Dr.S.K.Kabra and G.C.Khilnani

Management protocol for bird flu cases

When to suspect:

Patents presenting with Fever (body temperature of 38^o Celsius or high) with one of the following symptoms:

Muscle ache, cough, abnormal breathing (unusual breathing difficulty) or suspected pneumonia by the physician, or influenza

in addition to

History of direct contact with infected / dead birds in past 7 days or

Occurrence of unusual death of birds in the community within the past 14 days; or

Contact with a pneumonia patient or another patient suspected of avian influenza

Case definition of probable case:symptoms of suspected case and Preliminary test shows infection of influenza group A, but cannot yet be confirmed whether it is from human or birds or

Respiratory failure or

Death

Case definition of Confirmed cases: A suspected or probable case with at least one of the following:

• Positive viral culture for influenza A/H5
• Positive RT PCR for influenza A/H5
• Positive IFA for influenza A/H5
• A 4 fold rise in influenza A/H5 specific antibody titers.

Management guideline for all suspected cases of avian flu:

Obtain NP swabs from all the patients (see annexure 1)

Assess severity of illness: Look for presence of following:

Respiratory distress as indicated by: increased respiratory rates, chest indrawing, dehydration, hypotension, altered sensorium or oxygen saturation of less than 93% in room air. If any of these are present patient should be admitted to ward in designated area and manage on following principles

1. Isolate cases
2. Monitor vital signs every 1-2 hours
3. Maintain air way breathing and circulation (ABC)
4. Maintain hydration, electrolyte balance, and nutrition
5. Provide oxygen and assisted ventilation when indicated
6. Manage fever with paracetamol
7. Give antiviral Oseltamivir (For doses see annexure 2)
8. Broad spectrum antibiotics for treatment of secondary pulmonary infection
9. Avoid giving nebulized medications: chances of spread

Management of non severe cases

If patient is stable: (absence of above clinical features): take NP aspirate from all the patients and isolate them in the designated area identified for them and Start on Oseltamivir

Obtain lab results and see clinical course. If lab tests negative: discontinue Oseltamivir and provide supportive care, shift them to regular wards if hospitalization indicated otherwise send them home

If lab test is positive: Transfer to designated in patient area and continue supportive care and oseltamivir

Discharge policy

Adult patients: Infection control precautions for 7 days after resolution of fever

Children: Infection control measures for 21 days after onset of illness.

If discharged earlier: child should not attend school and parents should be educated to observe infection control measures at home.

Precautions for health care workers handling cases of avian flu Wear personal protective equipments

1. Protective clothings:
   1. Overall plus an impermeable apron or surgical gown with long cuffed sleeves plus impermeable apron
   2. Heavy duty rubber work gloves that may be disinfected
   3. Standard well fitted surgical masks should be used if N 95 respiratory masks are not available.
   4. Goggles
   5. Rubber or polyurethane boots or protective foot cover
2. Chemoprophylaxis:

   For close contacts: Oseltamivir 75 mg daily for 7 days

   Persons at risk: Oseltamivir 75 mg daily for the entire epidemic

3. Monitoring of close contacts and health care workers exposed: observe for fever of >38 Celsius, watery diarrhoea, pain abdomen, headache, cough, rhinorrhoea, sore throat, shortness of breath and CNS manifestations. Check for them daily till 14 days of last exposure

Annexure 1

Collection and transport of samples

Samples from upper respiratory tract include

1. Nsopharyngeal aspirate
2. Nasal wash
3. Throat swab

From lower respiratory tract samples >include :

1. Transtracheal aspirate
2. Bronchoalveolar lavage
3. Lung biopsy
4. Post-mortem lung or tracheal tissue

Specimens for the laboratory diagnosis of avian influenza A should be collected in the following order of priority:

• nasopharyngeal aspirate/swab
• acute serum
• convalescent serum.

The sample collection should be done with all the necessary biosafety precautions including use of gowns, gloves and masks

The samples should be kept on ice and transported to virology laboratory as soon as possible

Annexure II

Antiviral drugs and their doses

Oseltamivir: is the only drug effective against H5N1 virus Doses are:

• Adults: 75 mg twice a day for adults,
• Children weighing

  < 15 Kg: 30 mg twice a day

  15-23 Kgs: 45 mg twice a day

  23-40 kgs: 60 mg twice a day

  > 40 kg: 75 mg twice a day

  Adverse effects of oseltamivir

  Nausea and vomiting: transient and occur in the beginning and are self limiting

  Abdominal pain, epistaxis, conjuctivitis

  Should be used in pregnancy with caution

  Contraindications:Hypersensitivity to drug

  Algorithm for management of Avian flu patients

  Suspect case of Avian flu

  (Patents presenting with Fever (body temperature of 38^o Celsius or high) with one of the following symptoms: Muscle ache, cough, abnormal breathing (unusual breathing difficulty) or suspected pneumonia by the physician, or influenza in addition to History of direct contact with infected / dead birds in past 7 days >or Occurrence of unusual death of birds in the community within the past 14 days; or Contact with a pneumonia patient or another patient suspected of avian influenza)

  
  

  Obtain NP aspirates and send to lab

   

   

  Asses severity of illness

  (Look for presence of following Respiratory distress as indicated by: increased respiratory rates, chest indrawing, dehydration, hypotension, altered sensorium or oxygen saturation of less than 93% in room air)

  

  Any one of the above present

  

  Admit in designated area and treat as follows

  Isolate cases

  Monitor vital signs every 1-2 hours

  Maintain air way breathing and circulation (ABC)

  Maintain hydration, electrolyte balance, and nutrition

  Provide oxygen and assisted ventilation when indicated

  Manage fever with paracetamol

  Give antiviral Oseltamivir (For doses see annexure 2)

  Broad spectrum antibiotics for treatment of secondary pulmonary infection

  Avoid giving nebulized medications: chances of spread

  None of the above present

  

  Keep the patient in designated out patient area, start oseltamivir and collect lab report reportresults

  

  

  

  Send home with supportive care

  

  Transfer to general ward and manage according to

Cochlear implant – Patient information sheet

Introduction

A cochlear implant is an electronic device that restores partial hearing to the properly selected deaf. It is surgically implanted in the inner ear and activated by a device worn behind the ear. Unlike a traditional hearing aid, which simply amplifies sound which is then heard in the normal way, a cochlear implant converts sound to electrical impulses which are then transmitted to the nerve of hearing that would normally carry the auditory signal to the brain. The device bypasses damaged parts of the auditory system and directly stimulates the nerve of hearing, allowing individuals who are profoundly hearing impaired to receive sound. Presently, cochlear implant is the only hope for these groups of patients for developing and learning linguistic ability for communication. Cochlear implant is now an accepted and established method of therapy for deafness in children and adults.

Prof. William House from House Ear Institute (USA-1961) first described the successful outcome from a single channel 3-M House Implantation in terms of making a deaf patient able to perceive sound as well as improve lip-reading ability. Since then, there has been a large body of research knowledge available to the clinicians and audiologists pertaining to the implant technology and its clinical use in managing patients with bilateral deafness. Professor Graeme Clark and his team consisting of engineers and other scientists from university of Melbourne, Australia made significant breakthrough in devising the multi-channeled Cochlear Implant and demonstrating its superiority over the single channel- cochlear implant in terms of providing open set recognition of language and speech following implant surgery and supported by auditory –verbal habilitation therapy. Soon the multi-channel Nucleus Implant (Cochlear make, Australia) made history in the world, in successfully managing a deaf person. In 1984, Professor Clark founded the Bionic Ear Institute which continues to lead research in collaboration with Cochlear Limited in achieving significant improvements in the device technology. Early in eighty’s this device was, after clinical trials, approved by the FDA (Food and Drug Administration, USA) as a safe and useful implantable device for use in adult post-linguistically deafened patients and later in 1991 it was also approved for use in children.

Normal Hearing

Human ear consists of three parts—the external ear, middle ear, and inner ear.The mechanism of hearing involves two components. In the conductive component, sound travels along the external ear canal causing the eardrum to vibrate. Three small bones of the middle earconduct this vibration from the eardrum to the cochlea (hearing organ) of the inner ear.

In the sensorineural component, the vibrations of the bones of the middle ear start waves of fluid in the cochlea, and these waves stimulate delicate hearing cells called hair cell. The movement of the hair cell generates an electrical current in the auditory nerve and it travels through interconnections to the brain area that recognizes it as sound.

Types of Deafness

There are two types of deafness

1. Conductive deafness: If the patient has disease in external or middle ear, it leads to conductive deafness. Medical or surgical treatment can correct this type of deafness
2. Sensorineural deafness: Sensorineural impairment or nerve deafness occurs if there is an innerear problem. Sensorineural hearing loss cannot be corrected with medicines. Hearing aids help the people with moderate to severe sensorineural hearing loss by amplifying the sound. But if there is bilateral severe or profound sensorineural hearing loss and if there is no benefit with hearing aids, cochlear implant is the only treatment option.

How does a cochlear implant work?

In cases of sensorineural deafness, the hair cells are damaged although many auditory nerve fibers may be intact. These nerve fibers are unresponsive because of hair cell damage. But these fibers can transmit electrical impulses to the brain on stimulation. Cochlear implants bypass damaged hair cells and convert speech and environmental sounds into electrical signals and send these signals through the hearing nerve to the brain.

Parts of cochlear implant:

Cochlear implant has external (outside) parts and internal (surgically implanted) parts.

External Parts:

The external parts include a microphone, a speech processor, and a transmitter . The microphone looks like a behind-the-ear hearing aid. It picks up sounds just like a microphone of the hearing aid and sends them to the speech processor.

The speech processor may be housed behind the ear with the microphone, or it may be worn on a belt or pocket. The speech processor analyzes and digitizes the sound signals and sends them to a transmitter worn on the head just behind the ear.

The transmitter sends the coded signals to an implanted receiver just under the skin.

Internal parts:

The internal (implanted) parts include a receiver-stimulating system and electrodes. The receiver is surgically fixed to the skull bone behind the ear. The receivertakes the coded electrical signals from the transmitter and delivers them to the array of electrodes that have been inserted in the cochlea during surgery.The electrodes stimulate the fibers of the auditory nerve to send information to the brain where it is interpreted as meaningful sound and thus the implanted person starts learning language and speech communication skills.

Cochlear implant surgery in AIIMS:

The Cochlear Implant team which includes surgical team and rehabilitation team works under the leadership of Professor RC Deka.

Surgical Team:

1. Professor RC Deka
2. Dr Alok Thakar
3. Dr Rakesh Kumar
4. Dr C Venkatakarthikeyan
5. Dr. Kapil Sikka
6. Dr. Rajeev

Audiology & Speech Rehabilitation Team:

1. Ms Shivani Agarwal
2. Ms Pallavi Rani
3. Ms Bharti Berry
4. Mr Rakesh Kumar

Evaluation of the candidates for cochlear implant surgery

An implant team consisting of otolaryngologist, audiologist, radiologist, pediatric neurologist, clinical psychologist and speech therapist does the clinical and other laboratory assessment. The otolaryngologist examines the middle and inner ear to ensure that no active infection or other abnormality precludes the implant surgery and assess the patient in detail for fitness of implant surgery. The audiologist performs hearing tests to find out the severity of hearing loss and also does pre-implant assessment and counseling for prospective implant client. High Resolution Computerized Tomography (HRCT) of temporal bone and Magnetic Resonance Imaging (MRI) scans of head with 3D reconstruction for the inner ear and the 7^th and 8^th nerve complex are done to assess the morphologic status of the ear and the brain. Anesthetists will do a complete physical examination and analysis of the laboratory investigations to identify any potential problems with the general anesthesia. We also take opinion from pediatric neurologist and clinical psychologist regarding fitness for cochlear implant surgery.

After the completion of abovementioned evaluation, the patient/parents will be explained what they can reasonably expect after cochlear implant surgery. The complications of the implant surgery which include wound hematoma, infection, facial weakness etc will also be explained to the individual patient/relative/parent on his/her visit to the hospital.

Cochlear Implant Surgery

Implant surgery is performed under general anesthesia and lasts from two to three hours. An incision is made behind the ear to open the mastoid bone leading to the middle ear and then the inner ear is opened and implant electrodes are inserted. A well is created in the skull bone for the placement of the receiver-stimulating system. The procedure requires a stay in the hospital for 7 to 10 days. Antibiotics and other supportive medicines are given to such a patient.

Post operative switch-on, Mapping and training

The rehabilitation team, 3 to 4 weeks after surgery (when the surgical wound is well healed) activates the cochlear implant. During this “switch-on”, the patient’s implant is programmed using computer-based software. The impedance parameters of the electrodes are checked. The first MAP (a computer program that determines how sound signals will be converted to electrical signals) is created by determining the psychophysical parameters of threshold level, comfortable level for each active electrode and balancing the parameters for all the channels. Together, measures of the threshold level and comfortable loudness levels set the electrical dynamic range inside which all auditory signals will fall. The MAP is saved in the speech processor. It is very difficult to determine these behavioral parameters in younger prelingually deafened children. Objective assessment by Neural Response Telemetry (NRT) will be done in these patients. After the initial switch-on, the audiologist of the habilitation team will conduct the subsequent mapping sessions once or twice a week in the first month, then once a month for the first six months, then every three to six months as needed. This may differ according to individual children’s needs. The audiologist would do assessment tests such as speech perception tests at regular intervals and also offer ongoing technical support to the parents working with the child. The therapist works with the goal set for speech, language and listening. The therapist teaches the child to listen to the sound that is received from the cochlear implant and helps them in developing effective spoken communication. The therapist works closely with the parents to educate them about the stages of the development for speech and language and to counsel and inform them about realistic expectations about the cochlear implant

The parents and relatives are also made to actively participate in the training of the implantees. Parents are taught how to create a listening environment at home where the child can learn through play, daily routines and some planned listening activities. The parents are the main teachers and the language models, while the therapist is actually teaching the parents how to interact with their child at home. The parents need to have knowledge and confidence to effectively apply that role in their daily lives. Parents participation in the training is of paramount importance and one of the parent has to learn the therapy to train the child at home.

Outcome of surgery

The outcome of cochlear implantation depends on the age of the patient at implantation, previous sound experience, motivation/active participation of the patient/parents and good post operative auditory verbal training.

Till now (July, 2008), we have performed 216 cochlear implant surgeries in adults and children. 169 cases were prelingually deaf children and 47 were postlingually deaf adults. Habilitation with auditory verbal training and speech therapy is done by our audiologists and speech therapists in the cochlear implant Lab of our Department. Many of them also got training in their places by another speech therapist and they were coming to us at regular interval for follow up at AIIMS. After cochlear implantation, all postlingually deafened adults had significant improvement in the audiological perception, clarity of speech, performance in day to day activities and social interaction. Based on the age at implantation the prelingually deafened patients can be divided into 3 categories.

1. Category A:This consists of children of age less than 5 years. This was the group with the best results. The linguistic development was significantly seen and 80% of the children are going to normal schools. Their access to mainstream education is reportedly successful. They used fewer school support services according to available information from the parents. AIIMS now recommends cochlear implant more for this group of patients as they are our target group.
2. Category B: This group consists of children with age between 5 to10 years. This category of patients also developed significantly notable lip reading capabilities and audiological perception. They are acquiring linguistic development with auditory verbal training, but when compared to Category A children, they lag behind them. These children also required special support services for improvement in the academic performances.
3. Category C: This group consists of children of age more than 10 years. The result of cochlear implantation in this group was comparatively less notable in respect to language and speech learning processes. However improvement in the lip-reading abilities was observed especially in those children who had sound experience in early life and those who had used hearing aid with some limited acquisition of linguistic ability.

All candidates irrespective of age required good postoperative auditory verbal training by audiologist, speech therapist as well as by parents to achieve significant and notable results.

Types of Cochlear implants

Currently there are three FDA (Food and Drug Administration, USA) approved cochlear implants available in the Indian market namely

1. Nucleus (Cochlear-Australian make)
2. Advanced Bionic (American)
3. Med El (Austrian make)

For details, one can visit the following websites.

www.cochlear.com
www.medel.com
www.bionicear.com

At present AIIMS has the infrastructural facility for the Nucleus (Cochlear make) types of implants in RUAS (rehabilitation Unit of Audiology and Speech Pathology) laboratory Nucleus type is technically better than the other FDA approved implants available in the market because of its large number of channels, titanium casing (which has the property of Osseo integration), NRT facility and a better speech processor. It also has better service centers, located in Delhi and in other major cities of India for the repair/replacement/service of the wearable components, which include wires, microphone, speech processors and any other accessories like magnetic coil. Above all Nucleus 24 (Straight) is popularly used world wide and also decided upon by our Indian patients since it has the lowest price in Indian market (present price Rs.5.12 lakhs). All other FDA approved implants are costlier than this. AIIMS is following the selection procedure based on the purchase practice of cochlear implant made by the Directorate of AFMS, Defense Ministry, Govt of India for their cochlear implant programs in R&R Hospital, New Delhi, AFMC, Pune, and also Ashwani Hospital, Mumbai. They fully funded the cochlear implants but in AIIMS it is not funded.

Budget Estimate

The budget estimate based on the current price of the three types of Nucleus cochlear implants is as follows: (Prices are based on national prices declared by the Indian dealers /company)

1. 1. Price of the Nucleus 24 (Straight) cochlear implant system (Most popular and widely used one) = Rs. 5.12 Lakhs.
   2. Price of CI-Nucleus-24 (contour) Cochlear implant system (Hugging variety)= Rs. 7.00 Lakhs.
   3. Price of CI- Nucleus Freedom Contour Advanced (Latest and state of art implant) = Rs. 9.50 Lakhs.
2. Post operative programming and tuning of the system in our rehabilitation unit is free
3. Hospital Expenditure: Minimal but for certain essential medicines, disposables if they are not availablemay cost about Rs. 5,000/-

Procurement Procedure

Once it is decided by individual patient/relative/parent to undergo cochlear implant surgery, they have to decide the Once it is decided by individual patient/relative/parent to undergo cochlear implant surgery, they have to decide the type of implant based on their budget capacities. They have to generate funds for that particular implant from their own sources. In AIIMS, the process of procurement of cochlear implant will be through rate contract basis. It is under process and likely to be completed soon. As of now, AIIMS does not provide any implant. Patient/relative/parent can purchase the Nucleus implant from the authorized local Indian dealer, PIKA Medical Pvt Ltd, 201, A-285, Defense Colony, New Delhi- 110024 Ph: +91 11 24338080, Fax: +91 11 24338090 (Head Office , Bangalore). But if they needs assistance in procuring the implant, AIIMS helps him/her to procure the implant on his/her behalf on payment of the required amount in the form of a bank draft in favor of “The Director, AIIMS” (payable in Delhi). It processes the procurement on behalf of the individual patient/relative/parent and for the individual patient through Store Officer as per existing store purchase procedures approved by the competent authority (Director /DDA) since 1996.The ENT department assists this process of procurement for patient facilitation. The process is done by the AIIMS accounts and stores section for patient facilitation without any charges

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Cochlear implant – Patient information

PATIENT CARE

The Department provided a state of the art ENT Service and is equipped with the entire range of diagnostic and therapeutic equipments including a Cochlear Implant Lab, audiological facilities, Electronystagmographic facilities, Electrodiagnostic Audiometry, Hearing Aid Analyzer, ear mould lab, play therapy, stroboscopy & computer aided speech analysis and nasal and laryngeal endoscopes. The Rehabilitation Unit of Audiology and Speech Therapy functions with the clinical department to provide supportive diagnostic and rehabilitative services for the Hearing Impairment, Speech problems and post-laryngectomy speech disabled.

Besides the continuing post-lingual Cochlear implant programme in adults and adolescents, the Department has now also started the implant programme in early onset Prelingual deafened young children

ENT OPD ATTENDENCE

New 39629
Old 26511
Total 66137

SPECIAL CLINICS:

THE REHABILITATION UNIT OF AUDIOLOGY AND SPEECH THERAPY(RUAS)

The Clinical work undertaken by the unit included-

Outreach Rural Services- The department provides a comprehensive ENT service at the Primary Health Centre at Ballabgarh, Haryana. In addition two rural ENT diagnostic camps were organised at Haryana.

COCHLEAR IMPLANT PROGRAM (an overview)

The cochlear implantation (CI) program was started in All India Institute of Medical Sciences in 1996 under the chairmanship of Prof.RC Deka and the first adult patient was successfully operated upon in February in 1997. Soon, the department started the Children Program in 1998. Till now (July, 2008), we have performed 216 cochlear implant surgeries in adults and children. 169 cases were prelingually deaf children and 47 patients were postlingually deaf adults. Prof. RC Deka has also done the country’s first bilateral Cochlear implant successfully in an adult patient. The department has provided support in starting cochlear implant program in R.R. Hospital, Central Railway Hospital in New Delhi and also PGIMER in Chandigarh.

What is a cochlear implant?

A cochlear implant is an electronic device that restores partial hearing to the deaf. It is the only treatment option available for patients with bilateral profound sensorineural hearing loss, if there is no benefit with hearing aids.

How does a cochlear implant work?

Cochlear implant is surgically implanted in the ear and activated by a device worn behind the ear. It converts sound to electrical impulses. These impulses are then transmitted via hearing nerve to the brain. The device bypasses damaged parts of the auditory system (hair cells of cochlea) and directly stimulates the nerve of hearing, allowing individuals who are profoundly hearing impaired to perceive sound.

What are the components of Cochlear Implant?

Cochlear implants have two parts-

1. external (outside) parts that include a microphone, a speech processor, and a transmitter.
2. internal (surgically implanted) parts - a receiver-stimulating system fixed to the skull bone behind the ear and electrodes which are inserted into the cochlea.

The microphone picks up sounds and sends them to the speech processor. The speech processor analyzes and digitizes the sound signals and sends them to a transmitter worn on the side of head just behind the ear. The transmitter sends the coded signals to an implanted receiver. The receiver in turn delivers them to the array of electrodes that stimulate the fibers of the auditory nerve directly. The auditory nerve transmits this information to the brain where it is interpreted as meaningful sound and thus the implanted person starts learning language and speech communication skills.

Cochlear Implant surgery in AIIMS

An implant team consisting of otolaryngologist, audiologist, radiologist, pediatric neurologist, clinical psychologist and speech therapist does the clinical and other laboratory assessment before planning for surgery. Implant surgery is performed under general anesthesia and lasts from two to three hours. The procedure requires a stay in the hospital for 7 to 10 days.

Postoperative rehabilitation

The postoperative rehabilitation will be done by the rehabilitation team consisting of otolaryngologist, audiologist and speech therapist. Parents’ participation in the training is of paramount importance and one of the parents has to learn the therapy to train the child at home. When the surgical wound is well healed (usually 3 to 4 weeks after surgery) the cochlear implant is activated (switch-on) and a MAP is created using computer based software. The subsequent mapping sessions are individually tailored as per the progress made by the patient. The short and long term goals are set for listening and then language and speech. The therapist teaches the child to listen to the sound that is received from the cochlear implant and helps them in developing effective spoken communication, leading to development of language and speech.

When my child/ the patient start hearing and speaking ?

Cochlear implants do not restore normal hearing, and benefits vary from one individual to another. The implantees are expected to hear and/or recognize sounds/speech and learn language through the auditory input with the help of cochlear implant. In children, 4-5 years of intensive training is needed.

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REHABILITATION UNIT OF AUDIOLOGY AND SPEECH THEARPY

This unit provides comprehensive diagnostic and rehabilitative services in various speech and hearing disorders. It is started by clinical experts who provide for diagnostic audiology services, hearing therapy & hearing aid fitting & rehabilitation & speech therapy & training.

The unit is equipped with state of the art equipment and houses facilities for diagnostic audiometry, tympanometry, evoked response testing, hearing aid calibration, ear mould lab, play therapy, stroboscopy & computer aided speech analysis with VAGHMI & vocal-2, speech analysis with software.

Consultations with clinical experts in the unit are available every working day morning. All patients seen in the unit should however have had a previous consultation with the ENT medical staff. The unit has developed expertise in detection & evaluates of paediatric hearing impairment & with its rehabilitation & therapy. The facility for cochlear implant programming has recently become available. The speech therapy services provides therapy for stammering, misarticulation, voice disorder, post laryngectomy aphonia, cleft palate, and patients with hearing impairment.

A 3 year graduate course ( B.Sc (Hons) Speech & Hearing is available in the Unit & train students in the areas of diagnostic audiology, rehabilitation of the hearing impaired and speech therapy. The intake is 3 students per year.