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  • CERVICAL VERTIGO – Cervical spine Anatomy & Vertebro basilar syStem

    The vertebral arteries are branches of the subclavian arteries. Together with the basilar artery constitute the vertebrobasilar system which supplies blood to the posterior part of Circle of Willis and anastomose with blood supplied to the anterior part of the circle of Willis from the carotid arteries.

    Cranial portion of the Vertebral arteries

    Inside the skull, the two vertebral arteries join up to form the basilar artery at the base of the medulla oblongata. The basilar artery is the main blood supply to the brain stem and connects to the Circle of Willis to potentially supply the rest of the brain if there is compromise to one of the carotids.

    Cervical portion of the Vertebral arteries – Can be divided into 4 parts for the purpose of description

    Chronic Suppurative Otitis Media (Safe Type)

    Conductive deafness due to Chronic Ear infection


    Anatomy and Physiology of the Ear Click here

    Chronic Suppurative Otitis Media   (SAFE TYPE)
    Chronic Otitis Media is chronic infection of the middle ear cleft, can be of types:
    (>3 months duration)
    1. Perforation of Tubo-tympanic or Attico – antral type.
    2. Chronic non-suppurative otitis media ego     Serous otitis media.
    3. Chronic specific otitis media e.g. following  tuberculosis.

    Types:

    I. TUBOTYMPANIC DISEASE (SAFE TYPE)
    Etiology:
    i.  Residue of an acute otitis media infection during childhood.
    ii. Repeated infections from the eustachian tube.
    Perforation – Usually in the form of a central perforation situated exclusively in the pars tensa.
    The ossicular chain often remains intact and middle ear mucosa is pink and edematous.

    Clinical features:
    1. Discharge – is mucoid, copious and non foul smelling. It becomes profuse during an upper respiratory infection.
    2. Deafness – is conductive in type. Degree varies with the position and size of perforation.

    Treatment:
    1. Aural toilet – Is performed meticulously under direct vision, preferably suction and irrigation done under the operating  Microscope.
    2. Bora-spirit – Ear drops are advised only during active discharge.
    3. Focus of infection – Are treated medically     or surgically e.g. tonsillitis, sinustitis etG.
    4. Removal of polypi or granulation tissue – if present in the middle ear.
    5. Chemical cautery – Using 50% Trichloro acetic acid for smaller perforations ( < 65% area if tympanic membrane).
    6. A Myringoplasty operation – May be required for a persisting perforation.

    Chronic otitis media  (Safe type)

    Anatomy and Physiology of the Ear     Click here
    Perforation of the Ear Drum (Tympanic membrane)

    A perforated eardrum is a hole or rupture in the ear
    drum, the thin membrane that separates the ear canal
    and the middle ear.

    The Ear drum can perforate from infection or trauma.

    An Infective perforation of the eardrum
    Starts with infection from the nose after a head cold travelling up the Eustachian tube to reach the middle ear to promote an infection in the middle ear. Pus builds up in the middle ear behind the ear drum with pressure causing severe throbbing pain and breaks through a weak point in the ear drum leaving a perforation with a discharge of pus or blood.

    A Traumatic perforation of the eardrum may occur:

    – By a slap on the ear
    – As part of a skull fracture
    – After a sudden explosion from a bomb blast or fire cracker blast
    – Insertion of a pin, cotton bud or stick if pushed too far into the ear canal.
    A traumatic perforation usually has irregular shape and size and irregular edges.

    A Traumatic perforation Photograph of the left ear drum of a patient  K. E., after a Bomb blast in Mumbai

    Symptoms and Signs of a Ear drum perforation: A perforated eardrum is usually accompanied by decreased hearing, occasional discharge, tinnitus and sometimes vertigo. Pain is usually not present.

    Diminished hearing

    Due to loss of drum surface area, less sound vibrations reach the middle ear and internal ear with resulting deafness. It is difficult to determine the location of the source of sound – that is directional (stereophonic) hearing is difficult. Appreciation of stereophonic music is affected.
    When old age deafness sets in due to age related changes of the organ and nerves of hearing, the additional hearing impairment in the affected ear would be more pronounced than in the better hearing ear and becomes a definite handicap in communication.

    Usually, the larger the perforation, the greater the loss of hearing. If disruption of the chain of bones in the middle ear occurs less sound is transmitted to the inner ear, the loss of hearing is more severe. The type of of deafness is of the Conductive type.

    If the perforated eardrum is due to a sudden severe trauma (e.g. skull fracture) traumatic or explosive event like a cracker or bomb blast, because of shake up of the ultra microscopic hair cells in the inner ear, the hearing loss may be very pronounced – a mixed hearing loss from a summation of the conductive component – ear drum perforation and dislocation of the small bones in the middle ear and a sensori neural component due to inner ear damage. from damage to the inner ear structures,
    Rarely, a long standing perforation may be the precursor of a cholesteatoma

    Recurrent Eardischarge

    A perforation of the ear drum creates a system of a tube open at both ends. Water, oil or even ear drops instilled into the ear can flow freely from the external ear into the middle ear and into the back of the nose and throat by the eustachian tube. Conversely, nasal discharge can flow freely from the back of the nose via the eustachian tube into the middle ear and come out through the perforation into the external ear.
    As long as the perforation remains, there is therefore, a chance of getting recurrent ear discharge. This can happen every time after catching a cold since blowing the nose forces nasal discharge into the middle ear. It also happens if water accidentally enters the ear as during a bath or during swimming when the infected water comes into contact with the delicate lining of the middle ear and excites an inflammation (otitis media) with resulting ear discharge.

    Tinnitus (Noise in th Ear)

    A continuous or intermittent noise in the ear can be present. This usually disappears after closure of the perforation by surgery.

    Vertigo

    Continuous or intermittent episodes of vertigo may occur, since the organ of hearing and balance are one anatomically connected organ.

    Natural course of a Ear drum perforation

    Eardrum perforations of small size may heal spontaneously in a few weeks.
    Medium sized perforations may or may not heal on their own.
    Large perforations cannot heal on their own and require surgery.

    Investigations advisable
    Pure tone audiometry
    Acoustic Impedance Bridge
    X-Ray mastoid bone for central perforation & C.T. Scan temporal bone for chronic mastoiditis

    Treatment of a Perforated Eardrum

    The benefits of closing a perforation include prevention of recurrent middle ear infection by preventing water entering the middle ear while showering, bathing, or swimming (which could cause ear infection), improved hearing, and diminished tinnitus. It also may prevent the development of cholesteatoma (skin cyst in the middle ear), which can cause chronic infection and destruction of ear structures.

    A small perforation can be kept under observation to see if it could close spontaneously. or try to cauterize the edges of the perforation under the operating microscope, with a chemical to stimulate growth of epithelium from the surrounding area to grow over the perforation. If healing is not achieved, surgery has to be considered.

    A large or moderate sized perforation requires a surgical operation (Tympanoplasty or Myringoplasty) to close it. There are a number of surgical techniques, all of which aim at placing a piece of fascia covering the Temporalis muscle across the perforation. Surgery is typically quite successful in closing the perforation permanently, and improving hearing.

    By a small incision within the ear canal, the ear drum perforation edges are freshened. The ear drum has 3 layers. These layers are gently separated under an operating microscope. A tissue graft (temporalis fascia) is obtained by a small separate incision above the ear (requiring one stitch). This is placed carefully in between the ear drum layers. The operation is performed under local anaesthesia with sedation.  Hospitalization is for a few hours.

    Precautions to prevent recurrent ear discharge in patients with chronic ear infection

    • Water or oil should not enter the ear at all. Before a bath, the ear canal is sealed with a cotton ball smeared with vaseline or any other hair dressing. Wash hair with head  hanging down under a running tap. Dry well with a towel before standing up again.
    • Swimming is NOT advisable at all, till the perforation has been closed by surgery. If you  have to swim, do so without dipping the head under water.  No diving at all.
    • Do NOT allow your ear to be syringed by your doctor at all.
    • Do NOT use towel corners, match sticks, hair grips to clear the ear. They provoke infection
    • Do not blow the nose when you have a head ‘cold’. This will drive the nasal discharge into the middle ear via the Eustachian tube and start a ear discharge. To clear nasal discharge, sniff in and throw out the discharge through the mouth. If you sneeze, do so with mouth open.
    • If there is any itching in the ears  or you feel the need to clean the ear, do so with cotton buds only after smearing an antibiotic-antifungal cream like Surfaz SN cream
    • Every time you catch a ‘cold’, there is a likelihood of recurrence of ear discharge. Hence avoid iced water, ice creams, cold drinks etc.  Avoid undue exposure to cold.
    • On catching a cold, immediate treatment from the family physician is started.

    Chronic Suppurative Otitis Media (Unsafe Type)

    Conductive deafness due to Chronic Ear infection

    Chronic Otitis Media is a chronic infection (ear infection lingering on for over 3 months’ duration) of the middle ear cleft. It This includes disease of the middle due to infections by bacteria, virus etc. It may be Suppurative (with pus formation) or Non suppurative (without the formation of pus).

    Anatomy and Physiology of the Ear Click here

    Chronic Suppurative Otitis Media

    1. Perforation of Tubo-tympanic type (Safe type).

    2. Perforation of the Attico­ antral type (Unsafe type).

    3 Perforation of the Marginal posterior marginal type (Unsafe type).

    Chronic Non-Suppurative Otitis MediaAlso known as Serous or Secretory Otitis Media or Otitis media with effusion (OME)

    Chronic Suppurative Otitis Media of the Unsafe type

    ATTICO – ANTRAL or MARGINAL TYPE (UNSAFE TYPE)

    It is associated with formation of cholesteatoma and therefore regarded as unsafe. The term cholesteatoma is not an accurate description as it is not a tumour and always does not contain cholesterol chrystals. A cholesteatoma, truly speaking  is ‘skin in the wrong place’ (Gray). This usually affects the postero-superior quadrant of ear drum (pars tensa) or the attic or epitympanum (Pars flaccida).

    A cholesteatoma starts life as a dimple due to localised retraction of a portion of the tympanic membrane in the attic or postero superior quadrant of the pars tensa. It is in reality a retraction pocket and not a “perforation”. Epithelial squames (flat cells of skin) acumulate inside the dimple which soon shuts off and presents as an expanding bag. As more and more epethilium accumulates within the bag, the cholesteatoma forms an expanding erosive bag. This has the potential of eroding bone. Erosion of the small bones of the middle ear – ossicles  result in conductive deafness. If it erodes the labyrinth, a sensori neural deafness ensues. Erosion of the facial nerve canal can lead to facial muscle paralysis. Erosion of the labyrinth can cause vertigo. When it grows superiorly, it can erode the tegmen tympani and cause intra cranial complications like meningitis and brain abscess.

    Classification:

    1. Congential: - originates as embryonic rest cells, which eats away the bone until it breaks through the outer attic wall. The ear drum is normal in the initial stages. Derlaki and Clemis defined congenital cholesteatoma or Primary choleasteatoma as an embryonic rest of epithelial tissue in an ear without tympanic membrane perforation, in a patient without history of ear infection.

    2. Acquired:

    i. Primary - Type occurs following an eustachian tube malfunction resulting into retraction pockets into the attic (pars flaccida). Negative middle pressure causing retraction pocket

    ii. Secondary:

    a) Immigration - Of tympanic epithelium on deep meatal skin in the posterior superior quadrant of the tympanic membrane occurs. This is possible following destruction of the annulus after a previous middle ear discharge.

    b) Metaplasia - Is provoked by chronic infection in the ciliated mucous membrane of the middle ear. Here squamous metaplasia occurs as well as there can be a marginal migration of squamous epithelium from the meatus.

    Over time, untreated cholesteatoma can lead to bone erosion and spread of the ear infection to localized areas such as the inner ear and brain causing deafness, facial muscle paralysis, brain abscess, meningitis, and even death can occur.

    Formation of a Cholesteatoma (Pathogenesis)

    A cholesteatoma usually occurs because of poor eustachian tube function as well as infection in the middle ear. The eustachian tube normally conveys air from the back of the nose into the middle ear to equalize ear pressure. When the eustachian tubes works poorly perhaps due to allergy, a cold or sinusitis, the air in the middle ear is absorbed by the body, and a partial vacuum results in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum inwards, especially the superior part of the pars tensa or pars flaccida of the ear drum or areas weakened by previous infections.

    Cholesteatomas It usually takes the form of a cyst or pouch that containing scales of accumulated skin arranged in onion – like layers.

    Symptoms of a Cholesteatoma

    Initially, the ear may discharge off and on. The discharge may have a characteristic foul odour. As the cholesteatoma pouch or sac enlarges, it can cause a full feeling or pressure in the ear, along with hearing loss. Dizziness due to involvement of the balance organ and facial muscle weakness on the same side as the cholesteatoma can occur. Ideally, urgent evaluation is required as soon as the diagnosis of cholesteatoma is made.

    Dangers of ignoring a Cholesteatoma

    Ear cholesteatomas can be dangerous because of their ability to erode bone.They occur in an area crowded with important structures. There is only a thin plate of bone separating a cholesteatoma from the brain and meninges and lie close to the small bones (ossicles) of the middle ear, the organ of hearing and balance in the internal ear, facial nerve. should never be ignored. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain. If untreated, deafness, brain abscess, meningitis, and rarely death can occur.

    These are indicated by headache, giddiness, increasing deafness and noises in the ear and weakness of the facial muscles.  Over time, the cholesteatoma sac  increases in size, the mouth of the sac being blocked by skin flakes. With expansion, it starts eroding surrounding structures of the middle ear

    Progression of Cholesteatoma & Chronic mastoiditis and Complications

    Treatment of Chronic Mastoiditis and Cholesteatoma

    Hearing and balance tests, CT scans of the mastoid bone may be necessary to determine the hearing level and the extent of destruction the cholesteatoma has caused.

    A cholesteatoma usually requires surgical treatment to prevent serious complications. Surgery (called Tympano- Mastoidectomy involving extensive bone drilling of the mastoid bone and removal of disease from the middle ear is required. It may be performed under general or local anesthesia. The primary purpose of surgery is to remove the cholesteatoma and infection and achieve an infection-free, self-cleansing dry ear. Hearing preservation or restoration is a secondary goal of surgery. If the disease has been satisfactorily removed. The small bones of the middle ear are repositioned to restore the hearing. Various inert material prosthesis of teflon, stainless steel, silicone and hydroxyapetite as well as homo or auto graft of bone and cartilage may also be used. In cases of severe ear destruction, restoration of normal hearing  may not be possible. Reconstruction of the middle ear to its normal anatomy is usually not possible in one operation; and therefore, a second operation (if deemed necessary) may be performed later. Facial nerve repair or procedures to control dizziness are rarely required.

    Follow-up office visits after surgical treatment are necessary and important, because cholesteatoma sometimes recurs. In cases where an open mastoidectomy cavity has been created, office visits every few months are needed in order to clean out the mastoid cavity and prevent new infections. In some patients, there must be lifelong periodic ear examinations.

    Complications of Chronic mastoiditis and Cholesteatoma

    Fiberoptic Video Oto Endoscopy

    Visualisation of the External ear, Ear drum, and Middle ear

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    Endoscopic view of Normal Nose and Nose with nasal polyp

    Normal ear drum

    Ear drum perforation

    Fluid & bubbles in middle ear
    seen through ear drum

    Chronic NonSuppurative Otitis Media (Otitis Media With Effusion)

    Conductive deafness due to Chronic Ear infection

    Secretory Otitis Media  (Otitis media with effusion)

    Mechanism of Eustachian tube obstruction


    Anatomy and Physiology of the Ear Click here

    Nature’s mechanism of ventilating the middle ear through the nose to maintain air on the inner side of the ear drum has disadvantages. All nasal diseases and Endoscopic view of fluid conditions can cause infective and obstructive symptoms affecting middle and bubbles behind ear drum ear function – e.g. common colds, viral and bacterial infections of the nose.                                .

    Obstruction at the nasal end of the tube can be caused by by enlarged adenoids, tumours, infected water during swimming, pressure changes during air travel and diving under water. Chronic nasal allergy accounts for a sizeable number of patients suffering from Eustachian tubal obstruction.

    When tubal obstruction remains for long, a vacuum forms. Fluid pours into the middle ear  (Secretory Otitis Media). The fluid is thin initially and later as days go by, it becomes thick like glue (gum), when the condition is called ‘glue ears’.

    How is the diagnosis made?

    The patient or relatives notice increasing difficulty in hearing. One’s own voice may sound loud in the affected ear. When fluid is present, head movements can cause a feeling of fluid moving in the ear.

    Clinical E.N.T. Examination show the ear drum on the affected side/sides to be moving poorly with some parts of the ear drum/drums drawn in. The nose and throat may show evidence of infection or allergy. Enlarged adenoids or other growth of the nasopharynx may be noted.

    Special tests

    Pure Tone Audiometry shows a conductive deafness. Acoustic Impedance Bridge studies confirm a Type B flat curve when fluid is present or a Type C Tympanogram for  negative pressure in the middle ear.

    Fiberoptic endo laryng pharyngeal nasopharyngoscopy for detailed visualization of the nasopharynx & nose.

    For assessing, nose, nasopharynx and paranasal sinus conditions, a C. T. Scan with (usually without injection of contrast dye material) of these areas may be necessary.

    What is the treatment?

    Treatment is aimed at establishing middle ear ventilation by treating the nasal end of the Eustachian tube.

    Any nasal infection or allergy has to be treated. The swelling of the lining of the eustachian tube has to be shrunk up by the use of nose drops. This allows to and fro air passage along the eustachian tube. Attempts are made to force air into the middle ear through the eustachian tube actively by the auto inflation exercise (Valsalva maneuver). explained elsewhere. Nasal steroid sprays on a long-term basis may be required in allergic conditions, swollen (edematous) mucous membrane lining and cases with nasal polyp formation.

    In a small percentage of patients if middle ear fluid is present, if the above measures do not give relief, surgical treatment is required – a small incision is made in the ear drum under local anaesthesia and the fluid sucked out. If the fluid is very thick, a small ventilation tube (grommet) is inserted through the incision and left in place. It normally takes 3 to 6 months to extrude spontaneously.

    Treatment of the nasopharyngeal condition like removal of enlarged adenoids in children or adequate treatment of nasopharyngeal growth is required. Clearance of nose and paranasal sinus disease by Functional Endoscopic Sinus Surgery (F.E.S.S.) may be required.

    Detection of allergies by an allergy test followed by proper treatment may be necessary.

    Fiberoptic Video Laryngo Pharyngoscopy

    Visualization of the throat and vocal cords

    Endoscopic view of Normal Larynx, Laryngo pharynx and Vocal folds


    During respiration


    During vocalisation

    Endoscopic view of Larynx in a patient with early vocal nodules


    During respiration


    During vocalisation

    Otosclerosis

    Otosclerosis – A common cause of middle ear deafness

    What is Otosclerosis?

    Otosclerosis is a disease of the hearing mechanism in the middle (and internal) ear in which the third bone of the chain of 3 bones in the middle ear gradually gets fixed due to new bone formation and decreasing the vibrations of sound entering the inner ear.  (see diagram). The cause of the disease is unknown. It usually manifests after the age of 15 years and is commoner in females. In 80 % of cases, the disease affects both ears to a greater or lesser extent.

    The patient or relatives notice increasing difficulty in hearing, mainly in one ear. One’s own voice may sound loud and hence the patient tends to speak softly as compared with patients with a weakness of the hearing nerve (sensori neural hearing loss) who tend to speak loudly. In some patients the first complaint is an intermittent or  continuous spontaneous noise in the ear (tinnitus).

    For some reason, in females, every pregnancy increases the deafness.

    As the disease process advances, the otosclerosis can involve the opposite ear (in80% patients). When the inner ear is also affected by the process (cochlear Otosclerosis) a “mixed” deafness (conductive and sensori-neural) develops.

    Whites are the most affected race, with the prevalence in the Black and Asian populations being much lower. Females are twice as likely as males to be affected. Usually noticeable hearing loss begins at middle-age, but can start much sooner. The hearing loss often grows worse during pregnancy.

    The disease is inherited as an autosomal dominant fashion.

    Special tests for hearing

    Pure Tone Audiometry shows the exact levels of hearing and confirm a conductive deafness where hearing by bone conduction is better than hearing by air conduction. Acoustic Impedance Bridge studies confirm a fixation of the 3rd bone (Stapes) and also confirm normal middle ear pressure but diminished ear drum movement.

    What is the treatment?

    The main treatment is surgical. The ear drum is lifted up and the middle ear is entered. Under an operating microscope, the joint between the 2nd bone (Incus) and third bone (Stapes) is separated. The upper part of the Stapes bone (super structure) is removed. A very small microscopic hole of 0.6 to 0.8 mm diameter is made in footplate of the stapes bone (Stapedotomy). One end of a teflon piston is inserted through this hole, either directly or through a vein graft. The other end of the piston is hooked around the 2nd bone (Incus). The ear drum is then replaced back in the original position.

    Sound vibrations now travel from the ear drum via the  teflon piston.

    Hearing is restored to normal on the operating table in 97 to 98% of cases.

    A Hearing aid will also give satisfaction, as in any case of conductive deafness. However, it can  never give the satisfaction of normal natural hearing as a successful operation does.

    Otosclerosis is a slowly progressive disease. As years go by, deafness increases and the opposite ear too shows signs of involvement. In females, every pregnancy increases the deafness. Gradually, after the age of 45 or 50 years, when old age deafness sets in due to age related changes of the nerves of hearing, the hearing impairment becomes more pronounced and a definite handicap in communication.

    Treatment of otosclerosis relies on two primary options: hearing aids (more recently including bone-conduction hearing aids) and a surgery called a stapedectomy. Hearing aids are usually very effective early in the course of the disease, but eventually a stapedectomy may be required fordefinitive treatment. Early attempts at hearing restoration via the simple freeing the stapes from its sclerotic attachments to the oval window were met with temporary improvement in hearing, but the conductive hearing loss would almost always recur. A stapedectomy consists of removing a portion of the sclerotic stapes footplate and replacing it with an implant that is secured to the incus. This procedure restores continuity of ossicular movement and allows transmission of sound waves from the eardrum to the inner ear.

    A modern variant of this surgery called a stapedotomy, is performed by drilling a small hole in the stapes footplate with a micro-drill or a laser, and the insertion of a piston-like prothesis. The success rate of either a stapedotomy or a stapedectomy depends greatly on the skill and the familiarity with the procedure of the surgeon.

    Other less successful treatment includes fluoride administration, which theoretically becomes incorporated into bone and inhibits otosclerotic progression. This treatment cannot reverse conductive hearing loss, but may slow the progression of both the conductive and sensorineural components of the disease process. Recently, some success has been reported with bisphosphonate medications, which stimulate bone-deposition without stimulating bony destruction.

    Sequence of a Stapedectomy operation

     

    Equipment

    Equipment

    An Endoscope is an optical instrument with bundles of optical fibers that transmit light from a source outside the body so that one end can enter passages and cavities inside the body for visualization of these structures in utmost detail. The advantage is that the intensity of light at the source is transmitted almost with no loss of intensity to the end of the cable into the interior of the organ. This allows detailed visualization and also video photo recording at the tip at absolutely close quarters. The heat of the light source is not conducted and therefore the light source is referred to as a cold light fountain. Certain instruments also carry extra tubes for suction and tubes to guide instruments for biopsy of pathologies deep in. Also it replaces rigid tube endoscopes of the past.. Flexible cables can see around bends and corners. Flexible endoscopes are also used when required.

    image0021
    Endoscopes for visualization of the Ear, Nose & Throat passages

    image0061Endoscope with cold light switched on.

    image0041
    Light source – cold light “fountain” supplying illumination
    through light fibers from source to the end of the cable

    image008
    Recordings are stored in discs for study later, comparisons
    over a period of time, second opinions etc.

    Barotrauma

    Mechanism of middle ear pressure changes during air travel

     

     

     

     

     

    Need for Second opinion in E.N.T

    The Complexity of Radiology & Imaging Today

    Today, radiology and imaging includes a large number of modalities and covers virtually all organs in the body. It is virtually impossible for any one individual to keep abreast of all developments and to be as good in all of them.

    We, at Jankharia Imaging, have subspeciality training in specific organ systems and modalities and each one of us is an expert in our area of expertise

    Today, radiology and imaging includes a large number of modalities and covers virtually all organs in the body. It is virtually impossible for any one individual to keep abreast of all developments and to be as good in all of them.


    There are many situations in which, after you have had a radiology examination performed (e.g., x-ray, mammogram, bone densitometry, CT scan or MRI), you may feel the need for another opinion. The reasons may include one or more of those listed below:

    • When assurance is need about the report’s conclusions from another expert radiologist
    • When a subspeciality opinion is required as against that of a generalist
    • When the case is complex, and a diagnosis has not yet been reached

    Radiology Opinions

    Using our expertise, we will read your examinations, sent to us on CT, films or via the Internet, as the case may be and will get back to you within two working days at the most. We are happy to receive examinations from

    · Patients

    · Referring Doctors

    · Radiologists