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G
GUIDE BOOK
Balasubramanian Thiagarajan
1
Chennai
This e book was authored to serve as a guide to post graduate students pursuing
otolaryngology degree / diploma under The Tamilnadu Dr MGR Medical University.
This e book describes what a student of otolaryngology should do to complete the
course and come out with flying colors. This book helps the fresh student of
otolaryngology to understand the Tamilnadu MGR Medical University regulations,
syllabus, examination pattern etc. This book discusses the various aspects of
dissertation preparation.
This book is the first of its kind authored with an intention of helping the
postgraduate student in taking those baby steps, which is important before the
actual sprint.
Contents
1. Introduction - 4
2. Duties and Responsibilities – 6
3. Syllabus – 9
4. Clinical examination pattern – 14
5. Theory examination pattern for post graduate degree – 16
6. Theory examination pattern for post graduate diploma – 18
7. Outpatient instruments – 19
8. Books and journals – 24
9. Online resources – 25
10. Soft skills development for post graduates – 26
11. Clinical examination techniques in otolaryngology - 27
12. Dissertation – 54
13. Art of choosing dissertation topic – 56
14. Aims of dissertation – 60
15. Documentation - 69
Introduction
Otolaryngology as a specialty has under gone tremendous changes during the past
20 years. Lots of innovative equipment have been added to the armamentarium of
the otolaryngologist. This has emboldened members of the specialty to walk
through unchartered territories. Adjacent anatomical areas like orbit and skull base
are no more rigid boundaries for the otolaryngologist. Now more and more head
and neck oncological surgeries are being performed by otolaryngologists. Skull base
has successfully been breached. Studies reveal more and more otolaryngologists
are taking up thyroid surgeries. In a nutshell this is no more a specialty confined
only to tonsil / nasal septal surgeries. Boundaries cease to exist.
High definition Endoscopes and Angled Endoscopes provide the user a clear image
and has the ability to look around corners. It is not an understatement to say that
every nook and corner of the nasal cavity is within the reach of Rhinologist now.
Major advantage the present generation otolaryngologists have is the falling price of
nasal endoscopes. With the mandatory Royalty period with Hopkin's University
over, the manufacturers don’t have to pay royalty money to the university and they
readily pass on the concession to the customer. As with any other surgical specialty
it is a steep learning curve to climb for the budding otolaryngologist. With practice
and diligence nothing is impossible. This book is meant to give insight on various
aspects of otolaryngology to the incoming post graduate student. Even though
otolaryngology is an undergraduate subject, getting oriented in examination of ear /
nose / throat takes some time for the student. According to the author's rough
estimate it takes about a month for a student to get trained in using head mirror
and Bull's lamp to examine a patient. A post graduate student during the period of
study should acquire skills in managing patients with various otolaryngological
problems. In Indian scenario there are no simulated exercises for otolaryngology
students. They are simply pushed into the sea with instructions on how to swim.
More over the standard of training also varies from institution to institution. Now is
the time for the MCI to standardize post graduate training so that all our students
will get uniform training where ever they study.
The following surgeries which were not part of otolaryngologist's domain some
years back is very much in their domain now. They are:
5. Thyroid surgeries
Usually it takes some time for an otolaryngologist to master all the skills of the
trade. During the post graduate period they should strive to achieve competence in
basic otolaryngological surgical procedures which include:
Even though this list is no means complete but every postgraduate student should
attempt to master these procedures during their training period. Usually they have
2 / 3 years of study period at their disposal depending on whether they pursue
Masters degree / Diploma in otolaryngology.
During the first year of study a post graduate student is posted as Junior Resident in
otolaryngology. During the 2nd and 3rd year of their course they are posted as
senior Residents.
1. They are primarily responsible for patient care under guidance from senior
residents, Assistant Professors and Professor.
2. They should serve as first point of contact whenever queries are raised
pertaining to patient care.
3. In the face of persistence of symptoms / non alleviation of symptoms
Assistant Professors and Professors come into the picture
4. Junior Residents should render outpatient care, In patient care and
emergency care.
During the first 6 months of their Junior Resident period a post graduate student is
under direct supervision of senior resident. When they are adequately trained they
will go to a stage of indirect supervision with help available if necessary
immediately. Every Junior Resident is expected to reach the stage of working under
indirect supervision from the 7th month of their post graduate training period.
They will be posted in various departments for training purposes as given below:
For MS (ENT):
First year:
--------------
Total 12 Months
Second Year:
-------------
Total 12 Months
Third Year:
At the end of the First year of post graduation students of both diploma and masters
in otolaryngology will have to take up Applied basic sciences and audiology
examination (Theory).
Syllabus for Basic sciences Examination for Diploma and MS (ENT) Students:
Anatomy:
Internal ear
The Ossicles
Stapes
External Ear
Squamous portion
Mastoid portion
Petrous portion
Tympanic portion
External ear
Middle ear
Internal ear
4. Anatomy of cranial nerves: with particular reference to facial and auditory nerves
Venous sinuses
The brain
Development
The tonsil
The Mediastinum
Development of face
Bacteriology Syllabus
3. Neisseria group
4. Proteus group
4. Immunology
Biochemistry syllabus:
tracheostomy.
Pharmacology syllabus:
Pathology Syllabus:
Shock – Pathology
Special Pathology:
Ear:
Inflammation of Mastoid
Nose:
(Pre Nasal).
Constitutional diseases.
Physiology Syllabus:
Coagulation of blood.
Taste.
Smell.
Heating.
Physiology of deglutition.
Audiology syllabus:
Sound production.
Physics of sound.
The vibration.
The decibel.
Propagation.
Sound conduction.
Vestibular function.
Semicircular canals.
SCHEME OF EXAMINATION
(3x40 marks)
-----------
Total 200
-----------
1. OSCE = 50
------------
Total 100
------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
1. Pathology 05
2. Microbiology 05
5. Operative Surgery 05
6. Instruments – 5 (numbers) 05
8. CT/MRI – 5 (numbers) 05
9. Audiogram 05
(BERA/OAE/VEMP/CHAMP/
IMPEDENCE)
-----------
50
-----------
Note: Serial No. 1 to 10 should be common to all the candidates appearing on that
day.
PASS
Minimum 100 50 50
Candidate must pass each component separately. Even if a candidate fails in one
component, the candidate is deemed to fail in the whole examination.
At the end of first year of their course they need to sit for an university examination
which will be on applied basic sciences and Basic General Surgery. This theory paper
will be for 100 marks totally out of which securing 50 marks is a must for passing the
examination.
Paper I:
At the end of the course a post graduate student will take up 4 papers in theory
examination.
Paper IV: Recent advances in ENT Medicine and surgery as applied to ENT
Each of these question papers will be of 3 hours duration and 100 marks maximum.
A student will have to secure 50% in each of these papers for securing pass in the
theory examination.
Essay questions = 2
Marks = 15 each
Short notes = 10
Marks = 7 each
At the end of I year of the diploma program a student will have to take up a theory
exam covering basic topics in otolaryngology. This paper will be for 100 marks out
of which a candidate will have to secure 50 to pass the examination.
On completion of second year of diploma program a student will have to appear for
theory examination comprising of two papers.
Paper III - This paper includes otolaryngology including head and neck oncology and
Endoscopy
Each of these papers is for 100 marks out of which a candidate will have to
separately score 50% in each paper to pass the examination.
Log book:
All post graduate students are expected to maintain a log book. This is nothing but
a daily journal written by them. These log books need to be signed by Assistant
professors and Professors periodically.
Log book will have to be submitted by the student during their examination for
evaluation as separate marks are awarded for it.
Details of patients seen by the student, with neat illustrations. Details of surgeries
performed / assisted by the student including follow up records. Case discussion if
any participated by the student should also be recorded in this register.
Case record register - for recording case details pertaining to the approved
dissertation topic.
These instruments are necessary and will save them lots of trouble when they are
on duty. All these are specialized instruments which may not be available in all
wards.
Books:
Journals:
1. Laryngoscope
2. Archives of otolaryngology
3. North American Clinics of Otolaryngology
4. JLO
Online resources:
1. http://drtbalu.co.in/
2. http://drtbalu.com
3. http://otolaryngology.wikidot.com/
4. http://www.scribd.com/drtbalu
5. http://entscholar.net
6. http://enttutorials.com/
7. http://tonsil.entresources.net/
8. https://sites.google.com/site/drtbalusotolaryngology/
9. http://oscenotesent.wikidot.com
10. http://entslides.wikidot.com/
Present day post graduate student should be adept at modern communication skills
and computer skills. They should be conversant with:
1. Word processing - This will help them immensely in their publication efforts
and dissertation work
2. Presentation software - They should be conversant with currently available
presentation software like power point, Libre impress etc. This will help
them during preparation for case presentations and conference
participation.
All post graduate degree students are expected to submit one paper to Online
journal published by the University. This is again mandatory for the student in order
to become eligible for appearing for the examination.
Examination of Ear Nose and Throat needs specialized illumination and instruments.
Since these are cavities proper illumination, focusing of illumination special
instruments are necessary.
2. Mobile illumination like the Clair's head light, or cold light based head bands.
Bull's lamp: is a semi mobile source of illumination. It has a 100 watts milk white
bulb which provide the source of illumination. This light is focused with the plano
convex lens placed in front of the bulb. Ideally the Bulls lamp is placed 6 inches
above and behind the left shoulder of the patient, at the level of left ear of the
patient.
The examiner and the patient must be conveniently be seated on adjustable stools.
While using a Bull's lamp the examiner must focus the light using a head mirror to
illuminate the patient.
The head mirror is a concave mirror. It has a hole in the center. The approximate
focal length of the mirror is about 10 inches. It has a plastic head band with a lever
with 2 ball and socket joints. The joints are at right angles to each other.
Focusing the light with head mirror: The art of focusing the light to the desired spot
comes only with practice. But there are certain basic steps which must be followed.
1. The patient sitting on the stool must be at the same level as the doctor.
3. The distance between the doctor and the patient must not be more than 8 inches
(i.e. the focal length of the head mirror).
4. The mirror is fixed over the right eye in such a way part of the mirror touches the
nose.
5. The mirror is adjusted in such a way that the right eye sees through the hole in
the mirror. The mirror is adjusted while keeping the left eye closed and the right
eye is kept open. Then both eyes are opened.
Clair's head light provides mobile illumination. The source of light is from a small 9
volt bulb. It is placed in front of an adjustable concave mirror. The mirror and the
bulb are held via a plastic adjustable head band. The power supply to the bulb is
from a 9 volt transformer. The major advantage of this illumination is that it is
freely mobile and the patient may be examined in various positions. This
illumination is highly useful while performing operative procedures inside the
theatre.
Examination of throat:
1. Lips
2. Teeth
3. Gums
4. Tongue
7. Cheeks
1. Uvula
2. Soft palate
4. Tonsils
1. Malignancy
2. Herpes
3. Primary syphilis
Teeth and gums must be carefully examined for evidence of focal sepsis. Bleeding
gums are commonly seen in vitamin c deficiencies.
Tongue should be carefully examined. The patient's ability to protrude the tongue is
also ascertained. If the patient has tongue tie then full protrusion of tongue is not
possible. Size of the tongue must also be seen. Macroglossia is seen in acromegaly
/ Down's syndrome.
In hypoglossal nerve palsy the tongue deviates to the side of the lesion. The tongue
on the paralyzed side may show wasting of lingual musculature. Fasciculation of
tongue is seen in motor neuron disease.
Loss of papilla is seen in patient's with vitamin deficiency, in those patients who
have under gone irradiation of that area.
Malignancy of tongue is common over its lateral surface. Any suspicious swelling of
tongue must be palpated for signs of induration, which is a characteristic feature of
malignant lesions of tongue.
Tongue coating is seen in cases of oral thrush and in patients with febrile illness.
Opening of the wharton's duct can be seen under the tongue. If there is swelling in
this area then it must be palpated to rule out submandibular gland calculus.
The opening of the parotid duct can be examined after gently retracting the cheek.
It lies opposite to the upper second molar.
The position of the uvula must be seen. Normally uvula is in the midline. In cases of
palatal paralysis uvula deviates to the opposite side.
Grade 0 - Tonsils are found confined to the space between the anterior and
posterior pillars
Grade 1 - Tonsils are enlarged and is just seen coming out of the anterior pillar.
Grade 2 - The enlarged tonsil reaches to about half the distance of uvula.
Grade 3 - The enlarged tonsil comes into contact with the uvula.
Grade 4 - The enlargement of tonsil is so much that both tonsils lie virtually in
contact with each other i.e. kissing tonsils.
Hypopharynx include:
2. Pyriform fossa
1. Indirect laryngoscopy
3. Imaging
Indirect laryngoscopy:
2. It is held like a pen in the dominant hand with the mirror pointing downwards.
3. The mirror is warmed with a spirit lamp, the temperature is tested on the back of
the hand
4. The patient is asked to protrude the tongue and it is held with a gauze.
5. The mirror is introduced into the mouth and gently slide under the uvula.
Otological examination:
Before proceeding with clinical examination perse a good history taking is a must.
Without proper history taking it is not possible to come to a reasonably correct
diagnosis by clinical examination alone.
1. Deafness
2. Discharge
3. Tinnitus
4. Pain
5 Vertigo
Deafness: The patient must be asked whether deafness was sudden in onset, or
gradual in onset. If deafness is sudden in onset the triggering event if any must be
sought for. For example, deafness following head injury may be caused by a fracture
of petrous portion of temporal bone. If the damage occurs to the auditory nerve the
patient may have sensori neural hearing loss. Damage to 8th nerve is common
following transverse fractures of temporal bone. Sometimes acute trauma may lead
to dislocation of the ossicles causing conductive hearing loss. Of the 3 ossicles incus
is the most commonly dislocated bone following trauma.
1. Presence of wax (conductive deafness) - Patient will c/o severe itching in the
affected ear
In patients with deafness associated with ear discharge the presence of perforation
in the ear drum could be the cause.
In all patients with c/o deafness a proper drug history is a must. Ototoxic drugs like
streptomycin, gentamycin and aspirin may cause irreversible damage to the hair
cells of the cochlea causing sensori neural hearing loss. These drugs also sensitizes
the hair cells of the cochlea to damage due to noise exposure, hence occupational
history of these patients is a must. H/O exposure to loud noise must be sought.
Discharge: Ear discharge is one of the common problems that brings the patient to
the doctor. Before examining the patient a detailed history regarding
2. Quantity of discharge
3. Quality of discharge
If the duration of discharge is short then acute conditions must be borne in mind.
Common acute conditions which can lead to ear discharge are
2. Otomycosis - common fungi affecting the external canal are candida and
aspergillus fumigatus. Candida gives a curdy appearance in the external ear canal. In
a dried up state it could appear like a cotton wool. Aspergillus fumigatus appears as
a black color patches in the external auditory canal. These patients have ear
discharge mostly just wetness, not profuse in nature, associated with intense
itching.
Bedside test - One useful bedside test for CSF otorrhoea is Handkerchief test. If the
secretion is mopped with a handkerchief and allowed to dry, there will be stiffening
of the handkerchief if the discharge is from the middle ear because of the presence
of mucous, if the discharge is csf there is no stiffening seen.
Another important factor in the history taking is asking for the quantity of discharge.
If the discharge is profuse the following conditions must be borne in mind: chronic
mastoiditis, mastoid reservoir, extra dural abscess. Of these three in extra dural
abscess the discharge is so profuse the external canal fills up with pus immediately
after mopping. The presence of mastoiditis or mastoid reservoir can be ruled out by
looking out for tenderness in the mastoid tip area. In children with well
pneumatised mastoids the pus may cause erosion of the outer cortex and present as
a collection just under the mastoid periosteum. This condition is known as sub
periosteal abscess. If the ear discharge is scanty and foul smelling osteitic reaction
due to infection must be suspected. This is frequently caused by the presence of
cholesteatoma in the middle ear cavity associated with bone erosion.
Tinnitus
Tinnitus is defined as hearing abnormal sounds in the ear. It can be classified into
objective tinnitus and subjective tinnitus. Objective tinnitus is the one which is
heard by both the examiner and the patient eg palatal myoclonus. Subjective
tinnitus is heard only by the patient. Even a simple problem like impacted wax can
cause subjective tinnitus by the process of amplification of endogenous sound
(internal milieu sounds of the body like the sound of circulating blood, contraction
of muscle etc) Commonly tinnitus (subjective) in the absence of impacted cerumen
indicates early sensori neural hearing loss. This is caused by damage to hair cells of
the cochlea. The damage could be due to the adverse effects of medicines like those
belonging to the group of antibiotics, diuretics or cytotoxic drugs. Tinnitus
associated with hearing loss is commonly a manifestation of Meniere’s syndrome.
Tinnitus in this syndrome is roaring in nature and resolves within a day. It is also
associated with giddiness.
Pain: is one of the common complaints in patients with ear problem. Pain in the ear
can arise from 2 sources, pain due to problems confined to the ear, and referred
otalgia i.e. pain that is referred to the ear from a problem arising from other areas,
i.e. pain associated with tonsillar infection has a propensity to radiate to the ear due
to common nerve supply i.e. glossopharyngeal nerve. Pain due to inflammation in
the external ear is intense and is associated with swelling of the external auditory
canal. This can be differentiated from pain arising from middle ear inflammation by
the presence of tenderness on pressing the tragus. This sign is known as the tragal
sign. Tragal sign is negative in otalgia due to middle ear causes. Pain due to
mastoiditis (inflammation of mastoid air cells) can be differentiated from pain due
to otitis externa by the presence of three point tenderness. Three point tenderness
is elicited by using the middle finger to apply pressure over the well of the concha,
index finger is applied over the mastoid process, and the thumb is used over the
mastoid tip. The pressure over the well of the concha indicates tenderness over the
antral area, tenderness over the mastoid process indicates the presence of
mastoiditis, and tenderness over the tip of the mastoid process indicate
inflammation and thrombosis of mastoid emissary vein.
Inspection:
Evidence of previous surgery / presence of scars in the post aural / end aural region
The ear drum can be examined using an otoscope. The pinna should be grasped
between the index finger and thumb and is pulled postero superiorly. This
maneuver straightens the external canal bringing the ear drum into full view. This
maneuver should be done only in adults. In infants the pinna must be pulled
posteriorly and downwards in an effort to straighten the external canal. This is
because of the fact the bony portion of the external canal is not fully developed in
infants.
The use of Grubber's aural speculum itself is sufficient to straighten the external
canal. The status of the canal skin / presence or absence of discharge is noted. The
whole of the ear drum is visualized by tilting and moving the otoscope in various
directions.
The ear drum is roughly oval in shape and about 1 cm in diameter. Normal ear drum
is pearly white in color. The following structures of ear drum are visualized:
1. Attic area
2. Pars tensa
3. Cone of light
Head of stapes
Promontory
Perforations any must be identified, its position clearly documented. Through the
perforation the status of the middle ear mucosa must be observed and
documented. Presence of tympanosclerotic plaque (chalky mass over the ear drum)
is an indicator of previous ear disease.
The cone of light must be observed for any distortion. Cone of light is absent in
perforated ear drums, is distorted in retracted ear drums. It is also distorted when
the ear drum is bulging as in the case of Acute otitis media.
Mobility of the ear drum must be tested using a pneumatic otoscope, or a Siegel’s
speculum. The mobility of the ear drum is restricted in adhesive otitis media.
A Siegel’s pneumatic speculum has an eye piece which has a magnification of 2.5
times. It is a convex lens. The eye piece is connected to a aural speculum. A bulb
with a rubber tube is provided to insufflate air via the aural speculum. The
advantages of this aural speculum is that it provides a magnified view of the ear
drum, the pressure of the external canal can be varied by pressing the bulb thereby
the mobility of ear drum can be tested. Since it provides adequate suction effect, it
can be used to suck out middle ear secretions in patients with CSOM. Ear drops can
be applied into the middle ear by using this speculum. Ear is first filled with ear
drops and a snugly fitting siegel's speculum is applied to the external canal. Pressure
in the external canal is varied by pressing and releasing the rubber bulb, this
displaces the ear drops into the middle ear cavity.
Useful bedside test for hearing is performed using a tuning fork. Ideally 3
frequencies are used 256 Hz, 512 Hz, and 1024 Hz. These three frequencies are used
because they fall within speech frequency range. An ideal tuning fork should have
the following features:
Tuning fork tests are performed to identify whether the patient is suffering from
conductive deafness, sensor neural deafness, or mixed deafness. Three tests are
performed towards this end. They are 1. Rinnes test, 2. webers test, 3. Absolute
bone conduction test / ABC.
Rinnes test: Ideally 512 tuning fork is used. It should be struck against the elbow or
knee of the patient to vibrate. While striking care must be taken that the strike is
made at the junction of the upper 1/3 and lower 2/3 of the fork. This is the
maximum vibratory area of the tuning fork. It should not be struck against metallic
object because it can cause overtones. As soon as the fork starts to vibrate it is
placed at the mastoid process of the patient. The patient is advised to signal when
he stops hearing the sound. As soon as the patient signals that he is unable to hear
the fork anymore the vibrating fork is transferred immediately just close to the
external auditory canal and is held in such a way that the vibratory prongs vibrate
parallel to the acoustic axis. In patients with normal hearing he should be able to
hear the fork as soon as it is transferred to the front of the ear. This result is known
as Positive rinne test. (Air conduction is better than bone conduction). In case of
conductive deafness the patient will not be able to hear the fork as soon as it is
transferred to the front of the ear (Bone conduction is better than air conduction).
This is known as negative Rinne. It occurs in conductive deafness. This test is
performed in both the ears.
If the patient is suffering from profound unilateral deafness then the sound will still
be heard through the opposite ear this condition leads to a false positive rinne.
Weber's test:
Here again 512 Hz tuning fork is used. The vibrating fork is placed over the forehead
of the patient and he is asked to indicate on which side he is hearing the sound.
Normally when hearing level is equal in both the ears, it is heard in the middle, in
patients with conductive deafness the sound is heard in the left ear. This is known
as lateralization of Weber test. If the patient is suffering from sensorineural hearing
loss then the sound is lateralized to the normal ear or the better ear. Hence weber's
test must always be interpreted along with the Rinne's test. Weber's test is a
sensitive test, it can pin point even a 10 dB hearing difference between the ears.
This test is performed to identify sensorineural hearing loss. In this test the hearing
level of the patient is compared to that of the examiner. The examiner's hearing is
assumed to be normal. In this test the vibrating fork is placed over the mastoid
process of the patient after occluding the external auditory canal. As soon as the
patient indicates that he is unable to hear the sound anymore, the fork is
transferred to the mastoid process of the examiner after occluding the external
canal. In cases of normal hearing the examiner must not be able to hear the fork,
but in cases of sensori neural hearing loss the examiner will be able to hear the
sound, then the test is interpreted as ABC reduced. It is not reduced in cases with
normal hearing.
For making a basic assessment of patient's hearing the ear opposite to the one
tested is masked by occluding it. The patient is asked to repeat random numbers
uttered by the examiner. Ideally patient is blind folded to prevent lip reading. The
numbers are uttered at various intensities, quiet whisper, loud whisper, quite voice,
loud voice and shout.
Loud whisper - 20 - 30 dB
Quite voice - 30 - 45 dB
Loud voice - 45 - 60 dB
Shout - 60 - 80 dB
Examination of Nose
They are
2. Anterior rhinoscopy
3. Posterior rhinoscopy
1. Tenderness - If it is present over the nasal bone area then # nasal bone must be
suspected. If it is present over the tip of the nose, it could be due to vestibulitis, if
tenderness is present over the dorsum of the nose the septal hematoma, of septal
abscess must be strongly suspected.
2. Crepitus - when present over the nasal bone area then # nasal bone is a surety.
4. The nasal septal area must be palpated to ascertain the presence or absence of
septal cartilage.
Anterior rhinoscopy:
In anterior rhinosopy the following steps must be performed in the given order.
1. Examination of the vestibule (i.e. the skin lined cavity of the nares).
3. Patency test.
4. Probe test if examination of nasal cavity reveals a mass. This test is done to
ascertain the site of origin of the mass.
5. Examination of the nasal cavity after vasoconstriction. This is done after packing
the nasal cavity with cotton plegets dipped in oxymetazoline or xylometazoline
nasal drops.
Examination of vestibule:
This is carried out by tilting the tip of the nose. The vestibule is lined with skin
and has all the dermal appendages. All the diseases which affect the adnexia of the
skin can occur in the vestibule. Boils i.e. vestibulitis can cause swelling of the roof
and lateral wall. Ulcerations in this area can be infective or neoplastic. Excoriation
of skin lining the vestibule can also occur due to persistent nasal discharge.
A Thudichum's nasal speculum is utilised for this purpose. The speculum is held in
the non-dominant hand. The speculum is hooked with the index finger, while the
middle and ring fingers are utilized to press and release the speculum blade.
The axis of the anterior nares is upwards and backwards, while that of posterior
nares is backwards. The tip of the nose is lifted and the blades of thudichum's
speculum is introduced getting these two axis in a straight line. The speculum is
always introduced with the blade closed. The speculum is always introduced in a
upwards and backwards direction. Once inside the nose the blades are gradually
opened to avoid discomfort to the patient. The roof, floor, lateral and medial walls
of the nasal cavity are systematically examined.
Nasal septum is visualized with a special eye for the presence of spurs, deviations,
or perforations. The lateral wall displays the inferior and middle turbinates. Their
color, size and the quality of the mucosal lining is assessed. Discharge if any from
the middle meatus is also looked for.
Since the middle meatus is situated backwards the head is tilted upwards and
backwards up to an angle of 45 degrees. This maneuver brings the middle meatus
into clear vision. If polyp or neoplasm is visualized within the nasal cavity a probe
test is done to confirm its attachment.
Probe test: Is done using Jobson’s Horne probe. The nose is anaesthetized with 4%
xylocaine. Cotton is wound tightly over the probe end of Jobson's Horne probe.
The probe is used to assess the site of attachment of the nasal mass, its consistency,
mobility etc.
Is performed using a cold tongue depressor just under the nose of the patient and
comparing the amount of mist formation between both sides. A wisp of cotton can
also be used to ascertain the patency of the nose. Patency is compared with both
sides.
Posterior Rhinoscopy:
2. Flexible nasopharyngoscope
4. Examination under general anaesthesia after retracting the soft palate. Digital
palpation is possible only in this method.
The tongue depressor is held in the non-dominant hand, and the tongue is
depressed. The already warmed post nasal mirror is gently is passed under the
uvula visualizing the post nasal space. The mirror is tilted to visualize the various
portions of the naso pharynx.
Dissertation
It is mandatory for a post graduate student undergoing training for Master's degree
to complete dissertation during the study period. This enables the student to be
trained in research methodology and thesis writing. Since this must be completed
and submitted during the course of study period, time management becomes all the
more important. By definition dissertation is an inquiry made into some aspect of
physical, natural or social world. Students should also remember that their work
will be subjected to public scrutiny and peer review before being accepted. Every
dissertation should be accompanied by a meticulous analysis of the results
documented.
Points to ponder:
1. Dissertation is just one of the hurdle in the pursuit of the Master's degree
2. Non submission of dissertation will be considered more worse than exam
failure and will show the faculty in poor light
3. Dissertation is actually a compromise between what is desirable and what is
actually possible
4. A delicate balance should be maintained between academics / clinical duties
/ family
1. Incisive thinking
2. Ideas should be jotted down in the log book. Human brain is always
cluttered with unwanted details. To stay in focus it is always better to note
down ideas and thought process on dissertation in a log book maintained
for this purpose.
3. Never be too much influenced by other's research on the same topic
4. The set goal should be realistic and easy to achieve
5. The time line set should always be feasible
6. It is always prudent to conduct a preliminary survey / study before
embarking on the actual one. This effort is worth because it could forewarn
the researcher about the pitfalls that lie ahead.
Problems faced by a guide while guiding a student through with the thesis:
Guide is confronted with varying types of students. Some of them could be young,
energetic and enthusiastic, while the other group could be old and mature.
Problems faced by these groups are also highly varied. There is actually a divide
between these two groups. This divide is more acutely felt in the field of medicine
than in others. The older and mature students are more egoistic, and find it difficult
to adjust with more dynamic young colleagues. The older and more mature students
have the advantage of handling problems better. It calls for lots of tact to handle
these two groups on the part of the guide.
Self-assessment:
Every post graduate student should ruthlessly assess oneself. Only a person who is
capable of good and candid self-assessment could survive in this competitive
environment. Self-assessment should be on the following lines:
Current day postgraduate training schedule is really rigorous. One has to be really
motivated in order to come out successful. This course is not only challenging, but it
is also demanding. A delicate balance will have to be struck between the demands
of the course and that of the family.
Type of Institutional support one can get towards completion of the dissertation.
Expenditure involved:
Another factor that should be taken into consideration while choosing the topic is
the expenditure involved. Whether the candidate can afford to incur that
expenditure is an important criteria. Dissertation topics usually don’t receive any
funding from institutions.
Institutional support:
The topic chosen for dissertation should have been well researched and
documented elsewhere. All such references and documents should be available to
the student.
This is another aspect that should be taken into consideration while choosing a
dissertation topic. All research projects will have to be approved by the ethical
committee constituted for this purpose. A detailed proposal listing the various
aspects of the study along with references will have to be submitted to the ethical
committee. A specially designed consent form in vernacular language for getting
consent from the patient to participate In the study should also be included in the
proposal submitted to the ethical committee.
Care should be taken while choosing a topic. Topics like those shown below can be
rejected.
The following ethical issues should always be taken into consideration while
choosing a topic for dissertation:
1. The participants of the research project should not suffer any harm either
physically, mentally or socially as a result of participating in the project.
2. Children, elderly and physically challenged should not be exploited hence
should be excluded from the study.
3. The research project should not cause any environmental / physical damage
4. Privacy of the participant should be protected at all costs
5. The project should not cause disrepute to the institution
Computing and word processing skills are rather important in successful completion
of dissertation. Gone are the days when students used to sit behind typists and
oversaw their work being typed. Possession of computing skills which include word
processing and image manipulation will help a lot. Lack of this skill is going to cost
time and money. Students lacking this skill need to add an extra week / 10 days to
their dissertation schedule because it needs involvement of other people in the
completion of work. It is always better to keep back up copies in removable media
like CD-ROMs, pen drives and also printed copies are desirable. Computers can fail
at the most crucial time and it is necessary to safe guard the data.
Introduction = 5%
Conclusion = 10%
Bibliography = 5%
Before really diving into the actual work a blue print need to be drawn. This will
help the candidate to stay focused and complete the dissertation work on time.
Step II
Step III
Aims of Dissertation:
Dissertation should always have an aim. The possible aims of dissertation are given
below:
1. To develop a theory
2. To verify a hypothesis
3. To evaluate critically a practice
4. To increase the understanding of a topic
5. If possible to recommend policies
Hypothesis is the most crucial part of a dissertation. In fact it constitutes the kernel
in all dissertations. Usually hypothesis is based on observation or belief. A valid
dissertation topic should endeavor to prove or disprove a hypothesis. It is very rare
for a dissertation topic to exist without valid hypothesis.
Check list:
A student will have to draw up a check list before exactly starting the dissertation
work.
A student should not develop fondness to any page authored. Dissertation needs to
be ruthlessly edited to fulfill the page limitations specified by the University. Initial
write up should be considered as draft. It is advisable to spend a few hours each
week on dissertation issues. This will help the motivation levels of the student to
stay high.
Dissertation work will start in right earnest during the final year of Master's
program. Total duration available to complete dissertation is roughly 12 months.
This 12 month period can be divided as shown below to organize work in a better
way.
Given below are some of the types of research projects that can be taken up as
dissertation topics.
1. Action research
2. Surveys
3. Experimental methods
4. Ethnographic research
5. Case studies
6. Historical research
7. Correlational research
8. Evaluative research
Action research:
Surveys:
Survey type research is designed to gather information. Usually information for this
type of research is gathered through questionnaires / interview. Success of this
type of research is totally dependent on the question designed to gather
information. Questions should be structured in such a way that maximum
information should be gleaned from minimum number of questions. This type of
research needs compliance on the part of the participant. If they give false data
then the entire study will lose its accuracy. The possibility of the participant
withholding information or providing false information should always be considered
while analyzing the results.
Major advantage of this type of research is that it is easy to get approval from
ethical committee for survey based research.
Ethnographic research:
This term is derived from the Greek word "ethnos" which means people, and
"graphy" to write. This is in fact a qualitative and descriptive type of research which
takes a long time to complete. In this type of research the study group is integrated
into the society, and the researcher studies the behavior and customs of that group.
Since this is a time consuming research modality it is not advisable to take this up as
a dissertation work which has to completed within the specified time frame
Case study:
This is the commonest approach taken for dissertation topic. Student before taking
up the case study need to understand that the institution should get at least 50
cases belonging to the study category during the course of study to make this topic
a successful one. In this type of study both qualitative and quantitative data can be
harvested and interpreted. One word of caution is that the temptation to formulate
a universal theory out of trivia should be avoided.
Historical research:
Before embarking on this type of research, it should be checked with the University
whether this type of research can be taken up as dissertation topic. This is actually a
grey area. Availability of adequate historical literature and other archives is a must.
All historical documents used for this study should be checked for authenticity.
Statistical variables should always be accounted for.
Correlational research:
Evaluative research:
This research methodology deals with a possible set of questions. This work needs
to be highly structured. While attempting to seek answer to the questions the
researcher should against personal vagaries and variables. This is another protocol
commonly used for dissertation topics.
Sampling:
This is actually a mine field for researchers. Even though it is easy to obtain samples
in the physical world, the size of the sample is rather important. Sample size should
be at least 1% of the population studied. The procedure of sampling should be
opportunistic / random. In opportunistic sampling, sample is collected when
opportunity presents itself. In random sample collection computer randomizes and
tells the researcher from whom to collect samples from.
Aim and objective of the topic taken up for dissertation should be clearly stated
under this heading.
Introduction:
One need to ensure the following points when authoring this chapter.
Review of literature:
5. This shows that the author has read widely the subject
Methodology:
if any, a discussion on data observation and recording should find a place under this
head
Data analysis:
1. Data recording
Conclusion:
Bibliography:
This is nothing but a list of journals, reference materials, text book materials and
other resources you relied on to complete your work. References which are more
than 5 years old should not be included unless it is completely unavoidable. It is
ideal to index and number them for easy reference.
Appendix:
Tables, master chart and additional material if any should be incorporated under
this heading
Plagiarism:
The Tamilnadu Dr MGR Medical University routines conducts plagiarism check on all
submitted dissertation manuscripts. Before submission, the author of the
dissertation is encouraged to submit the manuscript for online plagiarism check.
Many sites offer free plagiarism check facilities. It can also be done via the
university website.
Documentation
Introduction:
Photo documentation:
Picture resolution:
In order to ensure good picture quality, the camera should have good resolution.
Picture resolution depends on the number of dots within the picture. More the
number of dots better becomes the picture quality. In lay terms the resolution of
digital camera is specified in megapixels. An ideal digital camera should have at
least 6 megapixels resolution.
Zoom quality:
This is another feature one should look for in a digital camera. Two types of zoom is
possible in a digital camera i.e. digital zoom and optical zoom. Digital zoom actually
attempts to enlarge each recorded pixel electronically whereas in optical zoom the
camera lens digitally magnifies the object. One should look for optical zoom values
when purchasing a digital camera. Buyers are usually confused with the term digital
and optical zoom. It is prudent to remember, the functions of digital zoom can be
done by any desk top computer with its installed program. At very high digital zoom
values the picture has a tendency to become fuzzy. A high optical zoom value is the
one a buyer will have to look out for in a digital camera. At high optical zoom levels
the camera provides the best results. Less expensive cameras have lower optical
zoom levels, and do not offer best results.
LCD screen:
Good digital camera should have an excellent color LCD screen. This is actually a
must for all digital cameras.
A digital camera with adequate storage space in the form of memory cards / hard
disk drives.
Modern day digital cameras have taken the uncertainties out of the art of
photography. The preview screen helps in composing excellent images.
Digital still cameras can be used to take clinical photographs of patient for purposes
of documentation.
Image format:
It is ideal to choose a camera which would save images captured in raw format. A
raw image can be manipulated by image manipulation program and converted into
any image format. The following are the various image formats.
To document intra oral pathologies it is best to have a camera with ring flash. Ring
flash throws uniform light into the cavity and helps in capturing well illuminated
shadow less images.
These captured images can be archived in a removable media like CDROMs, Pen
drives, or online storage services like SkyDrive, Picasa, and Flickr etc.
Video recording:
For web based projection of videos the best on line platform is YouTube videos.
Edited video can be saved in MPEG 4 format. This format is highly compressed and
support streaming via internet. After uploading to YouTube these videos can easily
be called by embedding to a website.
Surgical videos captured using Handy cam device can be recorded using fire wire
cord. Currently available hand cam cameras record in hard disk / memory cards.
These videos can easily be downloaded to a computer by simply mounting the
storage devices where these videos are stored.