Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241121EnglishN2020January9HealthcareA Two Years Study to Determine the Etiology and Risk Factor of Discharging Ear Below One Year of Age in a Tertiary Paediatric Health Care Teaching Hospital in India English0105Poulomi SahaEnglish Kapildev MondalEnglishIntroduction: Ear discharge in infancy is a major health problem and may lead to hearing impairment , delayed speech and language development , and poor academic performance .The most common cause of ear discharge in infants is ASOM which is due to swelling and infection in the middle ear. CSOM with or without cholesteatoma and otitis externa can affect a child’s ability to learn and consequently may have a lifelong impact on his/her quality of life and overall development. Aim of the Study: To find out the etiology and risk factors of neonatal and infant ear discharge. Study Design: Retrospective, observational, analytical study. Method: 2405 children (age group 0 – 1 years) attending the out-patient department from June, 2017 – June, 2019 were examined. Detailed history, clinical examination, and assessment were done after grouping the children in three age group(0-1 month,1-6 months,6-12months). Associated etiology and risk factors were also looked for at each stage of study. Results: Out of 2405 children under 1 year of age 1077 were seen in age group of 6 months 1 day to 12 months of age. In second group 745 patients were noted from 1 month 1 day to 6 months of age. Minimum patients were noted in 0-1 month age group and they were 583 in number. Most common etiology was noted to be A.S.O.M. Most common risk factor noted to be was Respiratory infection(both upper and lower). Conclusion: This present study have a robust result showing the current etiological causes of ear discharge in children below 1 year of age which would guide us for proper diagnosis and empirical treatment of ear infections in them. Most common aetiology is noted to be Upper respiratory tract infection(URTI) leading to otitis media(OM). The most common bacteriologic cause of the discharging ear was pseudomonas species. EnglishOttitis, Media, Infancy, Speech, Health, InfectionINTRODUCTION Ear discharge in infancy is a major health problem and may lead to  hearing impairment ; delayed speech and language development ; and poor academic  performance . Most common cause of ear discharge in infants is  A.S.O.M  which is due to swelling and infection in the middle ear. Chronic ear infection  mostly C.S.O.M with or without cholesteatoma and otitis externa can affect a child’s ability to learn and consequently may have a lifelong impact on his/her quality of life and overall development . It is estimated that almost all children will have had an ear infection by the age of five years. 50% of the  children aged 2 to 3 years have had at least one ear infection since birth and 13% of children had frequent (four or more) ear infections below the age of 2 years .There is no existing Indian study which shown the risk factors of  otorrhoea.  Colours of the ear discharge  indicates the cause of the otorrhoea. A purulent discharge indicates the presence of infection, while a bloody discharge may occur due to trauma or occur with granulation tissue associated with chronic infection. The presence of a mucoid discharge indicates a perforation of the tympanic membrane, there are no mucous glands in the external ear canal; the fluid must therefore arise from the middle ear. Clear, watery fluid, especially when associated with a history of trauma or skull base surgery, is likely to be CSF. Recurrent episodes of purulent otorrhoea suggest CSOM, while purulent otorrhoea of acute onset suggests acute otitis media with perforation of the tympanic membrane, or acute otitis externa. In acute otitis media, the pain characteristically improves when the tympanic membrane ruptures and otorrhoea starts. In otitis externa the pain is persistent. Otitis externa is characterised by a scanty, thin, watery discharge, usually preceded by itching or discomfort in the ear canal. A foul-smelling discharge is usually associated with cholesteatoma . In general, ear infections are mild and resolve by themselves over a short period of time; however, if left untreated, this infection could lead to hearing loss, some point in the future. Current recommendations for acute otitis media are to observe and treat with antibiotics only if the condition does not resolve in a few days, thus clinical assessment is important in managing the condition. The bacteriologic spectrum of ear discharge is highly variable specially in children. This study thus carry immense importance for accurate diagnosis and management of  ear discharge in first year of life.  The current study was carried out to determine the current risk factors of ear discharge in children below 1 year of age. As this study surveyed a large number of  rural and urban children under 1 year allowing robust results .This  data can  guide  empirical treatment of ear infections in neonates and infants  and also form a basis for further research to improve quality of care. AIM OF THE STUDY To find out the risk factors of   neonatal and infant ear discharge. STUDY DESIGN Retrospective, observational, analytical study Materials and Methods Study area: Department of  ENT,  Dr.B.C.ROY, PGIPS Department of ENT, Tertiary Pediatric   Health Care Center, Kolkata (W.B.). Study period: June, 2017 – June, 2019. Study sample: Two thousand four hundred and FIVE (2405) children (age group 0 – 1 years) attending the out-patient department . Children are subdivided in four age groups Group A – 0 to 1 month(583 Patients) Group B-  1 month 1 day  to 6 months (745 Patients) Group C –  6 months 1 day to 12 months(1077 Patients) INCLUSION CRITERIA All children were screened for deafness before the study and they underwent BERA test. Only the children who normal report on BERA were included in this study. Neonates with ear discharge                                                                                Infants with complaints discharge or decreased hearing or decreased response to sound stimuli. EXCLUSION CRITERIA Children with congenital anomaly Children with syndromes. Children with mental retardation and cerebral Palsy Children with chronic medical problems or anatomical or physiological defect of the ear or nasopharynx were excluded. ETHICAL CLEARANCE We have taken institutional ethics committee clearance prior to the commencement of the study. STUDY METHOD  Clinical history was obtained from each patient consisting of  10 preformed questionnaire  of prenatal, perinatal and post natal period. Specified  history  obtained from each mother regarding gestational drug intake, smoking ,diabetes, hypertension or any other illness. Then all risk factors of   infant hearing loss and progressive or late onset hearing loss were screened. All children had normal hearing at birth. Standard   ENT examination with was done in all children. otoscopy  and examination under microscope (EUM) were done in all children to ascertain the nature of discharge as well as the disease. Patients who presented with purulent discharge, ear swabs were taken maintaining all standard complete aseptic precautions and sent to Department of Microbiology for examination. All specimens were taken using dry sterile cotton and were cultured on blood, chocolate and Macconkey agar and incubated aerobically at 37 degree Centigrade for 24 hours. Isolated organisms were identified using standard biochemical tests, including urease and indole production, citrate utilization, hydrogen  sulphide  gas production and fermentation of sugars. The biochemical media used included Simon’s Citrate medium, Urea and Triple Sugar Iron agar (TSI).      Patients with clear water like discharge from ear with clinical suspicion of cerebrospinal fluid(C.S.F) , were subjected sample collection in a sterile syringe without needle, sent to Department of  Biochemistry for Beta 2 transferrin  for confirmation of diagnosis. RESULT AND ANALYSIS: Out of  2405 children under 1 year of age maximum patients, 1077, were seen in age group of 6 months 1 day to 12 months of age. In second group 745 patients were noted from 1 month 1 day to 6 months of age. Minimum patients were noted in 0-1 month age group and they were 583 in number. 38% (most common) type of patients presented with purulent discharge with ASOM(A.S.O.M), 25% presented with C.S.O.M, 17% presented with otitis externa ,15  % patients presented with wax with brown discharge in external auditory canal , 4 % patients presented with blood in external auditory canal mostly because of trauma  and  at last 1% patients even presented with CSF in the external auditory canal  1515 ear swabs were received by the Microbiology Department for processing over the two year period. Of these1380 had microorganisms being isolated from the discharge. Most common organism(82%) to isolate was Pseudomonas species.8%  Enterobacteria , 5% Gram positive organisms mostly staph aureus , 2 % Fungi mostly candida species  and 3% Actinobactor species were isolated from the ear swabs. 135 isolates were deemed contaminants. Most common etiology of ear discharge in neonatal period and infancy is upper respiratory tract infection(35%). In our study we have seen that 18% patients who were suffering from childhood Asthma, also had ear discharge due to both A.S.O.M and C.S.O.M. It was noted that 15% children below 1 year of age who were breast feed for less than 3 months had active ear discharge, whereas children who were breast feed for first 6 months of their life had significantly lower incidence (3%) of ear discharge. Mothers who smoked in their pregnancy were found to have neonates and infants with active discharge in 12% cases while 5% babies of this study had ear discharge who were subjected to passive smoking. In 5% cases, first born children were affected. DISCUSSION Worldwide Otitis media (OM) or middle ear infection is a very common ear disease among children under the age of 6 years. According to Kong and Coates, ear infections were common in two age groups: between 6 and 24 months of age and 4-5 years of age. The current study enlightens the specific factors leading to ear discharge due to OM in neonatal period and infancy. OM complicating URI is considered when OM occurs within 28 days of the URI, AOM(acute otitis media) was defined by acute onset of symptoms (fever, irritability, or earache), signs of tympanic membrane inflammation and presence of fluid as documented by otoscopy . Most URIs are self-limiting, their complications are more important than the infections. In developing countries like India with inadequate medical care, it mostly lead to perforated eardrums and chronic ear discharge in later childhood and ultimately to hearing impairment or deafness . Two viruses most commonly detected during URI were rhinovirus and adenovirus. While adenovirus was associated with high rate of AOM complicating URI, rhinovirus was associated with lower rate than that of corona virus, RSV and adenovirus. Correlations between virus concentrations and elevated levels of cytokines/inflammatory mediators (IL-6, TNF α, IFN-γ, IL-1, IL-8 MIP-1α), and disease severity have been shown previously in respiratory virus infections. Many studies showed that breastfeeding has a protective effect on the development of  otitis media. This could be due to presence of the immunoglobulin of  breast milk, which contains specific antibodies against respiratory viruses. The period of breastfeeding had a significant impact on the occurrence of otitis media. Salah et al. found that breastfeeding for less than three months was associated with an increased risk of developing otitis media compared with infants who were breastfed more than three months. Similar to these studies, this present study also supports the fact. Baraibar reported that these positive relationships between ear infection and having siblings could be due to both environmental and genetic factors. Similar to these earlier studies, this study showed that first born children had a significantly higher prevalence of ear infections. In this study too it is noted that in 5% cases first born children were affected more than their younger siblings.  Significant relationship between childhood obesity below 1 year  and ear infection was observed in this study in 5 % cases. Maternal smoking during pregnancy was a significant risk factor for ear infection and ear discharge and seen in 12 % case. Two studies have found that parental smoking increases the risk of otitis media and one did not. In the present study, maternal smoking during pregnancy was  risk factor in 5% cases.   CONCLUSION:  The ear discharge   is a common presentation in medical practice affecting all age groups but primarily children. Most of the studies were done in children under the age of five years. This present study have a robust result showing the current etiological causes of ear discharge in children below 1 year of age which would guide  us for proper diagnosis and empirical treatment of ear infection. The most common etiology is noted to be Upper respiratory tract infection(URTI) leading to otitis media(OM). The most common bacteriologic cause of the discharging ear was Pseudomonas species. In India no  such study was carried out in recent years so the present data would not only guide us towards empirical treatment of ear infections in neonates and infants, will also help to identify other aetiologies of ear discharge in them. Thus it can form a basis for further research to improve quality of care extended to neonates and infants. ACKNOWLEDGEMENT: We acknowledge the immense help received from  medical superintendent cum vice principal of  Dr B.C. ROY. HOSPITAL, scholars whose articles are cited and included in references of this manuscript, editor of different journal & text book from where we have taken references. SOURCES OF FUNDING: No funding CONFLICT OF INTEREST : There is no conflict of interest from our side for this study. ABBREVIATION OM      =      Otitis media. ASOM =      Acute suppurative otitis media. CSOM =      Chronic suppurative otitis media. C.S.F   =      Cerebro spinal fluid. EUM   =      Examination under microscope. TSI      =      Tripple sugar agar medium. BMI    =       Body mass index. URI     =      Upper respiratory tract infection. RSV   =       Respiratory syncytial virus. 10. IT      =       Interleukin. 11. TNF   =      Tumour necrosis factor. IFN      =     Interferron. 13.MIP=          Major Intrinsic Protein. 14.BERA=    Brain evoked response audiometry. Englishhttp://ijcrr.com/abstract.php?article_id=2647http://ijcrr.com/article_html.php?did=26471. Chandima P. Karunanayake et al, Ear infection and its associated risk Factors in First Nations an Rural School Aged Canadian Children. International Journal of Pediatrics. Volume 2016,  Article ID 1523897, 10 pages: http://dx.doi.org/10.1155/2016/1523897.  2. L. Appiah-korang, S. Asare-gyasi A. E. Yawson, K.Searyoh, Aetiological agents of ear discharge: A two year review in a Teaching Hospital In Ghana, GHANA MEDICAL JOURNAL,  June 2014, Volume 48, Number 2 .http://dx.doi.org/10.4314/gmj.v48i2.6 3. V. Yiengprugsawan, A. Hogan, Ear infection and its associated risk factors, comorbidity, and health service use in Australian  Children, International Journal of Pediatrics, Vol 2013, Article ID 963132. 4. M. Salah, M. Abdel-Aziz, A. Al-Farok, and A. Jebrini, Recurrent acute otitis media in infants: analysis of risk factors, International Journal of Pediatric Otorhinolaryngology, vol. 77 no. 10,  pp. 1665–1669, 2013. 5. Afolabi O, Salaudeen A, Ologe F, Nwabuisi C, Nwalolo C, Pattern of bacterial isolates in the middle ear discharge of patients with chronic suppurative otitis media in a tertiary hospital in North central Nigeria. Afr Health Sci. 2012;12(3):362–8. 6. Monasta L, Ronfani L, Marchetti F, Montico M, Vecchi B L,Bavcar A,  Burden of  Disease Caused by Otitis Media: Systematic Review and Global Estimates. PLoS ONE. 2012. April 30, 2012 https://doi.org/10.1371/journal.pone.0036226. 7 Vishwanath S, Mukhopadhyay C, Prakash R, Pillai S, Pujary K, Puiary P., Chronic Suppurative Otitis Media: Optimizing Initial Antibiotic Therapy in a Tertiary Care Setup.. Indian J Otolaryngol Head And Neck Surg.2012;64(3):285–9. 8. Dayasena R, Dayasiri M, Jayasuriya C, Perera D, Aetiological agents in chronic suppurative otitis media in Sri Lanka. Australas Med J. 2011;4(2):101–4. 9. J. A. M. Labout, L. Duijts, A. Lebon,  Risk factors for otitis media in children with special emphasis on the role of colonization with bacterial airway pathogens: the Generation R study,” European Journal of Epidemiology, vol. 26, no. 1, pp.61–66, 2011. 10. E. A. MacIntyre, C. J. Karr, M. Koehoorn et al., Otitis media incidence and risk factors in a population-based birth cohort, Paediatrics and Child Health, vol. 15, no. 7, pp. 437–442, 2010. 11. Amin M, Blayney A. J., The discharging ear. ENT Mastercl.2010;3(1):68–72. 12. Tasnee Chonmaitree, M.D et al., Viral upper respiratory tract infection and otitis media complication in young children. Clin Infect Dis; available in PMC 2009 September 15. 46(6): 815–823. doi:10.1086/528685.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241121EnglishN2020January9HealthcareComparing the Effectiveness of Maitland Mobilization Technique and Muscle Energy Technique on Pain, Range of Motion and Functional Activities in Adhesive Capsulitis English0610Parthiban S.English Manikandan M.English Ashraf Y.EnglishObjective: To find out the effect of Maitland Mobilization Technique versus Muscle Energy Technique on pain, range of motion and functional activities among subjects with Adhesive Capsulitis. Method and Subjects: 28 subjects with aged 40-65 years were selected for this study. They were randomly divided in to two groups. Group A- 14 Subjects were received Maitland Mobilization Technique, Group B- 14 Subjects were received Muscle Energy Technique for a period of 2 weeks. The pre and post score values of pain were measured by NPRS, for all shoulder ROM by goniometer and functional activities by SPADI. Data were analyzed by SPSS-20 to determine the effects of both the treatment regimens on the same outcome measures. Results: The patients with adhesive capsulitis who treated with Maitland Mobilization Technique and Muscle Energy Technique both showed significant improvement (p0.05) for all parameters. Conclusion: The study confirmed that both Maitland Mobilization Technique and Muscle Energy Technique had better effect on pain, range of motion and improving functional activities. But comparing both groups was insignificantly changes for all parameters. EnglishAdhesive Capsulitis, Maitland Mobilization Technique, Muscle Energy Technique, Numerical Pain Rating Scale, Range of Motion, Shoulder Pain and Disability IndexINTRODUCTION The term adhesive capsulitis is a well-defined shoulder disorder characterized by progressive pain and stiffness of shoulder which resolves after 18 months period the cause remain unknown which is due to fibroblastic proliferation in the rotator interval anterior capsule and coraco-humeral ligament (4). The annual incidence of adhesive capsulitis in the general population in approximately 3 to 5% and up to 20% in people with diabetes. It is most frequently found in patients between the fourth and sixth decades of life and it is more common in women than men (20). Duplay in 1896 first described about this condition and named as periarthritis scapula humerale identifying as the lesion of periarticular structures (19). Nevasier coined the term adhesive capsulitis to describe a contracted thickened joint capsule that seemed to be drawn tightly around the humeral head with a relative absence of synovial fluid and chronic inflammatory changes with the synovial layer of the capsule(3). The movements will be restricted in all planes without any radiological abnormalities and both active and passive movements will be painful and restricted with external rotation and abduction limited to the maximum(19). The Etiology remains unclear, adhesive capsulitis can be classified as primary or secondary. Frozen shoulder is considered primary if the onset is idiopathic while secondary results from a known causes or surgical event. Three subcategories of secondary frozen shoulder include systemic –Diabetes mellitus and other metabolic conditions. Extrinsic – cardiopulmonary disease, cervical disc disease, Cerebrovascular accident, humerus fractures, Parkinson’s disease. Intrinsic factors rotator cuff pathologies, biceps tendonitis, calcific tendonitis, Acromioclavicular joint, arthritis (21). The disease process affects the anteriosuperior joint capsule, maxillary recess, and the coraco-humeral ligament. It has been show through arthroscopy that patient tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderated synovitis but no actual adhesions. Contracture of the rotator cuff interval has also been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in this population.             Consists of Three Phases:Painful PhaseGradual onset of shoulder pain at rest with sharp pain at extremes of motion and pain at night with sleep interruption which may last anywhere from 3-9 months.Stiffening Phase:Pain starts to subside, progressive loss of glenohumeral motion in capsular pattern, pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.Thawing Phase:Spontaneous, progressive improvement in functional range of motion which can last anywhere from 1 to 3.5 years (21). In phase II, the contracted capsule does not allow normal free movement of the shoulder which causes the scapula to move excessively in upward rotation and lateral trunk lean to compensate for the loss on glenohumeral rotation(3).The capsular pattern of restricted range of shoulder motion in adhesive capsulitis is external rotation, abduction and internal rotation. In adhesive capsulitis of shoulder, there will be proportional limitation in all movements of the glenohumeral joint in all planes (7). Pain, active movements (External rotation, abduction, internal rotation and flexion) and functional outcomes were used as primary outcome measures because they are important features in adhesive capsulitis of shoulder. Physiotherapy intervention usually used for the management of this specific condition are heat or cold modalities. Active exercise, Maitland Mobilization Techniques and Muscle Energy Techniques. Maitland Mobilization Techniques and Muscle Energy Techniques is an important part of intervention which includes the normal physiological movement and the accessory movement. MATERIAL AND METHODOLOGY The study design was a Prospective, open labelled, quasi-experimental comparative design. The Study was done in the Department of Orthopedics & Department of Physical Medicine and Rehabilitation, PSG Hospitals Coimbatore. The period June 2017- April 2018.The study approval from the PSG institutional of medical science and research- Institutional Human ethical committee reference project No: 17/126 date approved 06.07.2017. Participants (n=34) with adhesive capsulitis were recruited from the orthopedics PMR department. 28 subjects met the inclusion criteria and accepted to consent. They were randomly allocated into 2 groups by simple random sampling method. The Selection Criteria were withthe age group of 40-65 years, both male and female, Apley’s scratch test positive, Painful phase and stiffening phase of adhesive capsulitis and those who will consent to participate were included. The subjects Shoulder dislocation, Upper limb neurological deficit , trauma to the joint structure and soft tissue particular shoulder, Thoracic outlet syndrome, Manipulation under anesthesiacondition, pathology neck pain, those who Received physiotherapy for the same problem before 3 months, Myocardial infarction, Red flags to mobilization. Study Materials Assessment chart, Goniometer (universal), Shoulder Range of motion (goniometer), Numerical pain rating scale (NPRS), Shoulder Pain And Disability Index (SPADI)were used for pre and post measures.Treatment Duration week for 2 weeks. Group A- 14 Subjects – Received Maitland Mobilization Technique(Figure No: 1). Group B- 14 Subjects – Received Muscle Energy Technique(Group Figure No: 2). RESULTS STATISTICAL ANALYSIS AND INTERPRETATION The Mean, Standard deviation and Paired-t- test, Independent-t- test values were used to find out any significant difference between the two groups. (Group A and B). Data collected from Group A (Maitland Mobilization Technique) and Group B (Muscle Energy Technique) were analyzed by using paired t- test to measure the changes between the pre and post-test values within the group and independent t test was done to measure the changes between group analysis. All these statistical analysis were performed through SPSS-20 Version. WITHIN GROUP ANALYSIS The Group A (Maitland Mobilization Technique) for the Pain‘t’ value 5.229 (p< 0.001). Shoulder abduction ‘t’ value was 8.850(p< 0.001) and the shoulder external rotation‘t’ value was5.375 (PEnglishhttp://ijcrr.com/abstract.php?article_id=2648http://ijcrr.com/article_html.php?did=2648  Abhay Kumar et al., Effectiveness of Maitland Techniques in Idiopathic shoulder Adhesive capsulitis. ISRN Rehabilitation, Vol 2; 2012, pp: 8. Anwar Ali Gayasi et al., Most preferred manual therapy technique among physiotherapist for treating frozen shoulder.Oct-2014.pp:322-327. Brian J Tovinet al., Evaluation and treatment of the shoulder Greenfield (CPR) 01 Jun 2001. Bunker .D.Timothy and Peter J. Scharnz. Clinical challenges in Orthopaedics of shoulder, United Kingdom Publishing house, 01 Mar 1998. Carolyn Kisner MS, PT., Therapeutic exercise foundations and techniques, 4th edition, 2003. Codman E.A, The Shoulder rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa, 1934. David J Magee BPT, Ph.D., Musculoskeletal Rehabilitation series, Orthopaedic physical assessment,5th edition. Erin McLaughlin, Department of social&health services,Range of motion is a measurement of movement around a jointOct 19, 2015. Fred Mitchell, Musxsscle energy technique: An evidence-informed approach. International Journal of Osteopath Med. 2011; 14(1):3-9. International Association for the Study for Pain: 2014. Jayant Joshi and Prakash Kotwal, Essential Orthopaedics and applied Physiotherapy fourth edition-1999. Lisi, Anthony J: Muscle Energy Technique in chiropractic practice. Journal of the American Chiropractic Association-Oct 2002. Moore SD et al., A randomized controlled trial of the immediate effects of MET on posterior shoulder tightness, therapy, Journal Orthopaedics sports physiotherapy.3239, Epub 6 Aprill 2011. Narayan et al., Efficacy of Muscle Energy Technique on functional ability of shoulder in Adhesive Capsulitis, Journal Exercise & Physiotherapy- 2014, Vol 10, pp: 72-76. Robert Donatellia, Physical Therapy of shoulder, Sports Specific Rehabilitation3rdedition: 1997& 2000. Vermeulen H.M et.al. Comparison of high grade and low grade Mobilization Techniques in the management of adhesive capsulitis of the shoulder. Randomized controlled trial, Physical therapy-2006, vol86, pp.3. Physiopedia: Adhesive Capsulitis, UK, no.1173185. Physiopedia: Muscle Energy Technique UK, no.1173185.