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December 15, 2006

Caring for the airway

From: Hindu Business Line - India - Dec 15, 2006

Rasheeda Bhagat

Whether chronic snoring or congenital deafness, complete cures are now possible.

Did you know that your vocal chords vibrate 150 times a second? A special machine can magnify this vibration frame by frame, and its slow motion videography can pick up the earliest stage of throat cancer, the slightest change in your vocal chord tension or an early stage of thyroid disease, says Dr Mohan Kameswaran, Managing Director of the Madras ENT Research Foundation (MERF), which is trying to bring cutting-edge technology in ENT diagnosis and treatment.

Such a machine, available at the voice lab of MERF (cost around Rs 40 lakh) is "much more sophisticated than a CAT scan" and is being used by singers, professional speakers and others for whom voice quality is very important. Early detection makes treatment simpler and far more effective.

Did you know that a person who suffers from chronic snoring could stop breathing 150 times in a night because during snoring the oxygen level drops in the blood to dangerous levels? Luckily when the oxygen depletes sharply, the person wakes up and starts breathing. "Next morning you ask him and he'll say he had comfortable sleep, but the guy might have stopped breathing 150 times," says Dr Kameswaran.

When you ask "In a single night?" in an incredulous tone, the ENT specialist smiles and says, "Oh, in our sleep medicine department we've had patients who stopped breathing 300 times in a night without realising it."

He explains that in a bad lung infection the oxygen level comes down 2 per cent, but for these people it can become as low as 60 per cent. "It is almost like near-death, but the brain wakes them up... they keep getting up and the next day feel sleepy."

Snoring occurs due to an obstruction in the breathing passage and it is "possible to cure it absolutely". It is a huge social embarrassment for people who travel frequently and spend nights in aircraft or trains. While laser treatment is an option, what is gaining popularity, particularly in the US, is CPAP (continuous positive airway pressure), which looks like a laptop. Nasal CPAP, considered the most effective non-surgical treatment for alleviation of snoring, delivers air into the airway through a specially designed nasal mask; "the flow of air creates enough pressure opening out the airway, so that the person stops snoring. What's more, the next morning he gets up fresh and says: `I've never slept like this for ages'," says Dr Kameswaran. The machine costs around Rs 25,000.

So why do more men than women snore? "It's the structure of the throat. After 45, about 60 per cent of men snore, and their wives are terrified about their breathing stopping temporarily. They see their husbands struggling in sleep and are very scared."


Detailing the recent milestones at MERF, Dr Kameswaran says it crossed an important landmark this year by completing 200 cochlear implants. "Chennai has taken the pride of place in the management of deafness not only in India but in South Asia."

It achieved another feat when Dr Kameswaran's team did an auditory brain stem implant on Jayalakshmi, a Plus Two student from a Corporation school in Chennai. She was diagnosed with tumours on both her auditory nerves, which connect the ear with the brain and through which hearing is achieved. The tumours, which caused total deafness, were benign but were pressing on the lower part or the stem of the brain... the area that is concerned with breathing, heartbeat and other vital functions. Jayalakshmi came from a poor family — her father works as a peon — and the neurosurgeons said that though they could remove the tumours, they could not cure her deafness. "Luckily they contacted us and that too at a time when brain stem implant was the happening thing," he says.

A cochlear implant could not have helped because this is put in the inner ear "but when there is no nerve connecting the inner ear to the brain, there is no point in putting a cochlear implant. But we now have an implant that can be put in the brain stem or part of the brain concerned with hearing."

After the neurosurgeons had removed the tumour on the second side, "we went in and put this implant into the brain stem and she became the first recipient of the brain stem implant or the bionic ear in Asia." The surgery done in December 2005 lasted eight hours.

The implant is the size of a peanut and was imported from Australia. "The girl is a brilliant student and wrote to me saying `I want to be a microbiologist but can't hear; I'm very confident you can help me but I can't pay for it'. I gave the letter to Indira, my wife, and she said we should help this girl."

Though MERF does have a charitable trust the entire cost of Rs 9 lakh was borne by the couple. Their satisfaction is that Jayalakshmi's hearing has returned, she has joined a microbiology course and is "topping the class". The bionic ear, which requires no servicing, will last her for life.

New vistas opening up

"Dramatic changes are taking place, new vistas are opening vis-à-vis treatment for deafness and we are entering a new era. Earlier we opened up the ear or neck, did surgery to repair the defect. Now we don't open up the affected organ, we bypass it and go beyond."

On the causes for deafness, he says congenital defect is the most common cause for nerve deafness, which is the most common congenital abnormality affecting our children. The incidence is 1-2 in every 1,000 live births; "an estimated 10-15 lakh children in India need a cochlear implant. Even people with normal hearing like you and I can suddenly lose our hearing due to viral infections like mumps, measles, or drugs and antibiotic abuse. Infections such as typhoid and meningitis can also cause deafness, and now we have noise pollution."

This Diwali Dr Kameswaran saw nearly 20 people who lost their hearing thanks to the noise explosion from fireworks. Says the angry surgeon, "Somebody is driving a scooter and some idiot throws a cracker from his house on the road and it bursts in his ear and he gets noise-induced deafness. The most tragic part is these people are in the 20 - 40 age group. We have stringent rules on the permissible decibel level, but who monitors it? This year we got high-end crackers from all the companies, burst them and recorded the sound; at least 75 per cent of them exceeded the prescribed sound levels."

If the emergency medicine on which he has put these people doesn't work, they will have to be fitted with cochlear implants, which cost around Rs 5 lakh.

On such a tab being picked up by medical insurance, he says now some insurance companies are doing that and he has done a few such procedures where the insurance company covered the cost.

"But it is the brain stem implant that has given us the confidence that virtually for anybody who has lost his/her hearing it can be restored. We're also thinking of fixing hearing aids to the skull, so they won't be visible. It will go behind the hairline and is called a bone-anchored hearing aid." Its other advantage is that it becomes integrated with the skull and a part of the body and hence is very effective. It costs the patient about Rs 2 lakh, with Rs 1 lakh being the cost of a good digital hearing aid.

A big media event at MERF was the operation on 3-year-old Hassan, a Pakistani child who had come with a completely closed windpipe. "The child had never talked because of it and after surgery he talked immediately and the first words he uttered were `Amir Khan', and after that started chattering away!"

Underlining the need for prevention, he says a child needs to be tested for auditory functions soon after it is born. "We've now demonstrated our ability to define and correct deafness, now we have to look at prevention, and educate people about noise pollution and unnecessary honking."

Voice culture

The voice department at MERF provides specialised service to people who have to use their voice a lot in their professional work. "Teachers, politicians, singers, lawyers, doctors need to talk a lot, and can be in trouble if they are not careful. Through slow-motion videography we can pick out small problems at early stages. Better still, we teach them to avoid problems. Just like for a football player his knees and thighs are important, and he is trained to strengthen them, so also voice training can be done," says Dr Kameswaran.

He gives a few simple tips to conserve your voice.

If you're giving an hour-long lecture, have a sip of water every ten minutes. It's simple but very effective.

Avoid certain food items, particularly oily stuff.

Even more important, do not skip or delay meals. If this is difficult sometimes, have at least a biscuit.

Avoid extreme temperatures — both very cold and very hot are bad.

Do some simple exercises of 5-10 minute duration to strengthen the vocal chord muscles; voice is a muscular activity and the muscles need looking after.

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© 2006, The Hindu Business Line.