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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE.
ANNEXURE-II
APPLICATION FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.
NAME OF THE CANDIDATE
Dr RISADAKA PAPANG
& ADDRESS
DEPARTMENT OF HOMOEOPATHIC
PAEDIATRICS,
FATHER MULLER HOMOEOPATHIC
MEDICAL COLLEGE AND HOSPITAL,
UNIVERSITY ROAD,DERALAKATTE,
MANGALORE – 575 018.
KARNATAKA.
PERMANENT ADDRESS
Dr RISADAKA PAPANG
C/O Dr WIKIL DHAR
MAWLAI IEWRYNGHEP
G. S. ROAD,
SHILLONG - 7930017
MEGHALAYA.
2.
NAME OF THE
FATHER MULLER HOMOEOPATHIC
INSTITUTION
MEDICAL COLLEGE AND HOSPITAL,
DERALAKATTE,
MANGALORE-575 018,
KARNATAKA.
3.
4.
COURSE OF THE STUDY &
M.D.(HOM)
SUBJECT
HOMOEOPATHIC PAEDIATRICS
DATE OF ADMISSION TO
THE COURSE
5.
01. 06. 2011
TITLE OF THE TOPIC:
“A CLINICAL STUDY TO EVOLVE A GROUP OF EFFICACIOUS
HOMOEOPATHIC
MEDICINES
IN
PAEDIATRIC AGE GROUP”
1
ACUTE
OTITIS
MEDIA
IN
6.
BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR STUDY:
Middle ear infection and their sequel have plagued mankind from the
beginning of time. This condition was first described by Hippocrates in 450 BC.
This universally observed phenomena, still continues to be one of the most
perplexing medical problem of childhood, while also being the leading cause of
hearing loss in this age group. The disease process knows no age boundaries but
occurs mainly in children from newborn period to seven years of age. Later the
incidence gradually decreases with increase in age. The concept, that the incidence
of Acute otitis media has decreased in this era of advance medical science is a
rumour. Even today, it is one of the important causes for hearing impairment in
urban population.
Acute otitis media is the inflammation of the middle ear, mostly due to an
infection. When the pressure crosses the threshold, the eardrum perforates to drain
out the discharge and surgery (tympanoplasty) becomes the only treatment option.
The probability of recurrence always persists because the outcome is treated
rather than the main underlying cause. Homoeopathy safely and gently treats the
root cause rather than just the disease symptoms. In Homoeopathy, the approach to a
patient with Acute otitis media varies, depending upon the nature of the discharge,
the odour, the affected ear and many such variables.
This makes Homoeopathy a unique science, very different from the
conventional line of treatment where surgery and antibiotics are the only avenues.
It is evident that Homoeopathy not only helps to treat acute otitis media, but
also reduces the chances of a recurrence, thereby circumventing the need for
surgery9.
Thus in this study it’s my earnest attempt to evaluate what homoeopathy can
do in this particular area.
6.2 REVIEW OF LITERATURE:
DEFINITION:
Acute otitis media is a fairly common infection affecting the mucosa of the
middle ear cleft and it may cause severe pain which often wakes up the patient at
night1.
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AETIOLOGY:
1. AGE: It occurs at all ages, but is more common in children.
2. SEX: It affects both sexes equally.
3. GEOGRAPHICAL DISTRIBUTION: It occurs all over the world.
4. PORTAL FOR ENTRY OF INFECTION:
i. EUSTACHIAN TUBE: In majority of cases the infection in middle ear
reaches via the Eustachian tubes due to the following causes,
a. Anatomical obstruction: caused by adenoid and nasopharyngeal tumour.
b. Infection: like adenoid, tonsillitis, rhinitis, sinusitis, allergic pharyngitis,
influenza and infection secondary to cleft palate.
c. Hygiene: Often forcible blowing of nose under pressure may spread the
nasal infection to the middle ear.
d. Iatrogenic: After postnasal packing and badly performed adenoidectomy.
e. Feeding bottles: The use of a feeding bottle for infants in supine position
may allow the contaminated milk to enter the Eustachian tube.
ii. EXTERNAL EAR: Trauma to the ear drum while cleaning the external ear
canal or slap on the ear may rupture the ear drum.
iii. HEAD INJURY: May affect the middle ear if there is a fracture of the
temporal bone involving the middle ear.
iv. BLOOD BORNE INFECTION: Rarely reaches the middle ear.
5. PREDISPOSING FACTORS:
i. REDUCE VITALITY: If the vitality of the patient is reduced, infections in
the middle ear may be easily caused.
ii. ATMOSPHERIC PRESSURE (BAROTRAUMA): May occur
during
flying and diving ,the infection reaches the middle ear via eustachian tubes.
CAUSATIVE ORGANISMS:
Streptococcus
haemolyticus,
Staphylococcus
aureus,
Heamophilus
infleunza, Pneumococcus, Klebsiella sp., E. coli.
If the infection follows trauma, Gram negative
Bacillus coli may be present15.
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baccili
from skin like
PATHOLOGY:
The infection passes through 5 stages.
1. CATARRHAL STAGE (Stage of congestion):
Characterised by occlusion of Eustachian tube and congestion in the middle
ear.
2. STAGE OF EXUDATION:
Exudate collects in the middle ear and the drum is pushed laterally. Initially
the exudate is mucoid, later it becomes purulent.
3. STAGE OF SUPPURATION:
Pus in the middle ear collects
under tension, stretches the drum and
perforates it by pressure necrosis and exudate starts escaping into the external
auditory canal.
4. STAGES OF HEALING:
Depending upon the virulence of organisms, resistence offered by the body
and anti-biotics administered, the infection starts resolving from any of the earlier
stages mentioned. Usually the infection clears up completely without having any
sequeles.
5. STAGE OF COMPLICATION:
In this stage, because of spread of pus to the mastoid results in mastoiditis,
which, if untreated, may lead to empyema mastoid.
These stages are compared very well with those of lobar pneumonia which is
a respiratory tract infection caused by similar organisms1.
CLINICAL FEATURES:
Usually acute otitis media follows an attack of upper respiratory tract
infection. In young children, the classical features may not be clearly present, may
just be unwell and have fever.
1. CATARRHAL STAGE (Stage of congestion):
Due to blockage of Eustachian tube, the oxygen in the middle ear cavity is
absorbed and negative pressure is created. This retract the tympanic membrane,
irritate the mucosa and causes congestion.
SYMPTOMS:
a. Fullness: Patient complains of heaviness in the ear, pain follows soon.
b. Pain: Severe pain in presenting symptoms. The pain tends to be more severe
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at night in recumbent position due to venous congestion.
c. Deafness: Is always present but not noticed by the patient, because he is
worried about the severe pain. Deafness increases progressively.
d. Tinnitus: Bubbling sound may be present.
e. Autophony: Is often present, where the spoken words of the patient echo in
his ears.
f. Constitutional symptoms: Due to absorption of toxin, fever and malaise may
be present.
SIGNS:
a. Retraction: Initially drum gets retracted .
b. Congestion:Soon the tympanum becomes congested and may present with
cart-wheel appearence because of the dilated blood vessels .Later the drum
become completely red.
c. Light reflex: Due to oedema of the ear drum, light reflex is lost.
2. STAGE OF EXUDATION:
All the symptoms become more severe, when the drum starts bulging and
becomes convex. The exudate exerts pressure on one spot of the drum which may be
the point of perforation later and that point appears like anyellow nipple.
The suprameatal triangle may become tender even without the spread of
infection to themastoid antrum, described as ‘mastoidism’.
3. STAGE OF SUPPURATION:
At this stage the drum perforates and pus starts flowing out. So, painand
other constitutional symptoms reducein this stage.
a. Otorrhoea: Begins now and may be initially blood stained. This type of
discharge can range from mucoid to frankly purulent.
b. Perforation: Examination of ear drum reveals a small perforation, usually in
theantero-inferior quadrant with purulent discharge.
4. STAGE OF HEALING: Healing may begin from any stage.
5. STAGE OF COMPLICATION:In the second week, infection may spread to
the mastoid and other neighbouring structures1.
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DIAGNOSIS:
Diagnosis can be established by inspectingthe ear drum with an otoscope.
The following can be seen according to stages.
1. Loss of light reflex and hyperemia of the drum.
2. As theexudate accumulates in the middle ear, the drum bulges outwards.So
the landmarks are first obscured and then obliterated.
3. Dusky red (angry) colour of the drum, if accumulation still progresses.
4. Yellow gray appearence prior to the rupture / myringotomy.
The bulge of the drum is generally in the upper and posterior portion. When
the short process of the malleus is no longer seen, the drum is said to be fully
bulged7.
DIFFERENTIAL DIAGNOSIS:
1. Acute otitis externa
2. Herpetic lesion of external ear
3. All the causes of ear pain
4. Crying child:The ear drum becomes red but not oedematous1.
INVESTIGATIONS:
1. TEST OF HEARING:
a. Tuning fork test reveals conductive deafness.
b. If the patient is in a condition to undergo audiometry, it shows conductive
deafness.Inearly stages, conductive deafness is mild, but becomes severe
as the disease progresses.
2. RADIOGRAPHY: In first 3 stages, the radiograph of the mastoid shows no
changes. Changes begin when infection invades the mastoid.
3. BACTERIOLOGICAL EXAMINATION: Detection of the causative
organism1.
COMPLICATIONS:
1. Minor temporary hearing loss.
2. Ruptured or perforated ear drum.
3. Chronic, recurrent ear infection.
4. Enlarged adenoid or tonsil.
5. Mastoiditis.
6. Scarring or thickening of tympanic membrane.
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7. Loss of expression or movement in the face.
8. Permanent hearing loss.
AUXILIARY MEASURES:
Along with the Homoeopathic remedy, some measures are needed for faster
recovery. It includes:
a. Keeping the child well hydrated.
b. Eliminate dairy products which thicken the mucous, making it more difficult
for an infected ear to drain.
c. To promote drainage prop the child at a 300 angle,this will reduce pain.
d. Apply cold compression, if your child feels comfortable with.
e. Never use an instrument or cotton tipper applicator to clean the ears.
f. Lastly a good nutritional program
including proper supplementation is
imperative to enhance immune system functioning11.
PREVENTION:
a. Keep the sick child away from the other children.
b. Do not expose the child to a secondhand smoke.
c. Always hold an infant in an upright, seated position during bottle feeding.
d. Breastfeeding for at least 6 months can make a child less prone to ear
infection.
e. Do not use a pacifier.
f. Encourage children to wash their hand often10.
HOMOEOPATHIC MANAGEMENT:
According to Dr Hahnemann, in §71, “The disease to which man is liable is
either rapid morbid process of abnormally deranged vital force, which has a
tendency to finish their course more or less quickly, but always in a moderate time –
these are termed as acute diseases.”6
In acute diseases, case taking will be easier because the symptoms will be
fresh in the patient’s memory and still new and striking. Often you will not have a
“never well since” or mental/emotional symptoms in acute cases. However, if
present, remember that they rank higher than the physical symptoms. Finding the
acute totality which should include complete symptom with its characteristic
location, peculiar sensation and qualifying modalities. Concomitants, if present are
invaluable gift for a homoeopathic physician to find the correct prescription.
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These differentiating factors are referred to, as singular, uncommon,
striking,any peculiar features of the case, by Dr Hahnemann. However, if sequel
develops, the case needs miasmatic remedy4, 6, 13.
According to Dr Hahnemann, in §73, an apparently healthy person may
suddenly be affected by an acute disease because of his or her inherent or acquired
hyper susceptibility to the same created by Psora, which spontaneously returns to its
dormant state, if the acute diseases were not too violent a character and were soon
quelled. Hence it is explained as the transient explosion of latent Psora6.
The guiding features of ‘latent Psora’ are generalised hypersensitivity to
allergens, frequent cold catching tendency on exposure to dry, cold winds and
frequent weariness from least exertion.
REPERTORISATION:
Medicines are selected on the basis of repertorisation of the diagnostic signs
and symptoms of Acute otitis media. The rubrics are as follows:
1. DISEASES - OTITIS interna, inner ear infection – OTITIS media, middle
ear infection (35)
2. EAR – PAIN, ears – lying, in bed, while – ear, on (10)
3. EAR – PAIN, ears – night (34)
4. EARS – DISCHARGES, from – purulent (61)
5. EARS – EARDRUM, ruptured, tympanum (09)
6. EARS – FULLNESS, sensation, of (41)
7. HEARING – DEAFNESS, general – otitis, after (1)
HOMOEOPATHIC REMEDIES:
Merc
sol,
HeparSulph,
Pulsatilla,
Silicea,
KaliBich,
Chamomilla,
Tuberculin, Capsicum, Tellurium, Calc carb, Lycopodium, Aconite, Belladonna,
Dulcamara, Sanguinaria, Nitric acid, Natrum carb, Phosphorus, Mercuriusdulcis,
Graphites, Sulphur.8
HOMOEOPATHIC THERAPEUTICS:
1. MERCURIUS SOLUBILIS: Very valuable in suppurative middle ear diseases,
with swelling of parotid glands and offensive breath. It suits especially
scrofulous and syphilitic ear conditions. The discharges are thin and acrid, the
ears, teeth and face ache, symptoms worse at night, and characteristic is a feeling
of stoppage and of internal soreness as if raw, and also roaring in ears.
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2. HEPAR SULPH: Is useful in earache when suppuration impends. There is great
soreness and sensitiveness to the slightest touch, acute exacerbations of the
trouble with increased discharge, which is thick, creamy and somewhat
offensive. Patients requiring Hepar are irritable and sensitive to the slightest draft
of air.
3. PULSATILLA: The ear is hot, red and swollen, and there are very severe
darting, tearing, pulsating pains in it which are worse at night. It, too, occupies
the highest place for acute inflammation of the middle ear. It is indicated also by
profuse thick, yellowish green discharge from the ear, deafness and a feeling as if
the ears were stopped up, or as if something were being forced out; there are also
roaring noises synchronous with the pulse. It suits especially sub acute cases.
Itching deep in the ear.
4. SILICEA: Perforations of the membrana tympani heal rapidly under Silicea. A
peculiar symptom leading to the remedy is an itching and tingling in the locality
of the Eustachian tube. There are also shooting pains through the ear and profuse
perspiration, sudden snuffing, cracking sound in the ear like the explosion of a
percussion cap. It promotes repair of the drum head.
5. KALI BICH: Inflammation of middle ear; ulceration of membrana tympani with
tenacious, stringy and purulent discharges; pains sharp stitching in character.
Also a valuable remedy in the later stages, when, on account of pharyngeal
involvement, the Eustachian tube is hard to inflate2, 3, 5, 12, 13.
6.3. OBJECTIVES OF THE STUDY:
1. To study the scope of Homoeopathy in the treatment of acute otitis media in
paediatric age group.
2. To analyse the group of remedies effective in the treatment of acute otitis
media in paediatric age group.
7.
MATERIALS AND METHODS
7.1 SOURCE OF DATA:
The subjects will be selected from OPD, IPD and peripheral centres of Fr.
Muller Homoeopathic medical college and hospital, Mangalore.
7.2 METHOD OF COLLECTION OF DATA:
A sample size of minimum 30 cases will be selected using purposive
sampling technique based on the inclusion criteria and will be followed for a
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minimum period of 1 month duration.
Every case will be analyzed with reference from material medica, repertory
and therapeutics whenever required.
The potency selection and repetition of the doses will be done according to
the demand of the case, on the basis of homoeopathic principles.
INCLUSION CRITERIA:
1. The sample of both sexes aged less than12 years.
2. Diagnostic criteria are mainly based on clinical presentation and laboratory
investigations.
EXCLUSION CRITERIA:
1. Cases above 12 years of both sexes.
2. Patients with advanced complications like mastoiditis, empyaema mastoid,
perforated ear drums etc.
RESEARCH HYPOTHESIS:
Homoeopathic medicines are effective in the treatment of acute otitis media
in the paediatrics age group.
NULL HYPOTHESIS:
There is no significant improvement of acute otitis media in paediatric age
group with homoeopathic treatment.
PLAN FOR DATA ANALYSIS:
The collected data will be analyzed by Paired ‘t’ test and the data will be
presented in the form of mean, standard deviation, frequencies and percentages.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS TO BE
CONDUCTED ON PATIENTS, OR OTHER HUMANS (OR ANIMALS)? IF
SO PLEASE DESCRIBE BRIEFLY.
Yes, if required.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE OF 7.3?
Yes, enclosed.
10
8.
LIST OF REFERENCES
1. Bhargava KB, Shah. TM. ENT diseases. 5th ed. Mumbai, India: Usha
publications; 1999. p. 53-8.
2. Boericke W. Pocket manual of homoeopathic material medica. New Delhi,
India: Indian Books & Periodical Publishers; 2001. p.
3. Clarke. JH. A dictionary of practical materia medica. New Delhi, India: B. Jain
Publishers (P) Ltd; 2000. p. (vol 3)
4. Close S. The genius of Homoeopathy. Reprint ed. New Delhi, India: B. Jain
Publishers (P) Ltd; 2004. p. 87-121.
5. Dewey WA. Practical Homoeopathic therapeutics. 3rd ed. New Delhi, India: B.
Jain Publishers (P) Ltd; 1996. p. 129-34.
6. Hahnemann S. Organon of medicine. 6th ed. Reprint. New Delhi, India: B. Jain
Publishers (P) Ltd; 1997. p. 172-86.
7. Hughes JG, Griffith. Synopsis of paediatric. 6th ed. Princeton: LCV Mosley
company; 1984. p. 381-2.
8. Murphy R. Homoeopathic medical Repertory. 1st Indian edition. New Delhi,
India: Indian Books & Periodicals Syndicate; 1994. p. 315-34, 780-96.
9. Available
from
URL:
http://www.drbatras.com/en/featured-articles/otitis-
media.aspx, accessed on dt. 15.02.12.
10. Available
from
URL:
http://www.umm.edu/altmed/articles/otitis-media-
000121.htm#ixzz1mGfe1XRo, accessed on dt. 15.02.12.
11. Available
from
URL:
http://www.myhealth911.com/2011/10/otitis-media/,
accessed on dt. 15.02.12.
12. Raue CG. Special pathology of diagnostic hints with homoeopathic
therapeutics. 4thed. New Delhi, India: B. Jain Publishers (P) Ltd; 2002. p. 193-7.
13. Roberts HA. The principles and art of cure by Homoeopathy. 2nded. New Delhi,
India: B. Jain Publishers (P) Ltd; 1999. p. 188-34.
14. Tiwari SK. Homoeopathy and child care principle, therapeutics, children type,
repertory. Reprint ed. New Delhi, India: B. Jain publisher’s (P) Ltd; 2004. p.
167-8.
15. Vishwanathan J. Achar’s textbook of paediatrics. 3rd ed. Madras: Orient
Longman publications. 1991. p. 505.
11
9.
SIGNATURE OF THE
CANDIDATE
10.
REMARKS OF THE GUIDE
11.
NAME& DESIGNATION OF
(IN BLOCK LETTERS)
11.1 GUIDE
Dr JYOSHNA SHIVAPRASAD.
M. D. (HOM)
PROFESSOR & GUIDE,
HEAD OF THE DEPARTMENT OF
PAEDIATRICS,
FR.MULLER HOMOEOPATHIC
MEDICAL COLLEGE & HOSPITAL,
DERALAKATTE, MANGALORE.
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE
Dr JYOSHNA SHIVAPRASAD.
DEPARTMENT
M. D. (HOM)
PROFESSOR& GUIDE,
HEAD OF THE DEPARTMENT OF
PAEDIATRICS,
FR.MULLER HOMOEOPATHIC
MEDICAL COLLEGE & HOSPITAL,
DERALAKATTE, MANGALORE.
11.6 SIGNATURE
12.
12.1 REMARKS OF THE
CHAIRMAN & PRINCIPAL
12.2 SIGNATURE
12