Atraumatic suppurative mediastinitis is an uncommon infection. A case with an associated purulent pericarditis caused by Eikenella corrodens is reported.The infrequent isolation of Eikenella corrodens in pure culture from patients with subdural empyema, endocarditis, meningitis, osteomyelitis, septic arthritis, pneumonia, lung abscess, and empyema'2 indicates that this organism is probably a low grade but important pathogen in some circumstances. Eikenella corrodens has also been reported in mediastinitis but only as part of a mixed bacterial flora after oesophageal perforation.3We report a case in which Eikenella corrodens was the sole causative agent of infection at an uncommon site: atraumatic suppurative mediastinitis45 and an associated purulent pericarditis6 occurred concurrently in a previously healthy young woman, whose primary infection was probably pneumonia.Case report A 28 year old woman was admitted with a five day history of retrosternal chest pain, severe headache, vomiting, and sore throat, treated for two days by her general practitioner with oral erythromycin. Three weeks earlier, within two days of returning from Portugal, she had had an episode of nonbloody diarrhoea and abdominal pain lasting seven days. There was no recent history of aspiration, foreign body inhalation, or oral cavity or dental infection. Five years previously she had been investigated for recurrent haemoptysis and intermittent production of purulent sputum. Bronchography at that time suggested minimal bronchiectasis of the right middle lobe.On admission she had a tempera re of 39 9°C, with neck stiffness and tachycardia (120 bea /min). The peripheral blood count showed a polymorph leucocytosis of 20-6 x 109/1 and an erythrocyte sedimentation rate of 110 mm in one hour. Lumbar puncture showed normal cerebrospinal fluid. Cultures of sputum, urine, blood, and throat swabs and serological tests for mycoplasma and legionella gave negative results. The electrocardiogram was normal. The chest radiograph (figure) showed considerable anterior mediastinal widening to the left of the trachea, suggesting

Objective: To explore perceptions of medical students and faculty, regarding challenges of e-learning they faced, during COVID-19 pandemic. Study Design: Mixed method study (Quantitative and Qualitative - Phenomenological approach). Place and Duration of Study: Army Medical College Pakistan, from Apr 2020 to Sep 2020. Methodology: A self-made questionnaire, having both qualitative and quantitative elements, was developed after interviews of participants. It was pilot tested, finalized and sent via Google forms. Total 318 students and 6 faculty members responded, data was transcribed verbatim, themes were identified, and qualitative inductive content analysis of participants‟ reports was done. Results: Twenty-seven subthemes were identified by analyzing students‟ and faculty perceptions. They were grouped under five major themes, namely, communicational, technological, institutional, related to educators and students. Conclusion: Despite limiting factors like communication gap, digital refugee faculty teaching digital native students, limited technical support, digital divide and unplanned curricular delivery, e-learning was found to be beneficial in terms of flexibility in timings, improving learners‟ self-efficacy, faculty transformation and gradual acceptance. Moreover, it provided opportunity for hybrid e-curriculum development.

Objective: To find out the frequency and types of malignancy in patients treated surgically for nontoxicmultinodular goiter and its correlation in different age groups and gender. Study Design: Cross-sectional study. Place and Duration of Study: Department of ENT, Combined Military Hospital Rawalpindi, from Dec 2018 toDec 2019. Methodology: A total of 116 patients operated for nontoxic multinodular goiter were included in the study.Demographic details along with pre-op Ultrasonography findings, Fine Needle Aspiration Cytology, thyroidfunction test results and post-op histopathological reports of the thyroid specimen were entered on pre-designed proforma. Results were analyzed using the Statistical Package for Social Sciences (SPSS) Version 22. Results: Age ranges from 19 to 70 years (mean 43.51 years). Out of 116 cases operated for multinodular goiter,37 (31.8%) had malignant thyroid lesions (13 males, 24 females). Papillary carcinoma of the thyroid (45.9%) wasthe commonest malignancy followed by a follicular variant of papillary carcinoma (24.3%). The most common age group with malignancies was 49-58 years. Conclusion: Malignant Thyroid cancers showed a female preponderance and were most common in age group49-58 years. Papillary carcinoma of thyroid was the commonest tumor. Radical thyroid surgery is a recommended surgical management option for nontoxic Multinodular goiter.

Objectives: To determine the sensitivity and specificity of computed tomography angiogram (CTA) in detecting number and location of renal arteries and veins as well as crossing vessels causing uretero-pelvic junction obstruction (UPJO), and to determine if this can be used in decision-making algorithms for treatment of UPJO. Methods: A prospective study was carried out in patients undergoing open, laparoscopic and robotic renal surgery from April 2005 until October 2006. All patients were imaged using CTA with 1.25 collimation of arterial and venous phases. Each multi-detector CTA was then read by one radiologist and his results were compared prospectively with the actual intra-operative findings. Results: Overall, 118 patients were included. CTA had 93% sensitivity, 77% specificity and 90% overall accuracy for detecting a single renal artery, and 76% sensitivity, 92% specificity and 90% overall accuracy for detecting two or more renal arteries (Pearson c 2 = 0.001). There was 95% sensitivity, 84% specificity and 85% overall accuracy for detecting the number of renal veins. CTA had 100% overall accuracy in detecting early dividing renal artery (defined as less than 1.5 cm branching from origin), and 83.3% sensitivity, specificity and overall accuracy in detecting crossing vessels at UPJ. The percentage of surgeons stating CTA to be helpful as pre-operative diagnostic tool was 85%. Conclusion: Computed tomography angiogram is simple, quick and can provide an accurate pre-operative renal vascular anatomy in terms of number and location of renal vessels, early dividing renal arteries and crossing vessels at UPJ.

Objective: To apply the St Thomas’ Hospital (STH) classification of round window type, in a Pakistani pediatric population undergoing cochlear implantation, and rate the inter observer variability of applying this classification. Study Design: Cross sectional study. Place and Duration of Study: Combined Military Hospital Rawalpindi, from Apr 2019 to Dec 2020. Methodology: Patients were examined per-operatively by a panel of four surgeons after "optimal" posterior tympanotomy for round window variations, as per STH classification of approachability of RWM. The observations of the four surgeons were recorded and interobserver variation was assessed and analyzed. Results: A total of 100 patients were operated, 45 females and 55 males. Mean age was 3.8 years. There was minimal inter observer variability with regards to round window type and extent of "optimal" posterior tympanotomy. Three patients had type I, 76 had type IIA, 15 had type IIB and 6 patients had type III. Round window insertion/membranous cochleostomy was possible in 70 patients, whereas the rest require extended round window approach or bony cochleostomy. Conclusion: The STH classification is a useful predictor of route of CI electrode insertion and most patients can undergo RW insertion with confidence based on minimal variation between surgeons when applying the STH classification as well as when deciding the extent of surgical exposure.

Objective: Pharyngocutaneous fistula (PCF) is a complication of post radiotherapy total laryngectomy. Early post operative feeding is a risk factor for development of PCF. Delayed oral feeding (DOF) and inserting a nasogastric tube has been considered a safe practice among head and neck surgeons, and there is no general agreement on the timing of initiation of the oral intake. This study compared the effect of EOF and DOF on PCF formation. Study Design: Prospective case-controlled trial. Place and Duration of Study: Combined Military Hospital Rawalpindi, from Apr 2019 to Jul 2020. Methodology: Non-probability convenience sampling was done for both groups. The patients were not matched and were assigned to either EOF or DOF alternately. EOF was defined as feeding at seventh post operative day and DOF criterion was feeding on fourteenth post operative day. The primary outcome was development of PCF within the 30th post operative day. A total of 20 patients with prior radiotherapy for laryngeal cancer who presented with recurrence of carcinoma were included in the study. Same technique closure of neopharynx was done in all cases of laryngectomy. Results: Overall PCF frequency was 20% (4/20). In EOF group, 30% (3/10) of patients developed PCF whereas 10% (1/10) of patients in DOF developed PCF. However, the difference in outcome of two groups was not statistically significant. Conclusion: DOF in cases of Salvage total laryngectomy is a safe practice and it might help to reduce the frequency of pharyngocutaneous fistula.

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Objective: To determine the diagnostic accuracy of tympanometry for diagnosing fluid in the middle ears of children with Otitis Media with Effusion taking myringotomy as a gold standard. Study Design: Cross-sectional study Place and Duration of Study: Department of ENT & Head and Neck Surgery, Combined Military Hospital, Peshawar Pakistan, from Oct 2018 to Sep 2020. Methodology: A total of 201 patients who underwent tympanometry followed by myringotomy of aged between 3 to 12 years of either gender were included. All patients underwent tympanometry. After that, myringotomy was carried out through a radial incision in the anteroinferior quadrant using a general inhalational anaesthetic agent. The operative findings at myringotomy were recorded. The presence of fluid on intraoperative findings using myringotomy was considered positive for the presence of fluid in the middle ears of children. Results: The age range of the patients was from 3-12 years, with a mean age of 7.35±2.41 years. Of these 207 patients,133(64.18%) were males, and 74(35.82%) were females. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of tympanometry for diagnosis of fluid in the middle ears of children with Otitis Media with Effusion taking myringotomy as the gold standard was 85.7%, 86.3%, 89.4%, 81.7% and 85.9% respectively. Conclusion: This study concluded that the diagnostic accuracy of tympanometry for the diagnosis of fluid in the middle ears of children with Otitis Media with Effusion is quite high.