent dis- the tympanic membrane, usually a large charge and there is usually an anterior central perforation (persistent perforation perforation of the tympanic membrane. This is usually seen in adults nasal examination, a deviated nasal and often involves one ear only. There is septum, features of sinusitis or adenoids usually profuse discharge which responds may be seen. Tympanic type: It is usually seen in adults mality of the nose, paranasal sinuses and who complain of deafness and repeated nasopharynx, and if found, it should be infection of the ear. Aural These patients complain of improved toilet is better performed under the hearing when the external auditory canal microscope and the ear examined in detail is full of pus, which deteriorates when the for any pathology that may otherwise be pus is mopped off. Culture sensitivity: Culture sensitivity of the that the transmission of sound waves is discharge is done to select proper antibio- better in the presence of pus. Both systemic as well as local anti- Patch test A cigarette paper or a piece of biotics are used. Local antibiotics are used gelfoam is placed on the tympanic membrane as ear drops and include neomycin, genta- perforation and the patient asked if he hears micin, quinolones and chloramphenicol better. Surgical Management (Tubotympanic Type) The aim of surgery is to provide a safe, dry Investigations and a hearing ear.