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.
Saturday, August 27, 2011
Thursday, August 25, 2011
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
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
Tuesday, August 23, 2011
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.
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.
Sunday, August 21, 2011
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.
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.
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