Otolaryngology Commons^™

Postoperative Complications Of Powered Intracapsular Tonsillectomy And Monopolar Electrocautery Tonsillectomy In Teens Versus Adults., Douglas R Johnston, Michael Gaslin, Maurits Boon, Edmund Pribitkin, David Rosen

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

OBJECTIVES: This study was performed to determine whether teens have different rates of posttonsillectomy hemorrhage, admission for dehydration, or recurrent tonsillitis compared to adults. Specifically, these parameters were compared within two groups: patients who underwent powered intracapsular tonsillectomy (PIT) and those who underwent monopolar electrocautery tonsillectomy (MET).

METHODS: In a retrospective review of 579 patients at least 12 years of age from January 2000 to July 2006 in a tertiary referral center, outcome measures of reoperation for hemorrhage, readmission or emergency room visit for dehydration, and postoperative tonsillitis were compared for 200 patients 12 to 19 years of age and …

Intelligibility Of Electrolarynx Speech Using A Novel Actuator, Brian Madden, Mark Nolan, Ted Burke, James Condron, Eugene Coyle

Conference Papers

During voiced speech, the larynx provides quasi-periodic acoustic excitation of the vocal tract. Following a laryngectomy, some people speak using an electrolarynx which replaces the excitatory function of the absent larynx. Drawbacks of conventional electrolarynx designs include the buzzing monotonic sound emitted, the need for a free hand to operate the device, and difficulty experienced by many laryngectomees in adapting to its use. Despite these shortcomings, it remains the preferred method of speech rehabilitation for a substantial minority of laryngectomees. In most electrolarynxes, mechanical vibrations are produced by a linear electromechanical actuator, the armature of which percusses against a metal …

Endoscopic Repair Of High-Flow Cranial Base Defects Using A Bilayer Button., Adam J. Luginbuhl, Peter G. Campbell, James Evans, Marc Rosen

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

OBJECTIVES/HYPOTHESIS: Repair of the skull base still begins with a direct repair of the dural defect. We present a new button closure for primary repair of the dura for high flow defects.

STUDY DESIGN: Retrospective review.

METHODS: We reviewed our 20 cases of primary button grafts and compared the results to the previous 20 high-flow open-cistern cerebrospinal fluid (CSF) cases. Subjects were excluded if they had no violation of the arachnoid space or potential for low-flow CSF leak. The button is constructed so that the inlay portion is at least 25% larger than the dural defect, and the onlay portion …

Parotidectomy: A Review Of 112 Patients Treated At A Teaching Hospital In Pakistan, Naeem Sultan Ali, Ahmad Nawaz, Shaheryar Rajput, Mubasher Ikram

Section of Otolaryngology, Head & Neck Surgery

Objective:The Purpose of this study was to analyze the clinical presentation, histopathology and complications following parotid surgery.

Methods:

We retrospectively reviewed the charts of 112 Patients who underwent parotidectomy from January 2000 to February 2010. Data including age, sex, clinical signs and symptoms, histology and complication were collected from medical records.

Results:

Of the total, 82 (74%) had benign lesions, 30 (36%) had malignant tumors. The most common benign tumor was pleomorphic adenoma (57%), and the most common malignant tumor was mucoepidermoid carcinoma (16%). Analysis of the correlation between fine-needle aspiration cytology and final histology revealed that fine-needle aspiration …

Comparison Of Different Treatment Modalities In Advanced Laryngeal Hypopharyngeal Squamous Cell Carcinoma, Shehzad Ghaffar, Mubasher Ikram, Sardar Zakariya Imam, Yasir Jamal Sepah

Section of Otolaryngology, Head & Neck Surgery

OBJECTIVE: To compare outcome of patients with advanced laryngeal hypopharyngeal squamous cell carcinoma treated surgically or with chemotherapy and/or radiotherapy.

STUDY DESIGN: Observational study.

PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from January 2000 to December 2005.

METHODOLOGY: Medical records of already treated stage-III and IV squamous cell carcinoma of larynx/hypopharynx patients were reviewed. Group-A comprised of patients treated with surgery +/- adjuvant therapy whereas non-surgically managed patients were labeled as group-B. One hundred and nineteen out of 275 met the inclusion criteria. Kaplan Meier technique was used to estimate mean recurrence time with standard errors. …

Factors Associated With Recurrent Nasal Polyps: A Tertiary Care Experience, Shabbir Akhtar, Mubasher Ikram, Iqbal Azam, Tariq Dahri

Section of Otolaryngology, Head & Neck Surgery

OBJECTIVE: To assess the factors associated with recurrence of nasal polyps in operated patients by endoscopic surgery.

METHODS: A retrospective study was conducted on 192 patients operated for nasal polyps in a hospital set-up between 2001 and 2007. The median follow-up period was 24 months (range 12 months to 60 months). Ten variables were analyzed to study their association with polyp recurrence namely; age, gender, history of purulent nasal discharge, facial pain, anosmia, post nasal dripping (PND), headache, nasal allergy, asthma and computed tomography (C.T) staging. Analysis of recurrences was accomplished using independent sample t-test, chi-square and Fishers exact test. …

Clinical Profile, Outcomes And Improvement In Symptoms And Productivity In Rhinitic Patients In Karachi, Pakistan., Taimur Saleem, Umair Khalid, Ubaid Ur Rehman Sherwani, Shehzad Ghaffar

Section of Otolaryngology, Head & Neck Surgery

Background:Rhinitis can cause a heavy toll on Patients because of its bothersome effects on productivity. This retrospective study was conducted to explore the clinical profile, outcomes and improvement in the symptoms and productivity resulting from treatment of allergic rhinitis in Pakistan.

Methods:

We carried out a retrospective file review of all allergic rhinitis Patients who presented to the Ear, Nose, Throat Consulting Clinic from January, 2006 to June, 2008 using a structured proforma especially designed for this Purpose. Data was entered and analyzed using SPSS v. 16.0.

Results:

The charts of 169 Patients were reviewed. The mean age of …

Modulation Of Outer Hair Cell Electromotility By Cochlear Supporting Cells And Gap Junctions, Ning Yu, Hong-Bo Zhao

Surgery Faculty Publications

Outer hair cell (OHC) or prestin-based electromotility is an active cochlear amplifier in the mammalian inner ear that can increase hearing sensitivity and frequency selectivity. In situ, Deiters supporting cells are well-coupled by gap junctions and constrain OHCs standing on the basilar membrane. Here, we report that both electrical and mechanical stimulations in Deiters cells (DCs) can modulate OHC electromotility. There was no direct electrical conductance between the DCs and the OHCs. However, depolarization in DCs reduced OHC electromotility associated nonlinear capacitance (NLC) and distortion products. Increase in the turgor pressure of DCs also shifted OHC NLC to the negative …

Two Cases Of Primary Laryngeal Amyloidosis, Taimur Saleem, Sanna Fatima, Shehzad Ghaffar, Kanwal Aftab, Sohail Awan

Section of Otolaryngology, Head & Neck Surgery

The larynx is a rare site of involvement of amyloidosis. We report two cases of laryngeal amyloidosis. Both patients were middle aged females with history of persistent hoarseness. Fibreoptic laryngoscopy used for diagnosis in both and debulking of the tumour was performed. Histopathological examination confirmed the diagnosis of amyloidosis. Appropriate follow up is an important part of the long-term management of the disease.

Adenoid Cystic Carcinoma Of The External Auditory Canal, Mohammad Hussham Arshad, Umair Khalid, Shehzad Ghaffar

Section of Otolaryngology, Head & Neck Surgery

This is a rare case of a young male with biopsy proven adenoid cystic carcinoma of the external auditory canal who underwent excision of the lesion with superficial parotidectomy sparing the facial nerve. Histopathology showed perineural invasion, which is a diagnostic hallmark of adenoid cystic carcinoma. Clinical examination, chest X-ray and CT scan showed no signs of recurrence or metastasis 2 years postoperatively.

Sour Ageusia In Two Individuals Implicates Ion Channels Of The Asic And Pkd Families In Human Sour Taste Perception At The Anterior Tongue., Taufiqul Huque, Beverly J Cowart, Luba Dankulich-Nagrudny, Edmund A Pribitkin, Douglas L Bayley, Andrew I Spielman, Roy S Feldman, Scott A Mackler, Joseph G Brand

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

BACKGROUND: The perception of sour taste in humans is incompletely understood at the receptor cell level. We report here on two patients with an acquired sour ageusia. Each patient was unresponsive to sour stimuli, but both showed normal responses to bitter, sweet, and salty stimuli.

METHODS AND FINDINGS: Lingual fungiform papillae, containing taste cells, were obtained by biopsy from the two patients, and from three sour-normal individuals, and analyzed by RT-PCR. The following transcripts were undetectable in the patients, even after 50 cycles of amplification, but readily detectable in the sour-normal subjects: acid sensing ion channels (ASICs) 1a, 1beta, 2a, …

Thyroid Lymphosonography: A Novel Method For Evaluating Lymphatic Drainage., Joseph M. Curry, Waleed H. Ezzat, Daniel A. Merton, Barry B. Goldberg, David M. Cognetti, David Rosen, Edmund A. Pribitkin

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

OBJECTIVES: We evaluated lymphosonography, or contrast-enhanced, ultrasonography (US)-guided sentinel lymph node (SLN) detection, as a technique for demonstrating the lymphatic drainage of the thyroid gland. METHODS: In this prospective animal study, four 50-kg Yorkshire swine underwent transcutaneous injection of a US contrast agent and methylene blue dye into the thyroid gland. Contrast-enhanced US was used to identify draining lymphatic channels and SLNs. Sentinel node biopsy was conducted. Subsequently, bilateral neck and upper mediastinal dissection was carried out. RESULTS: In 3 of 4 cases, a blue dye-positive and US contrast-positive SLN was identified. We identified SLNs in level IV in 2 …

Management Of Allergic Fungal Sinusitis With Postoperative Oral And Nasal Steroids: A Controlled Study., Mubasher Ikram, Akbar Abbas, Anwar Suhail, Maisam Abbas Onali, Shabbir Akhtar, Moghira Iqbal

Section of Otolaryngology, Head & Neck Surgery

In Patients with allergic fungal sinusitis, the mainstay of treatment remains surgical removal of allergic mucin and fungal debris. But as a single modality, surgery is associated with high rates of recurrence, so a number of adjunctive medical modalities have been tried, including postoperative corticosteroid therapy. We conducted a study of 63 Patients with allergic fungal sinusitis who underwent endoscopic sinus surgery with or without postoperative steroid therapy. A group of 30 Patients who had been treated prior to January 2000 had undergone surgery only, their cases were reviewed retrospectively, and they served as historical controls. Another 33 Patients who …

Multimodality Education For Airway Endoscopy Skill Development., Ellen S. Deutsch, Thomas Christenson, Joseph Curry, Jobayer Hossain, Karen Zur, Ian Jacobs

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

OBJECTIVES: Airway endoscopy is a difficult skill to master. A unique practicum was designed to help otolaryngology residents develop endoscopy skills. The learning modalities included lectures, an animal laboratory, high-fidelity manikins, virtual bronchoscopy simulation, and standardized patients. This study compares the relative subjective value of these learning modalities for skill development and realism. METHODS: Participants used a Likert scale (1=disagree to 5=agree) and open responses to anonymously rate the efficacy of 5 learning modalities for teaching airway management, endoscopy skills, and clinical leadership and for providing a realistic experience. RESULTS: The results in 2007 were uniformly positive, with mean scores …

Malignant Melanoma Metastatic To The Thyroid Gland: A Case Report And Review Of The Literature., Brian Kung, Md, Saba Aftab, Bs, Moira D. Wood, Md, David Rosen, Md

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

The thyroid gland is a relatively uncommon site for a secondary malignancy; even less common is a case of malignant melanoma metastatic to the thyroid. We describe the case of a 68-year-old man who presented with a neck mass in the posterior triangle. Fine-needle aspiration biopsy (FNAB) identified the mass as a malignant melanoma. The patient had had no known primary skin melanoma. He underwent a left modified radical neck dissection, and the mass was discovered to be a positive lymph node. Postoperatively, he declined to undergo radio- and chemotherapy. Eighteen months later, he returned with a diffusely enlarged thyroid. …

Unusual Fibrosclerotic Lesion Of The Laryngotracheal Complex Presenting As Subglottic Stenosis., Douglas R. Johnston, Joseph M. Curry, Raphael Rubin, Marc R. Rosen

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

We present a case report that describes the pathology, presentation, and management complexities of an unusual, destructive fibrosclerotic lesion of the laryngotracheal complex. An otherwise healthy 21-year-old man presented with a 1-year history of progressive shortness of breath and stridor. The initial examination revealed a 3-cm, grade III subglottic stenosis. Nodular fibrosis of the strap muscles, laryngotracheal cartilages, and trachea was evident. Biopsies revealed dense peritracheal desmoplastic reaction with focal erosion of cartilage. However, features diagnostic for relapsing polychondritis, desmoid tumor, or orbital pseudotumor were absent. The disease progressed to involve severe stenosis and thickening of the trachea and main …

Assessment Of Smoking Status Based On Cotinine Levels In Nasal Lavage Fluid., Mehmet Hakan Ozdener, Karen K Yee, Ryan Mcdermott, Beverly J Cowart, Aldona A Vainius, Pamela Dalton, Nancy E Rawson

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

ABSTRACT: Cotinine is a principal metabolite of nicotine with a substantially longer half-life, and cotinine levels in saliva, urine or serum are widely used to validate self-reported smoking status. The nasal cavity and olfactory system are directly exposed to tobacco smoke in smokers and in non-smokers who live with or work around smokers. However, despite the potential for a direct impact of tobacco smoke on the nasal epithelium and olfactory neurons, no prior studies have assessed cotinine levels in nasal mucus. We sought to determine whether cotinine levels in nasal lavage fluid (NLF) would provide a reasonable estimate of smoke …

Estrogen Replacement Therapy Induces Functional Asymmetry On An Odor Memory/Discrimination Test, Richard L. Doty, Mehreen Kisat, Isabelle Tourbier

Section of Otolaryngology, Head & Neck Surgery

The secondary afferents of the olfactory system largely project to the ipsilateral cortex without synapsing in the thalamus, making unilateral olfactory testing a useful probe of ipsilateral hemispheric activity. In light of evidence that lateralized performance on some perceptual tasks may be influenced by estrogen, we assessed left:right nostril differences in two measures of olfactory function in 14 post-menopausal women receiving estrogen replacement therapy (ERT) and 48 post-menopausal women receiving no such therapy. Relative to women not taking ERT, those receiving ERT exhibited better performance in the left nostril and poorer performance in the right nostril on an odor memory/discrimination …

Laryngotracheal Trauma: Its Management And Sequelae, Shabbir Akhtar, Sohail Awan

Section of Otolaryngology, Head & Neck Surgery

OBJECTIVE: Laryngotracheal trauma is a rare but clinically important injury. Complications are frequent. Early recognition, accurate evaluation and proper treatment is vital. In order to learn from our past experience and refine our management, we reviewed our cases.

METHODS: Fifteen patients with external laryngotracheal injuries were analyzed retrospectively. The outcome was assessed both in terms of voice and airway, on short term and long term basis.

RESULTS: Commonest cause of injury was cut throat injuries followed by road traffic accidents. The main presenting symptoms and signs were hoarseness, haemoptysis, odynophagia and stridor. Major laryngeal injuries (10 cases) outnumbered minor injuries …

Management Of The Neck In Differentiated Thyroid Cancer, David M. Cognetti, Edmund A. Pribitkin, William M. Keane

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

Differentiated thyroid cancer is characterized by an excellent long-term prognosis, which unlike other head and neck carcinomas, is not influenced definitively by regional lymph node metastasis. The relative rarity of the disease, together with its tendency for delayed metastasis and its low mortality, makes a prospective randomized trial comparing treatment outcomes difficult. As a result, the effect of cervical lymph node metastases on survival is unclear, making meaningful recommendations for their management somewhat subjective. This article discusses guidelines for the management of the neck in differentiated.

Blindness In Children At The Ida Rieu School For The Blind And Deaf, Sadia Javed Khan, Afshan Hassan, Laila Khalid, Uzma Karim, Erum Hashmi, Fariha Gul, Imtiaz Jehan

Community Health Sciences

Objective: To identify the causes of blindness at the Ida Rieu school for the blind and deaf, Karachi, Pakistan.Methods: A cross sectional study was conducted at the Ida Rieu School for the blind and deaf. The data collected from medical record of students was entered into the WHO/PBL eye examination form for children with blindness and low vision.Results: Records of 144 pupils aged between 4-30 years were reviewed, including 67% males and 33% females. One third (31%) children had visual impairment (< 6/18-6/60) and 69% were blind (< 3/60-NPL). The commonest anatomical site was retina (41%) and whole globe (20%). The etiology was unknown in 49% cases. In 33% of cases, the data suggested hereditary cause as the etiology, 40% of cases were preventable and 13% treatable.CONCLUSION: Avoidable causes of blindness were seenin 53% of children, 58% of which were preventable and 19 were treatable.

Sailing The Straits Of Approval: The Nature Of Fda Approval And Its Implications For Surgeons, David Reiter Md

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

Products approved by the US Food and Drug Administration (FDA) for one use are often put to other uses. This practice, known colloquially as "off-label usage," is neither illegal nor unethical. Physicians can and should pursue scientifically sound use supported by medical evidence. The FDA requires only that we:

--Be well informed about the product
--Base its use on firm scientific rationale and sound medical evidence, if available
--Maintain records of the product’s use and effects
--Carry out good medical practice
--Use good judgment
--Consider the best interests of the patient before all else

Nasal Airflow And Odorant Transport Modeling In Patients With Chronic Rhinosimusitis, Kai Zhao, Beverly J. Cowart, N. E. Rawson, Peter W. Scherer, K. T. Clock, A. A. Vainius, Pamela Dalton, Edward Pribitkin, David Rosen

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

Poster presentation at Association for Chemoreception Sciences (ACHEMS) in Sarasota Florida April 25-29, 2007.

Introduction:

Our on-going clinical project aims to quantify the conductive mechanism contributing toolfactory loss in chronic rhinosinusitis (CRS) patients, in addition to other inflammatory causes(see Yee, et al, 200 and Feng, et al, 203). CRS, a common disease affecting 32 millionAmericans annually, is reportedly associated with at least 15% of all olfactory losses. Airwayconstriction as a result of inflammation or the presence of polyps may limit odor access to thereceptor sites and lead to olfactory dysfunction. As yet, the functional impact of various nasalobstructions as sequelae …

An Unusual Presentation Of Adenoid Cystic Carcinoma Of The Minor Salivary Glands With Cranial Nerve Palsy: A Case Study, Amal Abdul-Hussein, Pierre A. Morris, Tsveti Markova

Wayne State University Associated BioMed Central Scholarship

Abstract

Background

Adenoid Cystic Carcinoma (ACC) is a rare tumor entity and comprises about 1% of all malignant tumor of the oral and maxillofacial region. It is slow growing but a highly invasive cancer with a high recurrence rate. Intracranial ACC is even more infrequent and could be primary or secondary occurring either by direct invasion, hematogenous spread, or perineural spread. We report the first case of the 5^th and 6^th nerve palsy due to cavernous sinus invasion by adenoid cystic carcinoma.

Case presentation

A 49-year-old African American female presented to the emergency room complaining of severe right-sided …

Iatrogenic Insertion Of Impression Mould Into Middle Ear And Mastoid And Its Retrieval After 9 Years: A Case Report, Mohammad Sohail Awan, Moghira Iqbal, Zakariya Imam Sardar

Department of Surgery Docs

Abstract

The magnitude of hearing loss in Pakistan is enormous. One in twelve children of Pakistan suffers from some form of hearing impairment. Many of them are unable to afford surgical procedures and resort to the use of cheap hearing aids fitted by untrained individuals or people lacking the required expertise. This predisposes the patients to significant complications during a process that is otherwise considered safe.We report the case of a child, where the process of making the mould for a hearing aid led to the perforation of the tympanic membrane and pouring of mould material into the middle ear, …

Neck Recurrence In Early Carcinoma Tongue, Mubasher Ikram, Sadaf Fatima Jafferbhoy, Maisam Abbas Shiraz Onali

Section of Otolaryngology, Head & Neck Surgery

Objective: To study the efficacy of different locoregional treatment options for tongue cancer in determining the prognosis, with reference to recurrence of disease in neck.

Methods: This is a retrospective analysis of 80 patients with early (T1/T2) carcinoma tongue who had hemiglossectomy with or without neck surgery and radiotherapy for 14 years.

Results: Eighty patients were included in this study, 49 (61.3%) men and 31 (38.8%) women; 36 (45%) patients with T1 lesion and 44 (55%) with T2 lesion. Sixty two patients (77.5%) were staged cN0 and 18 patients had a clinically palpable neck nodes (cN+). Thirty seven patients were …

Malignant Melanoma Metastacizing To The Thyroid Gland: A Case Report And Review Of The Literature, Brian Kung, Saba Aftab, Moira Wood, David Rosen

Department of Otolaryngology - Head and Neck Surgery Faculty Papers

Oral presentation 2006 AAO-H&NS Annual Meeting

Toronto, Canada September 17-20, 2006.

Objectives: The thyroid gland is a relatively uncommon site for secondary malignancy. Even lesscommon is metastasis of malignant melanoma to the thyroid gland. We present a case of malignantmelanoma metastatic to the thyroid gland presenting as thyroid enlargement.

Study Design: This is a case report which utilizes chart review, intraoperative photographs,radiographic images, and pathology slides.

Methods: A 68 year old patient with no prior evidence of primary skin melanoma presented witha neck mass which tested positive for melanoma. A year and a half following modified radical neckdissection, the patient …

Incorporating Endoscope In Middle Ear Surgery, Shehzad Ghaffar, Mubasher Ikram, Ahsan Raza

Section of Otolaryngology, Head & Neck Surgery

We conducted a study to evaluate the use of a pediatric rigid otoendoscope for determining the extent of middle ear disease and for assessing ossicular integrity and mobility during tympanoplasty. Our study population was made up of 132 patients who were undergoing surgery for the treatment of chronic suppurative otitis media; of this group, 41 patients underwent otoendoscopy and 91 underwent scutum lowering for purposes of visualization. In the otoendoscopy group, the ossicles were successfully visualized and their mobility assessed in 34 patients; the remaining 7 patients subsequently underwent scutum lowering. A 30° endoscope allowed for complete visualization of the …

Acetabular Morphometry For Determining Hip Dysplasia In The Singaporean Population, Masood Umer, Thambyah A, Wtj Tan

Department of Surgery Docs

Abstract

PURPOSE:

To assess and evaluate the usefulness of 7 morphological measurements of the acetabulum in establishing the prevalence of acetabular dysplasia in the Singaporean population.

METHODS:

Standardised plain anteroposterior radiographs of 522 hip joints of 261 asymptomatic patients (mean age, 60 years; range, 16-99 years) were evaluated. The 7 morphological measurements were centre-edge angle, acetabular angle, depth-to-width ratio, roof obliquity, extrusion index, lateral subluxation, and peak-to-edge distance.

RESULTS:

19 (7.3%) patients were acetabular dysplastic (centre-edge angle of <20 >degrees). The mean centre-edge angle was 31.2 degrees (range, 5-52 degrees), acetabular angle 39.46 degrees (range, 10-58 degrees), depth-to-width ratio 0.32, roof …

Socio-Demographic Correlates Of Betel, Areca And Smokeless Tobacco Use As A High Risk Behavior For Head And Neck Cancers In A Squatter Settlement Of Karachi, Pakistan, Samia Mazahir, Rabia Malik, Maria Maqsood, Kanwal Aliraza Merchant, Farida Malik, Atif Majeed, Zafar Fatmi, Muhammad Rizwanulhaq Khawaja, Shehzad Ghaffar

Community Health Sciences

Background

Head and neck cancers are a major cancer burden in Pakistan. They share a common risk factor profile including regular consumption of products of betel, areca and tobacco. Use of paan, chaalia, gutka, niswar and tumbaku is acceptable in Pakistan and is considered a normal cultural practice. This cross-sectional study was carried out to understand the relation of socio-demographic factors for the consumption of paan, chaalia, gutka, niswar and tumbaku in Pakistani population. Through systematic sampling, 425 subjects from a squatter settlement in Karachi were interviewed using a structured questionnaire. High risk behavior was defined as Daily use of …