Rajiv Gandhi Univercity of Health Sciences

RAJIV GANDHI UNIVERCITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1 Name of the Candidates and SHIVANGOUDA. PATIL address (In Block Letters) C/O S.S INAMADAR H.NO.144 SHASTRINAGAR NEAR JANNATH MASJID BIJAPUR – 586201

2 Name of the Institution RAIARAJESWARI MEDICAL COLLEGE AND HOSPITAL BANGALORE

3 Course of study and subject M.S (ENT & HEAD & NECK)

4 Date of admission to Course 21.08.2012

5 Title of the Topic A CLINICAL STUDY OF BENIGN LESIONS OF PINNA. Introduction:

The ear is an organ of hearing. It is also concerned in maintaining equilibrium of the body. It forms the major part of communication system. It consists of three parts 1. External ear 2. Middle ear 3. Inner ear External ear consists of 1. Auricle (pinna) 2. External auditory meatus Auricle (pinna):The auricle (pinna) projects at a variable angle from the side of the head & has some functions in collecting sound. The lateral surfaces of the pinna has charesteristic prominences and depressions which are different in every individual even among identical twins. The curved rim is the Helix which often has a small prominence at its posterior auspect. Anterior to and parallel with the helix is another prominence the antihelix. Superiorly this divides into two crura between which is the triangular fossa; The scaphoid fossa lies above the superior of the two crura. In front of the antihelix, and partly encircled by it ,is the concha. This is divided into two portions by the descending limb of the anterior superior portion of the helix known as crus of the helix, which rests just above the external auditory meatus. The smaller superior position is the cymba conchae. The larger inferior portion is known as the cavum conchae. Below the crus of helix and overlapping the external auditory maetus is the tragus, which is a small blunt triangular prominance pointing posteriorly. Opposite the tragus, at the inferior limit of antihelix, is the antitragus. The intertragic notch seperates the tragus from the antitragus. The Lobule lies below the antitragus and is soft being composed of fibrous and adipose tissue. The body of the auricle is formed from elastic fibro cartilage & is continuous plate except for a narrow gap between the tragus and the crus of the helix; where it is replaced by a dense fibrous tissue band. The cartilage extends about 8mm down the ear canal to form its lateral third. The cartilage of the auricle is covered with perichondrium from which it derives its supply of nutrients, as cartilage itself is avascular. Stripping the perichondrium from the cartilage as occurs following injuries that cause haematotna, can lead to cartilage necroisis with crumpled up 'boxers' ears. The skin of the pinna is thin and closely attatched to the perichondrium of the lateral surface. On the medial surface, there is a definite subdermal adipose layer that allows dissection during pinna plasty surgery. The skin of the auricle is covered with fine hairs and most noticebly in the concha and scaphoid fossa, there are sebaceous glands opening into the route canals of these hairs On the tragus and inter tragic notch coarse thick hairs may develop in the middle aged and older male. Extrinsic and intrinsic muscles are attached to the perichondrium of the cartilage these muscles are vestigial in human being. Purpose of study is to study prevalence and aetiopathological factors of benign lesions of the pinna-2. The Blood supply of auricle derived from the posterior auricular and Superficial temporal arteries. The Lymphatics drain in to the auricular and post auricular and superficial cervical lymphnodes . Nerve supply: The two third of the lateral surface of the auricle are Supplied by the auriculo temporal nerve and lower one – third by great auricular nerve the upper two third of the medial surface are supplied by the lateral occipital nerve and the lower one third by great auricular nerve. The root of the auricle is supplied by the auricular branch of vagus nerve. The auricular muscles are supplied through branches of fascial nerve.1 The pinna may be afflicted by congenital, traumatic, inflammatory or Neoplastic disorders. The congenital disorders include bat ear, preauricular appendages , preauricular pit or sinus, anotia, macrotia & microtia. Trauma to the auricle can result in to haematoma, laceration avulsion , frost bite and keloid of auricle . Inflammatory diseases of the Pinna includes Perichondritis, relapsing Polychondritis, chondro dermatitis nodularis chronic helicis . Benign tumours - Pre auricular cyst or sinus Sebaceous cyst Dermoid cyst Keloid Haemangioma Papilloma Cutaneous horn Keratocanthoma Neurofibroma Malignant – Squamous cell carcinoma Basal cell carcinoma Melanoma Of all the cases of ear carcinoma, 85% occur on the pinna, 10 % in the external canal and 5% in the middle ear . Benign lesions are usually discovered during a routine ear examination or patient may present with lesions over pinna.2

6.1 Need for the study : Pinna contributes enormously to collection of sound and to the facial aesthesis. Lesions affecting the pinna can lead to overt disfigurement and change in entire appeal of the face. Not much worked up regarding aetiopathological factors and prevalence or the burden understanding.

Review of literature:

According to the U.S National library of medicine and national institute of health the human ear consists of outer , inner and middle parts and people use all the three parts to hear. The NIH states that a variety of ear conditions can affect a persons hearing and valence, and that ear conditions can be caused by prolonged exposure to loud noises, ear trauma and certain medical conditions-3.

Outer ear tumours are condition of the outer ear. The Merck manuals website states that outer ear tumour may benign or malignant and that most outer ear tumours are discovered by a persons physicion during otoscopic examination to determine the cause of hearing loss or hearing reduction. According to Merck manual website, benign tumours can manifest in the outer ear canal causing hearing loss and wax accumulation. Common types of benign outer ear canal tumours include sebaceous cyct, osteomas or bone tumours and keloids it also states surgical excision or removal of the tumour can restore a persons hearing-4.

Trauma can cause numerous outer ear conditions. According to Merck manual website, blunt force trauma to the outer ear can cause bruising between the ears catilage and the perichondrium. As the blood accumulates in this space and persons outer ear swells and takes on purple hue. The accumulated blood known as haematoma can decrease the blood flow to the ears cartilage, causing part of the cartilage to die, and deformities to arise. The deformities, known as cauliflower ear, occurs frequently among wrestlers, boxers, rugby players and others who engage in pugilistic endeavours. It also states that blunt force jaw trauma can also affect the function of the outer ear, distorting and narrowing of the outer ear canals shape , but that surgical intervention can often correct the problem -5.

Kishore Chandra Prasad et-al have done comprehensive study of the lesions of pinna. They have worked on 307 cases of men and women presenting with swelling of pinna who attended the department of ENT at KMC Mangalore during February 1992 to June 2002 result prompt surgical intervention under good anti biotic cover gave excellent results with minimum complications-6. PAGE 5 :

Nemechuk, amedee RG et al a Variety of medical specialists are exposed to patients who seek treatment of external ear neoplasms. They are uncommon occurances and malignancies if the external ear are even rarer. Only one patient in 10000 with an year complete will have pathologically proven malignancy of external ear. Tumours of the external ear both malignant and benign commonly resemble one another. A timely and correct diagnosis is necessary to avoid affecting the external ears ability to collect sound but also avoid more morbid and mortal complications of an external ear malignancy, related histopathology and treatment which encompasses a myriad of modalities and specialities. 7

Ear tumours : ear tumour are classified into

I. Benign tumours include - osteoma, exostosis, chemodectoma, acoustic neuroma.

II. Malignant tumours include - squamous cell carcinoma, basal cell carcinoma. 8

Leferink VJ, nicolai et al from 1982 - 1986, 17 patients with malignant tumours of the external ear were treated in regional center for plastic and reconstructive surgery Arnhem (Netherlands). There were 15 men and 2 women the mean age was 73 yrs. There were 4 basal cell and 12 squamous cell carcinomas and 1 had malignant melanoma of the external ear. 9 of these tumours were on the helix. During the follow up period, 6 patients had local recurrent disease. In 7 patients, re-excision had to be performed several times after incomplete excision. 69 patients are alive without any signs of disease and 3 patients died.

Tumours of the ear may be non cancerous or cancerous. Most of the tumours are found, when people see tumour or when doctor looks in the ear because people notice their hearing seems decreased. Non cancerous tumours may develop in the ear canal, blocking it and causing hearing loss ad building of ear wax. Such tumours include small sacs filled with skin secretions (sebaceous cyst), osteoma, keloids. The most effective treatment is surgical excision of tumour. After treatment hearing usually returns to normal. 10

Benign cyst or tumour will have symptoms of small soft skin lumps on behind, or infront of the ear, usually not painfull or tender. Cysts within the external ear canal can be extremely painful.The symptoms of benign tumours include ear disconmfort, a grudual hearing loss in 1 ear. There may be no symptoms as well. Treatment if the cyst or tumour is not painful and does not interfere with hearing, treatment is not necessary. if cyst or tumours are infected or present with symptoms treatment may include antibiotics or surgical removal. 11 6.3.1. Aim of studies

To know the burden of the disease or prevalence of the disease.

6.3.2. Objectives of the study

1. To find out the prvalence of the disease at Rajarajeswari Medical College and Hospital attending patients. Hospital based studies.

2. To evaluate aetiopathological factors of the disease (benign lesions of pinna)

7 Materials and method

1. Study setup - This is hospital based study. Patients attending RRMCH, ENT department are studied.

2. Study design - Cross sectional study.

3. Study duration - From January 2013 to December 2013 - 1yr study.

4. Study population - All patients attending RRMCH with benign lesions of pinna.

5. Sample Size - All the patients - Of all the age groups of either sex attending RRMCH during the year 2013 with benign lesions of pinna.

7.1 Source of data :

History taking and clinical examination of the case of benign lesion of pinna in a proforma.

7.2 Methods of data collection :

Prior informed consent will be taken from the study subject. History taking, clinical examination of the case of benign lesions of pinna in a proforma. Plan for data analysis :

Data collected will be entered in Ms-Excel worksheet. And results will be expressed in percentage.

Inclusion criteria :

1. All the patients attending ENT department of RRMCH Banglaore with clinical features of benign lesions of pinna.

2.Patients willing to participate in present study.

Exclusion criteria :

1. Inflammatory conditions of pinna.

2. Infections of the pinna.

3. Malignant conditions of the pinna.

4. Patients who do not give consent to participate in studies.

7.3 Does the study require any investigations or interventions to be conducted on patients or other human or animals? If so please describe briefly. Ans : No 7.4 Has ethical clearance been obtained from your institution. Ans : Yes List of references :

1. Geroge G Browning, Martin J Burton etal scot brown’s otolaryngology 7th edition Vol-3 page 3107

2. PL Dhingra etal, diseases of ear, nose and throught, fourth edition pages 104, 105.

3. Martin hughes DC Conditions of outer ear july 28,201

National Institute of health : Ear disorders Live strong. com

4. Martin hughes DC Outer ear

tumours by Merck manual : Tumours

Live strong. com

5. Martin hughes Outer ear trauma by

Merk manual - Injury

Live strong. com

6. Kishore chandra prasad et al A comprehensive study on lesions of pinna by American journal of Otalaringology- Head & Neck, medicine and surgery vol-25 issue 1 pages 1-6, January 2005

7. Nemechek et al Tumours of external ear

Thlone university school of medicine, department of otolaryngology U.S.A

J-La state med soc 1995 june ; 147 (6); 239-42

8. Http : // www. Fpnotebook.com/ear tumour

Ear neoplasms (10013449)

Malignency tumours of the external ear

9. Leferink et at

Regional center for plastic and reconstructive surgery ARNHEM (Netherland)

10. Eji yanagisaw Ear tumours

Merk manual home health hand book

11. Guahyin MD Reliable medical information on disease and their associated health conditions.

1 Signature of the Candidate : 2 Remark of the Guide : 3 11.1 DR II NAGARAJ T.M. PROFESSOR Name and designation of AND HEAD OF THE DEPARTMENT Guide ENT AND HEAD AND NECK (in block letters) RAJAJESWARI MEDICAL COLLEGE AND HOSPITAL BANGALORE 4 11.2 Signature

5 11.3 Co- Guide (if any) 6 11.4 Signature

7 11.5 Head of the DR II NAGARAJ T.M Department 8 11.6 Signature

9 11.6 Signature 10 12.1 Remarks of the Chairman and dean 11 12.2 Signature CONSENT FORM

I Mr / Mrs am exercising my free power of choice, here by give my consent to be included as a subject in the study “A CLINICAL STUDY OF BENIGN LESIONS OF PNNA. “ I understand that the information I give will be kept confidential. I have been informed to my satisfaction by the researchers about the nature and purpose of the study and I may or may not immediately benefit from the study. I am also aware of right to opt out of the study at any time during the course of the study without having to the reason for doing so.

SIGNATURE OF THE PATIENT

DATE :

PLACE : PROFORMA

Name of the patient :

Age : I.P.NO :

Sex : D.O.A :

Occupation : D.O.D :

Religion :

Address :

Socio economic status : High

: Middle

Chief Complaints : 1.

H/O Presenting illness :

Duration : Days : Months

: Years

Onset : Insidious/ Sudden

Progression : Progressive/ Non progressive

H/O Trauma : Present/ Absent / Not known

Types of trauma : Piercing

: Assault

: Fall

: Others

Site of Lesion :

No. of Lesions :

Size of Lesion :

Shape of Lesion :

Skin over Lesion : Normal/ Inflamed

Visible Pulsations : Present / Absent

Past History :

Personal History : Appetite :

Diet :

Sleep :

Bowel & Bladder habits :

Family History :

General Physical examination : Here is a child/ adult/ elderly male/ female aged about------yrs.

Poorly/ moderately/well built. Poorly /moderately / well nourished. Conscious,

Co-operative/ un co-operative.

Pallor : Icterus

Cyanosis : Clubbing

Oedema: Lymphadenopathy

Vital Signs:

Pulse B.P

RR Temp.

Local Examination :

Site :

Size :

Number :

Consistency:

Tenderness :

Local rise of temperature :

Pulsations :

Systemic Examination :

PA: CNS:

Diagnosis :