A Family Doctor's Tale - MUSCLE TENSION DYSPHONIA

DOC I HAVE A MUSCLE TENSION DYSPHONIA

Muscle Tension Dysphonia is an excessive tightness or imbalnce of the muscles in and around the vocal box resulting in hoarseness and difficulty in using the voice.

The causes of Muscle Tension Dysphonia are:
1.Direct problem with the use of vocal technique

2.voice muscle habitual misuse

3.acid reflux from the stomach or laryngopharyngeal reflux

4.underlying inflammation of the vocal cord

5.growth on the vocal cord

6.neurological condition affecting the vocal cord

Symptoms  of Muscle Tension Dysphonia:
1.Hoarse voice

2.strained voice

3.pain or sore throat when talking

4.vocal fatigues easily

5.difficulty controlling pitch

Diagnosis of Muscle Tension Dysphonia:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords

3.videostroboscopy to view the vocal cords ( a thick endocscope with camera is passed down the nose to the vocal cords to examine its movements on video)

4.CT or MRI Scanning of skull from nose to vocal box to look for underlying causes.

5.evaluation of laryngopharyngeal reflux

There can be complications of Muscle Tension Dysphonia such as:
1.chronic hoarseness of voice

2.damage to the vocal cords

Treatment of Muscle Tension Dysphonia:
Medical:
1.Speech therapy
a.to improve voicing techniques
b.overcome bad vocal habits which strain on the voice
c.avoid unneccesary voice use to allow the voice muscles to relax and rest

2.medication to treat acid reflux

Surgery is usually not required.
The prognosis of Muscle Tension Dysphonia is usually fairly good .

Prevention of Muscle Tension Dysphonia:
1.It would be wise to hydrate the throat
2.warm up the voice before talking for long periods of time
3.use a microphone rather than shouting or using a loud voice to convey your message to a large crowd of people
4. Always rest the voice whenever possible

A Family Doctor's Tale - VOCAL PARALYSIS

DOC I HAVE A VOCAL PARALYSIS

Vocal paralysis is a paralysis of one or both of the vocal cords and results in inability to close the the vocal cords completely.

Vocal paralysis usually involve one of the vocal cords.

If the vocal cords do not close completely:
1.the voice becomes weak and hoarse

2.there may be choking on swallowing due to food or liquids going down the windpipe.

The causes of vocal paralysis are:
1.tumors pressing on the nerve that control vocal cord movement
Examples are cancers of the larynx, thyroid, nasopharynx or esophagus

2.injury of the nerve controlling vocal cord movement
a.during thyroid and chest surgery
b.following radiation treatment to the neck  
c.neck injury.

3.stroke or neurological condition affecting the movement of the vocal cords

Symptoms  of vocal paralysis:
1.Hoarse voice

2.breathless voice

3.low pitch husky voice

4.vocal fatigue

5.choking or coughing especially on drinking liquids

Diagnosis of vocal paralysis:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords and confirm the presence of  paralysis

3.videostroboscopy to view the vocal cords

4.CT or MRI Scanning of skull from nose to vocal box to look for cause of paralysis.

5.Laryngeal electromyography which use a fine needle to measure function of the vocal cord muscle

There can be complications of vocal paralysis such as:
1.choking with effect to breathing difficulty

2.chronic hoarseness of voice

Treatment of vocal paralysis:
Sometimes the recovery occurs by itself and no action is needed.
This may take up to one year.
Medical:
1.Speech therapy

2.injection of collagen to increase the bulk of paralysed vocal cord may help

Surgery:
1.Surgical treatment (medialization thyroplasty)may be needed to permently shift the paralysed vocal cord to improve the voice.
This operation is done under local anesthetic.

Phono-microsurgery is surgery to the vocal cord using micro-surgical techniques and instruments and sometimes lasers.

2.Rarely if both vocal cords are affected by paralysis there may be difficulty in breathing or noisy breathing because of the narrowed airway at the vocal box.
A tracheostomy may be needed. This involves making an opening in the windpipe and putting a trachecstomy tube into the opening to help breathing.

3.A laser procedure may be done to widen the the airway.

The prognosis of vocal paralysis is usually fairly good except when cancer is involved.

Prevention of vocal paralysis:
surgery around the neck and throat region should done carefully to avoid cutting the nerve to the vocal cords.

A Family Doctor's Tale - LARYNGOPHARYNGEAL REFLUX

DOC I HAVE LARYNGOPHARYNGEAL REFLUX

Laryngopharyngeal reflux disease (LPR) is a chronic disease of the pharynx (throat) and larynx (voice box) whose mucosa is damaged by abnormal acid backflow (reflux) of gastric acid from the stomach to the esophagus.

The following causes are responsible for LPR:
There are 2 sphincter muscles in the esophagus:
1.the Lower Esophageal sphincter (LES) prevents the backflow of food and acid from the stomach and acid from the stomach into the esophagus

2.the Upper esophageal sphincter (UES) prevents the food and acid from backflowing into the larynx

An incompetant Lower Esophageal Sphincter(LES) allow the acid and gastric juice to reflux up the esophagus giving rise to gastroesophageal reflux disease or GERD.

If the acid and digestive enzymes from the stomach back flows into the larynx then the condition is called laryngopharyngeal reflux or LPR.

An incompetant lower esophageal sphincter may also result from:
1.Hiatus hernia - hole in diaphragm separating esophagus from stomach is enlarged allowing the easier flow of acid up the esophagus

2.Obesity and pregnancy: increased body weight cause pressure in the abdomen to push gastric contents upwards towards esophagus

The most common symptoms are
1.frequent throat clearing

2.throat itchiness

3.sensation of something in the throat

4.excess phlegm in the throat

5.hoarseness- due to inflammation of the vocal cords from the acid reflux

6.frequent sore throat

7.chronic cough - the acid flow up the esophagus can irritate the larynx and spark off the cough reflex

8.Heartburn - there is a burning discomfort behind the breastbone due to acid flow up the esophagus

Diagnosis:
A detailed history of acid reflux into the larynx and pharynx

Useful investigations may include
1.barium swallow X-rays to check the flow a barium dye from the oral cavity down the esophagus to the stomach. It can detect any reflux of the dye into the esophagus and the presence of any growths in the esophagus and stomach.

2.nasoendoscopy - an endoscope is passed through the nose to the level of voice box in the throat under local anethesia to check on the vocal cords

3.24-hour esophageal pH monitoring - measures the acidity of the esophagus

4.Esophagogastroduodenoscopy (EGD) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Treatment is aimed at
A. prevention of reflux:
1.weight loss for the Obese

2.Positional therapy
a.Sleeping on the left side has been shown to drastically reduce nighttime reflux episodes in patients

b.Elevating the head of the bed is also effective.
The head of the bed can be raised by wooden bed risers that support bed posts or legs.
Elevation must be at least 6 to 8 inches (15 to 20 cm) to be able to prevent the backflow of gastric fluids.

c.a bed wedge pillow will also help to raise the patient's body higher

3.Certain foods should be avoided to prevent Laryngopharyngeal reflux:
a.Coffee,


b.alcohol,


c.Acidic foods, such as oranges,tomatoes and excess amounts of Vitamin C


d.Antacids based on calcium carbonate actually increase the acidity of the stomach.


e.Foods high in fats -delay stomach emptying


f.Carbonated soft drinks with or without sugar.


g.Chocolate and peppermint.


h.Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussels sprouts.


i.Milk and milk-based products containing calcium and fat,


j.Eating within 2 hours before bedtime.

k.Large meals- smaller meals reduces reflux as it means there is less food in the stomach at any one time.

4.Smoking reduce lower esophageal sphincter competence, and should be avoided

5.Avoid stress.
Learn to relax or meditate.
Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.

B. Neutralizing the Gastric Acid Reflux
1. Drug treatment
a.Proton pump inhibitors are the best drugs used in reducing gastric acid secretion. (eg Nexium, Losec)

b.Antacids taken before meals half hourly after symptoms begin can reduce gastric acidity (liquid antacid are more useful than tablets)

c.Alginic acid (Gaviscon) protects the mucosa as well as increase pH and decrease reflux.

d.Gastric H2 receptor blockers such as ranitidine or famotidine decrease gastric secretion of acid.

2. Surgical treatment
The standard surgical treatment, done laparoscopically, is the Nissen fundoplication.
The upper part of the stomach is wrapped around the Lower Esophageal Sphincter(LES) to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

3.New treatments
Eight years ago some new endoscopic devices to treat chronic heartburn were approved:
a.The Endocinch apply stitches in the LES to help strengthen the muscle.

b.The Stretta Procedure uses electrodes to use radio frequency energy to strengthen the LES.

c.The Plicator creates a plication, or fold, of tissue near the Laryngopharyngeal junction, and fix the fold using a suture-based implant.

Prognosis:
It is a chronic disease so treatment is lifelong and recurrences are common.

Prevention:
1.Prevent heartburn by limiting acidic foods, such as grapefruit, oranges, tomatoes, or vinegar
2.Spicy foods -Cut back on pepper or chilies.
3.Avoid lying down for two to three hours after meals.
When you are sitting up, gravity helps drain food and stomach acid into your stomach.
4.Eat lean meats and non-fatty foods.
Greasy foods (like French fries and cheeseburgers) can trigger heartburn.
5.Avoid drinks that can trigger reflux, such as alcohol, drinks with caffeine, and carbonated drinks.
6.Eat smaller meals to avoid triggering reflux symptoms.
7.Avoid stress.
Learn to relax or meditate.
8.Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.

A Family Doctor's Tale - EARLOBE INFECTION

DOC I HAVE A EARLOBE INFECTION

The earlobe or pinna is the outer lobe of the ear which help to protect the ear canal.


Infection can affect the earlobe which is made up of cartilage covered by skin,                                  


Earlobes can be of different sizes and fleshiness.


Some earlobes may be deformed as a result of earlobe infection leading to cauliflower ears.

Causes of earlobe infections are:
1.normal bacteria resides on the skin of the pinna or earlobe.
When the skin is broken as a result of
a.tears of the skin from scratching


b.injury of the skin


c.multiple earlobe piercing


the normal bacteria residing on the skin of the earlobe will infect the skin and the underlying cartilage.


If the cartilage is involved the condition is called perichondritis.


Sometimes the infection is severe enough to destroy the cartilage and cause an abscess.


Infection of the external ear canal may also spread to the pinna.

Symptoms of earlobe infections:
The infected earlobe is usually:
1.red
2.swollen
3.warm to touch
4.extremely painful especially to touch
5.Fever and chills in some cases

Diagnosis of earlobe infections:
1.The diagnosis is usually obvious from the history and physical examination.

2.A swab of the pus may be obtained for test and sensitivity to antibiotics

The Treatment for Earlobe infection:
Earlobe infections caused by bacterial infections are treated with 1.antibiotics both orally and topically


2.analgesics for pain

If the infection progress to an abscess formation, incision and drainage of the abscess may need to be done as well as daily cleansing and dressing.

The abscess may destroy the underlying cartilage and as it heals new cartilage growth may lead to a deformity called the cauliflower ear.

Prognosis of earlobe infections:
All earlobe infections normally will heal but recurrences are common.

Prevention of earlobe infections:
1.avoid unhygienic ear piercing


2.avoid wearing multiple ear rings


3.avoid scratching the skin of the earlobe too hrad because the skin is generally thin over the earlobe region.

What are complications of ear infections?
---------------------------------------------

Most external ear infections can be treated easily and resolved without any damage to the surrounding tissues.
In Otitis Media,there is danger of spread of the infections to the surrounding bone tissue,labrynth, meninges and brain.
Acute mastoiditis
labrynthitis
Meningitis
Brain abscess
Facial palsy
Deafness

A Family Doctor's Tale - CHRONIC SUPPURATIVE OTITIS MEDIA

DOC I HAVE CHRONIC SUPPURATIVE OTITIS MEDIA

Chronic Suppurative Otitis media is chronic inflammation and infection of the middle ear which can result in a persistent foul smelling ear discharge and hearing loss.

Chronic Suppurative Otitis media occurs in the area between the ear drum (the end of the outer ear) and the inner ear and is caused by a perforation of the eardrum and recurrent infection of the middle ear.

The ear drum perforation is usually due to previous injury to the eardrum or severe infection of the middle ear.

Part of the skin of the ear will grow into the bone of of the middle ear forming what is known as a cholestestoma. This can grow causing chronic ear discharge and hearing loss.

The Causes of Chronic Suppurative Otitis media are:
Bacterial infections:

1.Streptococcus pneumoniae

2.Haemophilus influenzae

3.staphylococcus aureus

4.Moraxella catarrhalis, a gram-negative diplococcus.

5.Mycobacterium tuberculosis.

6.E.coli

Viral infections:

1.common cold.

2.measles

Chronic Suppurative  otitis media occurs following acute otitis media with chronic infection of the middle ear and ear perforation.

The complications of  Chronic Suppurative Otitis media are:
1.mastoiditis

2.labrynthitis

3.facial nerve palsy

4.meningitis,

5.brain abscess,

6.febrile seizures.

7.death if a severe infection goes untreated long enough

The Symptoms and signs of Chronic Suppurative Otitis media are:
1.Recurrent ear discharge from infection of the middle ear and pus escaping through a perforated ear drum


2. Recurrent earache  from the collection of pus and infection in the middle ear


3.hearing loss from perforation of the eardrum and erosion of the ossicles of the middle ear


Signs:

1.Ear drum usually has a perforation


2.Pus present in the external canal


3.cholestestoma present in the middle ear


4.facial paralysis


The diagnosis of  Chronic Suppurative Otitis media is made on the basis of:
1.Inflamed ear drum with  perforation and purulent discharge.

2.Culture and sensitivity of pus swab from the ear discharge


3.X-rays or MRI of the mastoid air cells and temporal bones


5.Audiogram for hearing loss

The treatment of Chronic Suppurative Otitis media is based on:


Medical:

1. Antibiotics both oral and topical are given especially if the culture showed bacterial infections.

2. pain may be treated with paracetamol or analgesics


3.Antihistamines may be given for stuffed nose


Surgery:

1.Myringoplasty -Puncture of bulging ear drum if painful and aspiration of pus or fluid in the middle ear.

2.Tympanoplasty for eardrum whose perforation does not heal.

3.Mastoidectomy to remove cholesteatoma(growing of skin into middle ear cavity) in chronic otitis media with mastoiditis.

The prognosis of Chronic Suppurative Otitis media is:
Healing with appropriate treatment is generally good but recurrence is quite common.

Ear drum perforation can be closed with surgery.

Hearing loss may still be present in spite of treatment.


The Preventive measures for Otitis media are:
Avoid chronic infection of the ear


Avoid swimming and diving.

Proper ear hygiene.

A Family Doctor's Tale - DEAFNESS

DOC I HAVE HEARING LOSS
Deafness or hearing loss is the inability to hear.

The causes of Deafness are:

A.Conductive hearing loss
Here sound waves cannot be transmitted from the external environment to the cochlea.
The problem may lie in
1.the external ear canal
a.obstruction caused by wax
b.obstruction caused by foreign body
c.obstruction caused by infection (otitis externa)
d.obstruction caused by ear polyps

2.eardrum
a.perforation caused by trauma
b.perforation caused by infection
c.scarred eardrum from injury or infection

3.middle ear bones
a.dislocation of the bones from injury or infection
b.damage to the bones from injury or infection
c.fixed bones or osteosclerosis (hardening of the bones from aging)

4.middle ear infection
infection of the middle ear occurs with fluid in the middle ear cavity preventing sound from passing through

B.Sensorineural Hearing Loss
a.damage to hearing organ or cochlea which send nerve impulse to the hearing nerve and on to the brain
b.damage to the hearing nerve (auditory nerve)from loud sounds, infection or injury

Common causes of hearing loss are:
1.aging (presbycusis)
2,acute or chronic exposure to loud noise can cause damage to sensory cells of cochlea
3.infection of the inner ear by viruses and bacteria such as mumps, measles or influenza
4.Meniere's disease - a disease with tinnitus, deafness and dizziness
5.Acoustic neuroma - tumour of the vestibular nerve which lies near to the auditory nerve and affects its function
6.Ototoxic drugs which can damage the nerves involved in hearing or sensory cells in the cochlea such as:
a.antibiotics especially gentamycin and vancomycin
b.diuretics such as frusemide
c.chemotherapy drugs

The symptoms of Deafness are:
1.Deafness is a lack of hearing.

The hearing loss is gradual or sudden and can affect one or both ears.

There is difficulty in holding a normal conversation in a noisy environment.

People may complin the affected person does not respond when called or speak louder than usual

2.tinnitus (ringing in the ear) may be present

3.vertigo (spinning sensation) may be associated with it

4.pain and discharge from ear is associated with ear infections

Diagnosis:
1.complete history, ENT examination

2.examination of ear canal and eardrum

3.endoscopy examination of nose and nasopharynx

4.neurological examination

5.hearing test (audiogram) can confirm the presence and severity and type of hearing loss

6.Tympanogram may be performed to detect problems of eardrum and middle ear.

7.X-rays, CT scan or MRI may used to exclude acoustic neuroma or brain tumors.

Treatment
-----------------
Medical treatment depends on the underlying problem.
1.Removal of wax and foreign body in the ear
Ear polyps can be dissolved away with medicines.

2.Antibiotics oral and topical may be necessary in severe external ear infections.

3.In the case of eardrum perforation, once the underlying infection is cleared and the perforation still do not close after 3 months, then surgical repair of the perforation may be needed.

4.If the cause of deafness is due to medication, then the medication should be stopped or changed.

5.If the cause is prebycusis (due to aging) no medical treatment is needed.
The deaf person is assessed to see whether hearing aids will help.

Hearing Aids:
1.hearing aids can amplify the external sound and help the hearing process.
2.They are useful for both conductive as well as sensorineural hearing loss.
3.The side effects from wearing hearing aids include:
obstruction effect
sound feedback
tendency to ear infections

Hearing implants:
Surgical hearing implants are of 2 types:
1.middle ear implants are used for those with sensorineural and conductive hearing loss.
It consists of a transducer that is attached to the middle ear ossicles or directly to the round window of the cochlea.
It vibrates the middle ear structures and amplifies the transmission of sound.

2.Cochlear implants are used in people with moderate to severe sensorineural hearing loss.
The electical electrode of the implant is inserted directly into the cochlea and stimulates the neve endings in the cochlea to bypass any problem in the cochlea.
They can be used in both children and adults.

Prevention of Deafness
--------------------------------
1.Avoid loud sounds especially at concerts or construction sites

2.Avoid toys with sharp points, shafts, spikes, rods and sharp edges to prevent eardrum injuries in children.

3.Avoid medicines which cause cause damage to the hearing nerve.

A Family Doctor's Tale - BLINDNESS

DOC I AM BLIND

Blindness is the inability to see.

The degree of blindness depends on the extent of loss of vision.

The causes of blindness are:
1.cataract


2.glaucoma
Glaucoma is due to a build-up of pressure within the eye causing damage to the  optic nerve transmitting visual information from eye to the brain.

The damage is progressive with loss of peripheral vision  followed by reduction in central vision resulting in blindness.

3.Age-related macular degeneration
Age-related Macular degeneration (AMD) is a degenerative disorder affecting the macula at the back the eye.

4.Corneal opacities are often caused by infections or damage to the cornea


5.Retinal detachment
Retinal detachment occurs with ageing and myopia (nearsightedness) may cause the retina to be pulled and  detached.

6.Trachoma and other infections of the eye often cause loss of vision

7.Accidents (such as chemical burns,fireworks or sports injuries) affects the cornea of the eye


8.Vitamin A deficiency
Vitamin A deficiency leads to decreased production of a photosensitive pigment in the rods of the eye resulting in night blindness .


Three-quarters of all blindness can be prevented or treated.

Blindness is a lack of vision.
It may also refer to a loss of vision that cannot be corrected with glasses or contact lenses.

1.Partial blindness means that there is  very limited visual ability


2.Complete blindness means a total loss of visual or light perception .

3.People with a vision worse than 20/200 are usually legally blind.

Treatment of blindness:
1.Blindness due to some causes such as infection, Vitamin A deficiency or glaucoma can be prevented through early detection and appropriate treatment.

2.Although visual loss cannot be completely restored,  medical and surgical treatment can prevent the loss from further progress and  complete blindness.

3.Because many serious forms of visual loss are painless, any forms of vision loss will need to be detected early and treated to prevent blindness.

Prevention of blindness
1.Vitamin A deficiency cna be treated with Vitamin A to prevent scarring of the eye and the ensuing blindness

2.Diabetes must be well controlled and regular eye examinations are necessary to prevent retinopathy


3.Majority of eye injuries can be prevented by using safe physical activities and proper eye protection.


4.Ensure good lighting and install handrails along stairs to prevent falling especially among the elderly.

5.Sharp corners and edges of furniture may be padded or cushioned.

6.Protective eye glasses are used to prevent insecticides and corrosive liquids from entering the eyes


7.Children should avoid toys with sharp points, shafts, spikes, rods and sharp edges to prevent eye injuries.

A Family Doctor's Tale - GIANT CELL ARTERITIS

DOC I HAVE GIANT CELL ARTERITIS

Giant Cell Arteritis is an inflammatory syndrome of cranial arteries especially the temporal artery.

It may be associated with blindness and may be part of the polymyalgia rheumatica syndrome.

It is rare under the age of 50 years.

Women are more affected than men.

There are some signs that Giant cell cell arteritis may be inherited because the illness have found to run in families.

The causes of Giant Cell Arteritis are:
The cause is unknown although it may be postulated that an immune response may have caused the inflammation.

It has been associated with severe infection and high doses of antibiotics.


There is inflammation of all layers of medium sized arteries within the carotid distribution from the neck, head, arms and even other arteries in the rest of the body.


The symptoms and signs of Giant Cell Arteritis are:
1.pain and tenderness of the scalp arteries with palpable thickening

2.headache and systemic upset such as weight loss

3.visual disturbance with loss of visual fields and blindness in severe cases

4.loss of appetite

5.Fever and sweating

6.weakness and fatigue

7.associated depression

8.claudication pain of jaw muscles while talking or eating

Other symptoms may be:

1.bleeding gums

2.mouth ulcers

3.hearing loss

4.joint pains of jaws, face and body

The Diagnosis of Giant Cell Arteritis is made by:
1.classical symptoms of headache and tenderness of the temporal arteries of the scalp


2.high ESR rate


3.biopsy of temporal artery under local anesthetic is diagnostic with multinucleared giant cells seen with fibrous proliferation of intima and fragmentation of elastic tissue

4.MRI of the brain

5.Ultrasound of the temporal arteries

The Complications of Giant Cell Arteritis are:

1.Development of aneurysm of blood vessels in the brain

2.Sudden transient ischemic attacks or stroke

3.sudden blindness of eyes or weakness of the eyelids

The Treatment of Giant Cell Arteritis is by using:
1.high dose corticosteroids (60mg prednisolone by mouth daily).

2.Dosage of corticosteroids can be reduced 2-3 weeks after symptoms disappear

3.maintenance dose of corticosteroids should be continues for six to eight months

Because of the prolonged use of corticosteroids, the bones may become porous and fragile:

1.additional calcium and collagen producing drugs are needed to strengthen the bones

2.walking and weight bearing exercises are needed

3.avoid smoking and alcohol

The Prognosis of Giant Cell Arteritis is:
Prognosis is good with prompt onset of corticosteroids treatment before loss of vision however treatment may be needed to continue for 1-2 years. Even then recurrence may occur.


Any loss of vision is irreversible once it occurred

A Family Doctor's Tale - DIABETES INSIPUS

DOC I HAVE DIABETES INSIPUS


Diabetes Insipidus is an endocrine disease resulting from the loss of antidiuretic hormone (ADH) also known as vasopressin stored in the pituitary gland in the brain.

It is characterized by the copious flow of dilute urine (hence the term diabetes) and excessive thirst .

The Causes of Diabetes Insipidus are:
The cause of diabetes insipidus is unknown in 45 per cent of cases.

A.When it is caused by the lack of ADH, it is called Central Diabetes Insipus.

This usually results from any condition damaging the the neuro-hypophyseal (pituitary gland) system of the brain

It can occur at any age and affects either sex.

It is unusual in infants but can commence in early childhood.

Possible causes of central diabetes insipus are:
1.head injuries or birth injuries


2.neoplasm of the pititary gland


3.eosinophilic granuloma


4.primary or secondary cancer (particlarly breast cancer)


5.sarcoidosis

6.familial diabetes insipus

B.When it is caused by a failure of the kidneys to respond to the ADH hormone, the condition is known as Nephrogenic Diabetes Insipus

There is a defect in the parts of the kidneys that help to reabsorb water back into the bloodstream.

It may occur as a sex-linked inherited disorder where male children receive the abnormal gene  from their mothers.

Nephrogenic diabetes insipus can also be caused by:

1.drugs such as lithium or amphotericin B

2.hypercalcemia or high blood calcium

 3. Kidney problems such as polycystic kidney disease


The symptoms of Diabetes Insipidus are:
Symptoms:
1.polyuria or frequent passing of urine
a.urine output of 5-10 liters per 24 hours
b.specific gravity of urine 1.001 to 1.005

2.polydipsia or excessive thirst (with craving for cold water)

3.no other evidence of ill health

Diagnosis of Diabetes Insipidus is often based on
1. medical symptoms of polyuria and polydipsia


2.Urinary volume and specific gravity

3.Infusion of vasopressin

4.MRI of brain

The complications of Diabetes Insipidus are:

1. dehydration - fever, tachycardia or fast heart beats, sunken eyes, dry skin or mucosa, low blood pressure


2.electrolyte imbalance - which can affect the heart rhythm, fatigue, muscle aches and irritability of the nervous system


3.death from primary or secondary lesion in the brain

The treatment of Diabetes Insipidus is:

The underlying cause must first be treated.

In the case of Central Diabetes Insipus:

1.vasopressin can be given intravenously  or intranasally or as oral medication with very good effect


In the case of Nephrogenic Diabetes Insipus (hereditary or lithium induced)

1. stopping the use of lithium may restore kidney function

2.thiazide diuretics may lower urine output


3.anti-inflammatory medications such as indomethocin given orally may help

The prognosis of Diabetes Insipidus is:
generally good with replacement therapy and if the underlying cause can be treated

A Family Doctor's Tale - MARFAN'S SYNDROME

DOC MY CHILD HAVE MARFAN'S SYNDROME


Marfan's Syndrome is an inherited disorder of the connective tissue as a result of a defective  gene called fibrillin-1.

This gene causes defects involving the the collagen and glyccosaminoglycans tissue.

It is characterized by generally weak connective tissue which includes

1.muscles, ligaments and bones.

2.lung tissue

3.the heart and aorta

4.the eyes

5. the skin

6.the meninges

The Causes of Marfan's Syndrome are:
It is an inherited disease caused by an autosomal dominant gene.

Inheritance is passed to 50 per cent of offspring if one parent is affected and 100 per cent of offspring if both parents are affected.

Marfan Syndrome can also occur from mutation of the genes in 30 per cent of cases.

The symptoms of Marfan's Syndrome are:
Symptoms:
1.Long slender extremities with arm span exceeding height and long tapered fingers (also called spider fingers)


2.Skeletal deformities include:
a.kyphoscoliosis


b.pectus excavatum

c.pigeon chest

d.long narrow face


e.high arched palate


f.pronathism

3.Lax ligaments resulting in:
a.hyperflexiblity of joints


b.easily strained ligaments and joints


c.flat feet

4.Eye problems:
a.dislocation of lens due to lax ligaments


b.myopia

5.Heart problems:
a.dilatation of aorta and aortic aneurysm


b.dilatation of pulmonary artery

6.Learning disabilities

Diagnosis of Marfan's Syndrome is often based on
1. medical examination and  appearance

2. measurement of metacarpal index from X-rays
Ratio of length to midpoint width is greater than 8.5

3.Urinary hydroxyproline is excessive indicating increased collagen turnover

4. Genetic analysis

5.ECG and echocardiogram

6.Eye examination and tests

The complications of Marfan's Syndrome are:

1. dissecting aortic aneurym may cause death

2.collapsed lungs

3.retinal detachment

4.heart valve problems

Marfan Syndrome patients generally have a shorter life span because of skeletal deformities and heart problems

The treatment of Marfan's Syndrome:
1.Genetic counseling

2.Prevention of joint strains especially spinal joints

3.Beta blockers can reduce aortic blood flow and prevent dilatation of aorta

4.Avoid competitive sports or strenuous physical activities

5.Antibiotic should be given to prevent endocarditis before any dental treatment

6.Pregnancy should be monitored carefully especially in the third trimester because of the strain on the heart

The prognosis of Marfan's Syndrome:
1.Shorter life span because of heart and skeletal problems

2. Good care and surgery treatment of the heart and eyes may extend the lifespan further.

Prevention of Marfan's Syndrome:


Genetic counseling and testing for Marfan's Syndrome

A Family Doctor's Tale - TURNER'S SYNDROME

DOC MY CHILD HAS TURNER'S SYNDROME

Turner's Syndrome is an inherited disorder of the sex chromosone in which one of the X chromosone is missing(XO)

It occurs in females and is associated with amenorrhea and infertility.

The Causes of Turner's Syndrome:
It is an inherited disease caused by a missing X sex chromosone(XO) during cell division.

It occurs in 1 :2000 females births.

Normal females have two of the X sex chromosomes (XX)

Variations include mosaicism(XX/XO)

The ovary formation is affected result in streak ovaries and low estrogen production.

The symptoms of Turner's Syndrome are:

In infants there may signs of :

1.wide and webbed neck

2.swelling of feet and hands


Symptoms in older females:
1.short stature females

2.distinct facial features with small jaws, ptosis, low set ears,  short neck

3.broad shield like chest with small nipples

4.amenorrhea

5.infertility

6.sparse pubic hairs

7.Vaginal dryness


8.short fourth metacarpals

9.wide carrying angle of arm

10.autoimmune thyroid disease

11.abnormal urograms -horseshoe kidneys

12.heart problems like coarctation of aorta and bicuspid aortic valves

The diagnosis of Turner's Syndrome:
Diagnosis of Turner's Syndrome is often based on
1. medical examination and appearance

2. buccal smear for cells to test for chromosones

3.karyotyping

4.blood test for estrogen (low), follicle stimulating hormone(raised), luteinizing hormones (raised or normal)

5.Thyroid level may be low
TSH high

6.X-rays for cardiac and urinary abnormalities

7.ECG

8.MRI of the chest

9.Ultrasound of the kidneys

10.Pelvic examination

The complications of Turner's Syndrome are:

1. infertility

2.  Arthritis

3.   Cataracts

4.    Diabetes

5.   Hashimoto's thyroiditis

6.    Heart defects and coarctation of aorta

7.   High blood pressure

8.    Kidney problems

9.    Middle ear infections

10.    Obesity

The treatment of Turner's Syndrome:

1.female hormone treatment from the age of puberty

This may help to  trigger the growth of breasts, pubic hair, and other sexual characteristics of a female giving her confidence.

Thyroxine may be given for low thyroid hormones.

2.therapeutic support from:

a.physical

b.psychological

c.speech

d.occupational

e.behavioral therapists

3.Educational treatments:

a.Special services by special needs teachers to build up confidence in the child

b.Making tasks simpler by breaking up big tasks into smaller simpler tasks

Women with Turner syndrome  may consider using a donor egg if they wish to be pregnant.

The prognosis of Turner's Syndrome:
1.Short stature may not be changed


2.infertility even with treatment

3.Can lead normal life with treatment

Prevention of Turner's Syndrome:


Genetic counseling and testing for Turner's Syndrome

A Simple Guide to Amblyopia

A Simple Guide to Amblyopia
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What is Amblyopia?
---------------------

Amblyopia, commonly known as ‘lazy eye’, is reduced visual acuity in one eye that appears normal on examination.
It usually develop during early childhood.
If left untreated, amblyopia will usually continue into adulthood.

What are the Causes of Amblyopia?
----------------------------------

1. Squint

Squint or misalignment of the eyes occurs when one eye is looking straight and the other is looking in another direction.
The vision from the deviating eye is suppressed.
The part of the brain that receives the vision from the deviating eye does not develop normally.
Therefore there is a severe reduction of vision in the deviating eye.

2. Different refractive powers of the eyes

A significant difference in the degree of short-sightedness, long-sightedness or astigmatism between the two eyes may result in failure to form clear image in the eye with the greater refractive error resulting in Amblyopia.

3. Blurred vision in one eye

This occurs with:
1.An opaque cornea
2.Cataract
3.Drooping upper eyelids due to weakness of the muscles that lift the eyelids
4.Eye trauma or eye surgery
5.Toxic causes such as arsenic, lead, smoking,vitamin B1 and B12 deficiency
6.Neurological causes are chiasmal lesions in the brain
7.Amaurosis: complete loss of vision in one eye occurs in uremia, nephritis and eclampsia
8.Psychological causes like hysteria

Symptoms may include:
1.decreased vision in one eye
2.squint
3.drooping eyelid

Diagnosis and Early detection

1.Amblyopia in young children can only be discovered if vision in each eye is tested separately.

Treatment is usually more successful if amblyopia is detected early especially before the age of four.

2.regular eye and vision tests should be done by the family doctor, paediatrician or ophthalmologist.

Treatment

1.underlying conditions causing the ‘lazy eye’ such as refractive errors, drooping eye lid or squint should be treated.

2.The main purpose of treatment is to cause the part of the brain that reads images from the ‘lazy eye’ to work more harder to read images than the better eye.
The earlier the treatment is started, the better is the results.
Once the child is over 8 years of age, he/she may not respond well to treatment, resulting in permanently impaired vision.

Treatment can be given in two ways:
1.Eye Patch
 An opaque, adhesive patch is worn over the better eye for weeks to months. This treatment forces the child to use the weaker eye and stimulate the brain to read the images in the weaker eye.
The main problem with the eye patch is that no child likes to have his eye patched. Parents need to ensure that the eye patch is worn properly as advised by the eye doctor.

2.Atropine eye drops
In some cases where the child cannot tolerate eye patches, a drop of atropine is instilled in the stronger eye once a day to blur the vision temporarily in order that the child will prefer to use the ‘lazy eye’.

Prognosis:

Amblyopia if left untreated can lead to loss of vision in the ‘lazy eye’.

Even with treatment 1% - 2% of the population will remain amblyopic. This occurs especially if:
1.the amblyopic stimuli is excessive
2.detection of amblyopia is too late;
3.the child responds poorly to treatment.

Even with one good eye the child can go about his life provided he/she takes good care of the good eye and protect it from harm.

A Family Doctor's Tale - KLINEFELTER'S SYNDROME

DOC MY CHILD HAVE KLINEFELTER'S SYNDROME


Klinefelter's Syndrome is an inherited disorder of the sex chromosone in which an extra X chromosone is present(XXY).

It is named after Dr. Henry Klinefelter.

It occurs in males 1:500 and is associated with hypogonads and infertility.

The Cause of Klinefelter's Syndrome are:



It is an inherited disease caused by an extra X sex chromosone(XXY).

Variations include XXXY and mosaicism(XY/XXY)

The testis formation is affected result in hypogonadism and low testosterone production.

The symptoms of Klinefelter's Syndrome are:
Symptoms:
A.Physical Development:


As babies, they have weak muscles and reduced strength resulting in later development in walking and crawling.

After 4 years of age, they are usually:

1.taller with long legs

2.less muscular body

3.testes are small,insensitive and firmer than usual

4.Penis is small

5.gynecomastia in 50 per cent

6.less facial and body hair

7.Sexual desire and ability to have erections impaired

8.infertility

B.Language Development:

About 25- 75 per cent of the boys has some language problem:

1.difficulty in speech

2.difficulty in expression

3.difficulty in reading

4.difficulty in comprehension

C.Social Development:

1.quiet and unassuming

2.helpful

3.obedient

4.less assertive

5.less self confidence

In spite of these, they have very often normal social relationships

Diagnosis of Klinefelter's Syndrome is often based on
1. medical examination and appearance of the boy


2. buccal smear for cells to test for chromosones

3.karyotyping

4.blood test for testosterone (low), follicle stimulating hormone(raised), luteinizing hormones (raised or normal)

The complications of Klinefelter's Syndrome are:

1. infertility

2. erectile dysfunction

3.autoimmune disorders,

4.breast cancer,

5.vein diseases,

6.osteoporosis

The treatment of Klinefelter's Syndrome is:

There is no way the chromosomes can be changed however there are treatments to relieve the symptoms and improve the lives of these males.

A.Medical treatments:
1.Male hormone replacement treatment can increase the testosterone hormones to normal level for the males starting from puberty.

There may be improvement in muscle mass and more facial and body hairs.


2.mastectomy may be needed for obvious gynecomastia

3.therapeutic support from:

a.physical

b.psychological

c.speech

d.occupational

e.behavioral therapists

C.Educational treatments:

1.Special services by special needs teachers to build up confidence in the child

2.Making tasks simpler by breaking up big tasks into smaller simpler tasks


The prognosis of Klinefelter's Syndrome is:
1.infertility may occur even with male hormone treatment.

2.However there may be improved self confidence and more muscular body.

Prevention of Klinefelter's Syndrome :

Genetic counseling and testing for Klinefelter's Syndrome

A Family Doctor's Tale - VINCENT'S ANGINA

DOC I HAVE VINCENT'S ANGINA

Vincent's Angina is the non contagious infection affecting the interdental papillae named after Dr. Henri Vincent .

It extends to the gums causing necrotizing ulcerative gingivitis .

It is also known as Trench Mouth because of the smell from the mouth.

The cause of Vincent's Angina:
Vincent's Angina is caused by bacteria which are anaerobes such as  fusiform bacteria as well as spirochete such as treponema.

Vincent's Angina can occur in the mouth as a result of:
1.poor oral hygiene

2.nutritional deficiency

3.blood dyscrasias

4.debilitating diseases

5.heavy smoking

The Symptoms of Vincent's Angina are:
1.malaise, loss of appetite and weight loss

2.Painful bleeding gums

3.unpleasant breath or halitosis


4.increased saliva production

5.ulcers on the mucosa of mouth have
a.punched out appearance,
b.covered by greyish membrane
c.bleed easily  
d.affects neighboring gums

6.local lymph node enlargement

Diagnosis of Vincent's Angina:


Vincent's Angina is diagnosed by:

1.Dental examination .

2.buccal smear for culture and sensitivity of micro-organisms to antibiotics

Complications of Vincent's Angina:

If untreated, Vincent's Angina can lead to the following complications:

1.Destruction of the periodontium

2.necrotizing stomatitis

3.destruction of cheek tissues, lip mucosa and underlying jaw bone

Treatment of Vincent's Angina:
1.good oral hygiene
a.Brushing teeth twice a day with fluoride toothpaste.
b.Cleaning between teeth daily with floss.

2.dental debridement (cleaning and removal of debris)


3.mouth washes especially after eating food


4.Antibiotics -penicillin or erythromycin may be necessary to clear infection

5.avoid smoking

6.treatment of underlying diseases

Prognosis of Vincent's Angina:
good with proper dental treatment

Prevention of Vincent's Angina:

1.proper nutrition

2.good oral hygiene

3.avoid smoking

A Family Doctor's Tale - TOOTH DISCOLORATION

DOC I HAVE TOOTH DISCOLORATION

Teeth discoloration is seen as teeth that have stained yellow or darker and presents as a blemish on the facial appearance of a person.

It can affect self esteem.

The causes of Tooth Discoloration:
Discoloration can be caused by:
A.External factors stains the outer layer of the tooth and include
1.smoking,

2.beverages such as coffee, wine, cola

3.foods such as apples and potatoes.

B.Internal factors affects the inner structure of the tooth (the dentin) causing it to darken or become yellowish through:
1.excessive exposure to fluoride during early childhood

2.tetracycline antibiotics use during the second half of pregnancy and children 8 years old or younger.

3.tooth injury in a child with damage to the developing permanent tooth.

4.Systemic illness during tooth formation such as hemolytic disease of the newborn

5.Ageing discoloration - the dentin turns yellow naturally with ageing making the teeth look discolored.

6.infection(dental caries) result in greyish discoloration.

7.Dentinogenesis imperfecta - rare condition in which children are born with gray, amber or purple discolorations in the teeth

8.Amelogenesis imperfecta - genetic condition in which enamel formed during tooth development is abnormal and causes discoloration of teeth.

Symptoms include:

1.stains on the enamel such as yellow or brown spots.

2.yellow stains on the teeth from dentin showing through the worn away enamel.

Diagnosis

A dental examination can diagnose tooth discoloration.

Treatment

Treatment depends on the cause of the discoloration and may include.
1.Tooth hygiene -proper tooth brushing and flossing techniques

2.Avoid foods and beverages that can cause stains

3.Microabrasion of the stains on the outer surface of teeth

4.Bonding -tooth can be covered with a color-matched composite bonding material

5.Veneers are color-matched thin ceramic shells that cover the outer surfaces of the teeth.

6.applying a bleaching agent to the enamel of the teeth.
a.Vital bleaching over-the-counter whitening agents or in-office whitening procedures
b.Non-vital bleaching

7..Intrinsic stains that are caused by damage to a nerve or blood vessel in a tooth sometimes can be prevented such as removing the inner part of the tooth (the pulp) followed by non-vital bleaching.

Prevention

With some healthy lifestyle changes, teeth discoloration can be prevented.
1.Heavy coffee drinkers can reduce intake


2.smokers can consider quitting .


3.dental hygiene through regular brushing, flossing or


4.have teeth cleaned by a dentist every 6-12 months.

Prognosis

The prognosis is very good for teeth stains caused by external factors such as smoking, beverages.
Stains caused by internal factors may be harder to remove.

A Family Doctor's Tale - COLIC

DOC MY BABY HAS COLIC

Colic is defined as constant inconsolable crying by a baby   of about 2 weeks to 3 month for more than three hours a day, three days a week.

The baby draws up his/her legs as in extreme pain and becomes very red in the face.

This usually starts a few weeks after birth and often improves by age 3 months and ends by age 9 months in 90 percent of cases.

What are the causes of Colic?
-----------------------------------

1.Failure to bring up wind that enters the stomach during feeding or crying with the result gas passes into the small intestine and cause pain and excessive contractions.

2.Hunger may be a cause especially with breatfed babies as the milk may not be sufficient to satisfy the baby's hunger.

3.Allergies or lactose tolerance especially with cow's milk may also be a factor

What are Symptoms of Colic?
----------------------------

Typical symptoms of colic include:

1.Regular crying episodes. A baby who has colic often cries about the same time every day, usually in the late afternoon or evening.

2.Intense crying. Colic crying is often intense. It will be extremely difficult to pacify and comfort the baby.

3.Posture changes include curled up legs with clenched fists and tensed abdominal muscles during colic episodes.

Diagnosis:

A physical examination is performed to identify any possible causes for your baby's distress such as an intestinal obstruction.

Diagnostic tests are usually not required.

Treatment

Colic improves on its own, often by age 3 months.

Prescription medications such as simethicone have not shown to be very useful for colic.

It has been suggested that treatment with probiotics which help maintain the natural balance of "good" bacteria in the digestive tract can soothe colic. More research is awaited to determine the beneficial effects of probiotics on colic.

Tips to soothe your baby during colic include:
1.Feed your baby with frequent small feeds and burp the baby.

2.Offer a pacifier to the baby as sucking is a soothing activity for babies and calms the baby down.

3.Hold your baby close to you as cuddling may help some babies to quieten and calm down.

4.Keep your baby in motion by gently rocking the baby in your arms or in an infant swing. Alternatively you may lay your baby tummy down on your knees and then sway your knees slowly or take a walk with your baby.

5.Sing to your baby to soothe your baby.

Support for the mother

These suggestions may help the mother to cope with the stress.

1.Take a break from care giving by requesting help from your spouse or family.

2.It is all right to express your feelings. It is normal for parents to feel helpless, depressed or angry. Confide in your spouse, partner or friend.

3.Remember that it is temporary and improves as the baby grows older. Colic episodes often improve by age 3 months.