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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. 2 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. 3 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 4 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. 5 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. 6 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. 7 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. 8 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 9 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