Rashid Al-Abri

Patient Satisfaction Survey as a Tool Towards Quality Improvement

Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations. However, there are very few published studies reporting of the improvements resulting from feedback information of patient satisfaction surveys, and in most cases, these studies are contradictory in their findings. This article investigates in-depth a number of research studies that critically discuss the relationship of dependent and independent influential attributes towards overall patient satisfaction in addition to its impact on the quality improvement process of healthcare organizations.

Clinically Significant Anatomical Variants of the Paranasal Sinuses

OBJECTIVE Anatomic structural variations of the paranasal sinuses have a practical significance during surgical procedures conducted on the sinuses by otolaryngologists. This study aims to evaluate the prevalence of clinically significant anatomical variations of the paranasal sinuses. METHODS A prospective analysis of 435 computed tomography (CT) examinations of adult Omani patients was conducted to determine the prevalence of clinically significant anatomical variations of the paranasal sinuses. A total of 360 CT scans were included from January 2009 to January 2010. RESULTS The findings showed abnormal Agger nasi cells in 49% of cases (95% CI: 44-54%), concha bullosa in 49% (95% CI: 44-54%), Haller cells in 24% (95% CI: 18-31%), asymmetry in anterior ethmoidal roof 32% (CI: 29-37%), Onodi cells in 8% (CI: 5%-10%). The type of skull base were as follows; Type 1 was 30% (n=107; 95% CI: 25-35%), Type 2 was 34% (n=123; 95% CI: 29-39), and Type 3 was 36% (n=130; 95% CI: 31-41%). Many other surgically significant anatomical variations in small numbers (1-3) were incidentally identified. CONCLUSION Knowledge of the presence of anatomical variations of the sinuses has a clinical significance as it minimizes the potential for surgical complications. There is an ethnical difference in the prevalence of anatomical variations. Further studies of anatomical variations with clinical disease correlations are needed.

Non Allergic Rhinitis: Prevalence, Clinical Profile and Knowledge Gaps in Literature

OBJECTIVES Although Nasal symptoms induced by Non-allergic rhinitis| (NAR) are a cause of wide spread morbidity; the disease is trivialized. There is a lack of Epidemiological studies on the prevalence of non-allergic rhinitis. In spite of being one of the commonest conditions presenting to the General practitioner and otolaryngologists, the clinical profile, diagnosis, and management outcomes are unknown. The objectives of the study were to examine the prevalence and clinical profile of non-allergic rhinitis in Oman. Secondary objective was to identify Knowledge gaps in literature with the aim of directing future research. METHODS A cross sectional study of 610 consecutive adult patients presenting to the Ear, Nose and Throat clinic at Sultan Qaboos University Hospital is presented in this paper. The diagnosis of NAR was mainly based on step wise fashion; including a thorough clinical history and exclusion of other causes of rhinitis; all consecutive patients diagnosed with rhinitis (n=113) had a detailed history, nasal endoscopy, nasal smears, CT scans and an antihistamine response trial. The prevalence of NAR with its clinical profile was subsequently determined. Primary research articles and meta-analysis evaluated for the knowledge gap study were identified through MEDLINE search of English language literature published between 2000-2011. RESULTS A total of 610 consecutive patients were studied. The overall prevalence of rhinitis was 18.5% (n=113). The prevalence of NAR was 7.5% (n=46). Cases of allergic rhinitis (5.7%; n=35), Chronic rhinosinusitis (1.8%; n=11), and miscellaneous causes (3.4%; n=21) were excluded. Among the rhinitis population (n=113), the prevalence of NAR was 57% (n=46). The major presenting symptoms included nasal obstruction (93%; n=43), postnasal drainage (78%; n=36), and rhinorrhea (62%; n=29). For the knowledge gap study; 115 Medline titles were reviewed, four systematic reviews, and 34 research papers were reviewed. The text of two recent otolaryngology text books was also reviewed, and the main results of the study revealed the prevalence of NAR had not previously been studied in Oman. Although the recent text now clearly defines NAR, there is scant literature on the prevalence, diagnosis and management outcomes of NAR in the literature. CONCLUSION The study found that more than half of rhinitis patients suffered from NAR. There are no specific diagnostic tests for NAR; a thorough case history is the best diagnostic tool to date. A substantial knowledge gap exists in literature with relations to pathogenesis, clinical and laboratory diagnosis, as well as in reference to medical and surgical outcomes. Larger studies are required and management outcomes need to be studied.

The Accuracy of IOS Device-based uHear as a Screening Tool for Hearing Loss: A Preliminary Study From the Middle East

OBJECTIVES To determine and explore the potential use of uHear as a screening test for determining hearing disability by evaluating its accuracy in a clinical setting and a soundproof booth when compared to the gold standard conventional audiometry.  . METHODS Seventy Sultan Qaboos University students above the age of 17 years who had normal hearing were recruited for the study. They underwent a hearing test using conventional audiometry in a soundproof room, a self-administered uHear evaluation in a side room resembling a clinic setting, and a self-administered uHear test in a soundproof booth. The mean pure tone average (PTA) of thresholds at 500, 1000, 2000 and 4000 Hz for all the three test modalities was calculated, compared, and analyzed statistically.  . RESULTS There were 36 male and 34 female students in the study. The PTA with conventional audiometry ranged from 1 to 21 dB across left and right ears. The PTA using uHear in the side room for the same participants was 25 dB in the right ear and 28 dB in the left ear (3-54 dB across all ears). The PTA for uHear in the soundproof booth was 18 dB and 17 dB (1-43 dB) in the right and left ears, respectively. Twenty-three percent of participants were reported to have a mild hearing impairment (PTA > 25 dB) using the soundproof uHear test, and this number was 64% for the same test in the side room. For the same group, only 3% of participants were reported to have a moderate hearing impairment (PTA > 40 dB) using the uHear test in a soundproof booth, and 13% in the side room.  . CONCLUSION uHear in any setting lacks specificity in the range of normal hearing and is highly unreliable in giving the exact hearing threshold in clinical settings. However, there is a potential for the use of uHear if it is used to rule out moderate hearing loss, even in a clinical setting, as exemplified by our study. This method needs standardization through further research.

Phenomenology and outcome of factitious disorders in otolaryngology clinic in Oman.

The phenomenology of factitious disorders from the Arab part of the world has been lacking in the medical literature and few reports have emerged from otolaryngology. Using an observational prospective case series study (n =19) with long-term follow-up (two to six years), the present study reports the magnitude and mode of clinical profile of factitious disorders in a tertiary care hospital in Oman, an Arab-Islamic country. The outcome was operationalized as prognosis following culturally sensitive intervention akin to confrontation technique. The present observation suggests the prevalence of factitious disorders in the otolaryngology tertiary care setting was 0.2%. Approximately 42.1% (n = 8) had hemorrhagic factitious disorders, 15.8% (n = 3) were those who feigned for multiple surgical interventions. Approximately 15.8% (n = 3) presented neurological factitious disorders while the remaining 26.3% (n = 5) clinical profile suggested minor feigned illnesses. Objective “evidence factitia” was present in 68.4% (n = 13) of the cases. On subsequent follow-up, nine patients with chronic forms became asymptomatic, three patients had fewer episodes, four patients were unchanged, and three patients were lost to follow-up. The prognosis was good in patients who did not have associated psychiatric illnesses as compared to those with psychiatric disorders. Factitious disorders are often incorrectly diagnosed, with all consequences in terms of adverse sequels. The observed good prognostic outcomes are discussed in the context of socio-cultural patterning and the factors that may shape the presentation of factitious disorders in Oman.

Hydro-chemical evolution of groundwater in a sequence of Tertiary Formations in Northwest Oman

Tertiary Formations, which are widely spread in the Arab Peninsula, are fundamental to the oil industry in the world’s largest oil producing area. These formations host major aquifers that satisfy water demands for oil production such as steam injection and reservoir pressure maintenance . The current study investigates the hydro-chemical evolution of groundwater in a sequence of Tertiary Formations in Northwest Oman in the Kingdom of Saudi Arabia and the United Arab Emirates borders. Stable isotopes (18O and 2H) show three different groundwater types: (1) groundwater formed from precipitation originating from the Mediterranean Sea, (2) groundwater formed from mixing of northern (Mediterranean) and southern (Indian Ocean) moisture sources, and (3) groundwater affected by evaporation. Radiogenic isotopes 14C and 3H indicate younger groundwater close to the recharge source in North Oman Mountains and older age in the plain desert area that constitutes the discharge zone. Groundwater chemistry notably evolves from Ca–Mg–HCO3 dominant in the recharge area to Na–Cl–SO4 dominant type in the discharge zone. Water–rock interaction is the main process controlling groundwater chemistry in the recharge zone while evaporation becomes progressively effective down the gradient. The geochemistry and stable and radiogenic isotopes of the Tertiary Formations indicate that the study area has witnessed wet periods during the Early Holocene with surface water bodies formed by groundwater discharge at distal parts. The sustainability of such old groundwater that is being exploited for oil production should be thoroughly investigated to secure future oil production.

Reflections on the academic accreditation of the MD programme of the college of medicine & health sciences, sultan qaboos university, oman.

In November 2013, The College of Medicine and Health Sciences (COMHS) at Sultan Qaboos University (SQU) was “fully accredited” for a ten-year period (on its first attempt) by the Association for Medical Education in the Eastern Mediterranean Region (AMEEMR) in association with and in accordance with the standards of the World Federation for Medical Education (WFME).The accreditation decision was made on the basis that the MD Programme complies with the WFME’s “Basic and Quality Development Standards”.1 It is notable that COMHS’ “Quality Development Standards” are considered by the WFME as “Best Practice” thus conferring distinguished status on the COMHS’ MD Programme. This article describes the actions taken by the COMHS which led to this success. The achievement of accreditation was neither a sudden nor an unsystematic accomplishment. It was the result of a lengthy and extensive process of continuous improvement of the COMHS’ abilities and capacities that started long before the accreditation endeavour per se began in 2008. The process began by the construction of the “new” curriculum—an exercise that was accompanied and followed by other complementary measures. Only after that was the accreditation process initiated. Before explaining the process in more detail, a description of SQU and the COMHS might be helpful.

Plasma pseudo cholinesterase deficiency leading to seven hour apnoea in a child undergoing adeno-tonsillectomy

OBJECTIVE We report a rare, silent, potentially fatal operative complication of seven hour apnoea in a patient undergoing adenotonsillectomy secondary to deficiency of plasma cholinesterase. Awareness of this hereditary disorder is important to otolaryngologist as; it is difficult to diagnose, can be unexpectedly alarming for parents and the surgeon. METHODS Case report and review of world literature. RESULTS A four-year male with obstructive sleep apnoea underwent a routine elective adenotonsillectomy; there was no spontaneous recovery of respiration following surgery. He was transferred to the intensive care unit and 7 h later was successfully weaned from the ventilator and extubated. A plasma cholinesterase level of 456 1U/L was discovered much later. CONCLUSION To our knowledge this is the first case report of pseudo cholinesterase deficiency reported in otolaryngology literature and first in Oman. The patient should receive information about the condition, the associated risks, inheritance and need for testing other family members.

Allergic rhinitis and associated comorbidities: prevalence in oman with knowledge gaps in literature.

OBJECTIVES Allergic rhinitis (AR) is a global health problem and its impact on health related quality of life for patients is substantial, and the economic impact often underestimated. The prevalence of allergic rhinitis in Oman is unknown. This study aimed to estimate the prevalence of AR and associated co-morbidities among adults in Oman. Its secondary objective was to identify knowledge gaps in the literature with the aim of directing future research. METHODS A prospective, cross-sectional study of patients who presented to the outpatient otolaryngology clinic at Sultan Qaboos University Hospital with nasal symptoms between June 2010 and June 2011 was conducted. RESULTS A total of 887 patients were seen with nasal complaints. Among them 127 patients were diagnosed with non-infective rhinitis, the mean age of presentation was 27 years. AR was noted in 48% of patients, and non-allergic rhinitis in 52%. The prevalence of AR was 7%, with females being more affected than males, and age ranging from 18 to 51 years. Prevalence of perennial AR was 84% compared to seasonal AR which was 16%. The most common perennial antigens were house dust mites (80%) followed by cockroaches (67%). All patients diagnosed with seasonal AR were found to be sensitive to Russian thistle. The prevalence of chronic rhinosinusitis in patients with AR was 34%. CONCLUSION The prevalence of AR in the adult population presenting with nasal symptoms was found to be 7%, with associated chronic rhinosinusitis present in a third of these patients. However, there appears to be substantial knowledge gaps regarding the association of other comorbidities, like otitis media, bronchitis and bronchial asthma, the long-term outcomes of medical management, and indication of surgical intervention in patients with AR. Future research in AR among Omani patients should aim to address these issues.

A palatal mass.

A 19 year old female patient presented to the ENT department with complaints of slow growing, painless palatal mass for three months duration. On examination, there was a smooth surface 3x3 cm mass arising from the left side of hard palate (Fig. 1) which was firm in consistency on palpation. The rest of ENT examinations were normal. Figure 1 Pre-operative clinical photograph showing the palatal mass The Computed tomography (CT) showed a well defined contrast enhancing mass with no obvious bony erosion, (Fig. 2). The fine needle aspiration cytology from the lesion showed the histological features of epithelial and myoepithelial elements arranged in a variety of patterns and embedded in a mucopolysaccharide stroma. Figure 2 Showing a soft tissue mass arising from the hard palate at the level of ethmoid sinus Questions What is the likely diagnosis in this patient? What is the role of Fine needle aspiration cytology (FNAC) in such lesion? How would you manage this case and what is the role of CT scan in such lesions? Answer Pleomorphic adenoma of minor salivary gland arising from hard palate. The other rare differential diagnosis includes malignant minor salivary gland tumor, neurogenic tumors. Preoperatively, the FNAC has a diagnostic role in such lesions. The mass lesion arising from the hard palate can be a malignant lesion requiring a radical approach. Complete surgical excision under general anesthesia is the treatment of choice for such a lesion (Fig. 3). The preoperative CT scan not only helps in delineating the extent of lesion but also is useful in assessing any bony erosion of hard palate. Figure 3 Post operative scan of the patient showing a clear hard palate at the level of ethmoid sinus Discussion The palate has the highest concentration of minor salivary glands in the upper aero-digestive tract.1 The pleomorphic adenoma is the most common benign minor salivary gland tumor arising from the palate.2 The clinical presentation of such a lesion is typically a firm or rubbery submucosal mass without ulceration or surrounding inflammation. The exact etiology of this tumor is unknown but it is hypothesized that it originates from the intercalated and myoepithelial cell.2 Preoperatively, the fine needle aspiration cytology has a definite diagnostic role and shows epithelial, myoepithelial, and stromal components. The CT scan and magnetic resonance imaging (MRI) showed, always performed to asses for the presence of any bony erosion, soft tissue or nerve involvement. Since the majority of minor salivary gland neoplasms arising from palate are malignant, a detailed history, examination and investigations are essential before the excision of such lesions.3 The complete surgical excision is the treatment of choice in cases such as pleomorphic adenoma. The lesion in the current case was excised completely under general anesthesia and patient was symptoms free in the six months follow up.