POSITIONAL VERTIGO (BENIGN PAROXYSMAL POSITIONAL VERTIGO)

Benign paroxysmal positional vertigo is a sensation of spinning related to head movement and position. The spinning sensation or vertigo only lasts for brief periods and is not associated with ear fullness or tinnitus. The vertigo experienced can be quite intense and patient may have nausea.
It may occur repeatedly with certain head positions such as tilting the head backwards and forwards, looking to the sides and turning to right or left on the bed. In between episodes, patients are generally well.
BPPV is one of the most common cause of vertigo and it commonly affects those above 50 years of age. Occasionally it can be related to head trauma especially in young adults.

Understanding the disease process of BPPV
BPPV is a condition affecting the inner ear. Each inner ear consists of organs responsible for hearing (cochlea) and balance (utricle, saccule & 3 semicircular canals). The balance organs especially the semicircular canals are responsible to detect angular head movements.
When the head moves, the fluid within the semicircular canal would move in the opposite direction initially due to inertia. This fluid movement is detected by the cupula which contains hair like sensors. These sensors would then produce electrical signals to the brain.
In BPPV there is dislodgement of crystals from the utricle or saccule which then collects within the semicircular canals. Therefore during head movements, these crystals would cause the semicircular canals to send false signals to the brain. And this brain signal misinterpretation would cause the patient to feel the spinning sensation of vertigo.

Diagnosis of BPPV
The diagnosis of BPPV is a clinical diagnosis which the doctor makes from the patient's history and examination. A complete ENT examination should be performed to assess for other causes of vertigo. In BPPV, the ear examination is generally normal.
Sometimes a hearing assessment is also required. If the symptoms are non specific, imaging studies such as MRI (magnetic resonance imaging) may be performed to assess for any intracranial cause.
The doctor would also perform a Dix Hallpike manouvre to stimulate a vertigo episode. This test would be positive in cases of BPPV.

Treatment of BPPV
A canalith repositioning manouvre for BPPV can be performed by the doctor in the clinic. The side of the ear affected will be determined during the Dix Hallpike manouvre. And then the canalith repositioning manouvre will be performed according to the affected ear; right or left.
The canalith repositioning manouvre, also called the Epley's manouvre, involves a series of head movements aimed at bringing the crystals out from the semicircular canals and back into the utricle. This test may need to be repeated several times. It is usually performed twice and may be repeated during the next clinic review if still symptomatic.
In very rare situations that the canalith repositioning manouvre would fail and surgery is recommended. The surgical procedure performed involves plugging the semicircular canal that causes the vertigo.

Home advice after repositioning manouvre
There is no substantial clinical evidence that has shown that the following restrictions are very useful after the clinic canalith repositioning procedure. However doctors often advise patients to avoid lying flat or on the affected ear for 2-3 days after the procedure. Patients are also advised to lay their head on 2-3 pillows on the first night following the procedure.

CHOLESTEATOMA

Cholesteatoma adalah penyakit yang disebabkan oleh gumpalan sel-sel kulit mati dan inflammasi tisu yang mampu menghancurkan struktur-struktur tulang disekelilingnya. Sifat sebegini amat membahayakan sekiranya  ia tidak dirawat dengan segera.

Simptom-simptom yang dialami oleh pesakit adalah jangkitan telinga yang sukar dirawat dengan antibiotik, jangkitan telinga yang berulang-ulang, bau cecair yang amat busuk dan kurang pendengaran. Sekiranya cholesteatoma telah merebak pesakit juga boleh mengalami pening, sakit kepala, bengkak pada bahagian belakang telinga dan kelemahan otot muka.

Pakar ENT akan merawat jangkitan kuman yang berkaitan dengan cholesteatoma dan mengeluarkan cholesteatoma atau gumpalan sel-sel kulit mati tersebut di klinik. Sekiranya ia tidak dapat dirawat kerana kes cholesteatoma yang lebih serius, pakar ENT akan mengesyorkan pembedahan dilakukan untuk membersihkan dan mengeluarkan cholesteatoma tersebut. Sejurusnya mengelakkan daripada komplikasi cholesteatoma seperti lemah saraf muka (facial nerve palsy), jangkitan kuman pada otak (meningitis), nanah pada otak (brain abscess) dan pekak pendengaran. Komplikasi-komplikasi tersebut adalah amat serius.

Imbasan CT telinga perlu dibuat agar pakar ENT boleh menganalisis sejauh mana cholesteatoma itu sudah merebak ke dalam bahagian-bahagian telinga. Ujian pendengaran juga dilakukan sebelum pembedahan untuk mengetahui tahap pendengarn pesakit.

Pembedahan yang dilakukan bergantung kepada sejauh mana cholesteatoma itu telah merebak. Secara amnya, pembedahan yang dilakukan adalah pembedahan mastoid. Di dalam kes terpencil, pembedahan attikotomi boleh dilakukan bagi kes cholesteatoma yang hanya melibatkan bahagian atas gegendang telinga (attic).

PEMBEDAHAN MASTOID

Mastoid adalah bahagian tulang tengkorak yang berkaitan dengan telinga. Ia merupakan sambungan kepada bahagian telinga tengah dan tulang mastoid dipenuhi oleh rongga-rongga udara. Sekiranya terdapat jangkitan kuman pada telinga tengah (otitis media), jangkitan tersebut dapat merebak ke tulang mastoid (mastoiditis). Ini menyebabkan bengkak pada bahagian belakang cuping telinga dan pesakit merasa amat sakit dan demam.

Tulang mastoid terletak di bahagian belakang cuping telinga (anak panah). Ia mempunyai sambungan kepada telinga tengah.. Wikipedia image

Gambarajah di atas menunjukkan sambungan (melalui tympanic antrum) antara telinga tengah dan tulang mastoid. Ia juga menunjukkan bahawa tulah mastoid dipenuhi oleh rongga-rongga udara (mastoid cells). Wikipedia image

Pembedahan mastoid pula merupakan pembedahan yang dilakukan oleh pakar ENT sekiranya ada jangkitan kronik pada tulang mastoid (chronic mastoiditis), cholesteatoma, ketumbuhan (tumor) pada telinga tengah, implan koklear dan lain pembedahan telinga dalam/tengah.

Sebelum pembedahan mastoid, pesakit perlu membuat ujian pendengaran untuk mengetahui tahap pendengaran. Imbasan CT juga perlu agar pakar ENT dapat mengetahui sejauh mana jangkitan atau penyakit tersebut telah merebak.

Pembedahan mastoid dilakukan melalui torehan pada kulit di belakang cuping telinga (postaural). Tetapi kadangkala ia dilakukan melalui torehan di bahagian atas lubang telinga (endaural). Ia melibatkan penggunaan mikroskop dan drill untuk membersihkan tulang mastoid yang tidak sihat atau mengalami jangkitan.

Kenapa perlunya pembedahan mastoid?
Pembedahan mastoid perlu dilakukan sekiranya jangkitan kuman pada tulang mastoid tidak dapat disembuh dengan rawatan antibiotik dan cucian telinga yang dilakukan oleh pakar ENT di klinik. Ia juga perlu sekiranya pesakit mempunyai penyakit cholesteatoma atau ketumbuhan di dalam telinga. Ini adalah kerana sekiranya dibiarkan berlarutan jangkitan atau penyakit tersebut akan merebak ke telinga dalam menyebabkan pekak pendengaran, mengganggu saraf muka dan juga boleh berjangkit ke bahagian otak.

Saranan selepas pembedahan mastoid
Pesakit mungkin berasa pening selepas pembedahan dan disyorkan agar berehat di rumah selama 5-7 hari. Sekiranya pesakit mempunyai pekerjaan berat yang memerlukan banyak pergerakan dan mengangkat benda berat, pesakit mungkin perlu bercuti selama 2 minggu.
Kesakitan pada bahagian pembedahan selalunya dapat dikawal dengan ubat tahan sakit. Tetapi jika masih mengalami kesakitan yang teruk, mungkin ia tandanya jangkitan kuman telah berlaku.
Bahagian torehan akan dijahit dan jahitan ini perlu dibuka selepas 5-7 hari oleh doktor di klinik.
Bahagian telinga yang dibedah pula akan dibalut dengan 'mastoid bandage'. Ia kelihatan seperti serban kepala yang kecil dan ini perlu dipakai selama lebih kurang 24 jam.
Bahagian lubang telinga pula selalunya disumbat dengan kain antiseptik dan ini harus dibiarkan selama 2 minggu. Pesakit tidak boleh sama sekali menarik keluar sumbatan tersebut. Di bahagian luar sumbatan telinga tersebut pula ditutup oleh kapas (cotton ball). Kapas di luar ini perlu ditukar selalu oleh pesakit di rumah, sekurang-kurangnya setiap kali selepas mandi.
Pesakit harus mengambil langkah berhati-hati agar bahagian telinga yang dibedah dan 'dressing' tidak basah atau dimasuki air.

Perkara-perkara yang perlu dielakkan selepas pembedahan mastoid
Jaga kebersihan telinga yang dibedah dan jangan biarkan ia dimasuki air selama 6-8 minggu
Elak dari menghembus hidung dengan kuat. Sekiranya bersin, pastikan bersin dengan mulut terbuka
Elak daripada mengangkat benda berat dan aktiviti fizikal selama 3-4 minggu selepas pembedahan
Elak daripada menaiki kapal terbang selama 3-4 minggu selepas pembedahan
Pesakit disyorkan meminta nasihat pakar ENT sebelum memulakan pekerjaan dan sebarang aktiviti berat

Masalah-masalah yang dijangkakan selepas pembedahan mastoid
Dengan sumbatan di dalam lubang telinga,  pesakit boleh mengalami bunyi air atau buih di dalam telinga dan ini akan hilang apabila sumbatan tersebut dikeluarkan oleh pakar ENT pada masa 2 minggu selepas pembedahan.
Selepas itu tahap pendengaran pesakit bergantung kepada kerosakan yang dialami oleh telinga dalam disebabkan jangkitan kuman sebelumnya (mastoiditis atau cholesteatoma). Ujian pendengaran selalunya dilakukan 3 bulan selepas pembedahan.
Amat jarang sekali ada pesakit mengalami kelemahan otot muka. Ini kerana ada bahagian saraf muka (facial nerve) yang melalui bahagian telinga tengah boleh tercedera/terganggu semasa pembedahan. Dalam kebanyakan kes, kelemahan ini adalah sementara.
Pesakit juga mungkin mengalami deria rasa yang lain pada bahagian lidah dan ini juga bersifat sementara.

Bila pesakit harus mendapatkan rawatan doktor dengan segera selepas pembedahan mastoid
Demam tinggi
Cecair busuk/Nanah yang sentiasa mengalir dari dalam telinga
Sakit pada bahagian pembedahan yang teramat sangat
Bengkak ketara pada bahagian sekeliling telinga yang dibedah
Pening atau rasa kepala berpusing yang menyebabkan rasa loya dan muntah

NOTA:
Cholesteatoma adalah penyakit yang disebabkan oleh gumpalan sel-sel kulit mati dan inflammasi tisu yang mampu menghancurkan struktur-struktur tulang disekelilingnya. Sifat sebegini amat membahayakan sekiranya  ia tidak dirawat dengan segera.

GEGENDANG TELINGA BERLUBANG

Gegendang telinga merupakan selaput nipis yang memisahkan antara telinga luar dan telinga tengah. Ia amat penting bagi fungsi pendengaran yang normal. Ia juga penting untuk melindungi bahagian telinga tengah dengan struktur-strukturnya.

Gegendang telinga (tympanic membrane) memisahkan ruang telinga luar dan telinga tengah 

PUNCA GEGENDANG TELINGA BERLUBANG/PECAH

Gegendang telinga yang berlubang berpunca dari beberapa sebab seperti jangkitan telinga tengah (otitis media) dan trauma. Kebanyakan kes gegendang berlubang berpunca dari jangkitan telinga tengah. Jangkitan menyebabkan tekanan meningkat di dalam ruang telinga tengah dengan adanya cecair nanah. Tekanan tersebut menyebabkan gegendang telinga pecah dan cecair nanah akan mengalir keluar.

Trauma yang dimaksudkan termasuk dengan penggunaan putik kapas atau besi semasa mengorek telinga, tamparan pada bahagian telinga atau pipi, perubahan tekanan mendadak semasa aktiviti menyelam atau naik ke tempat tinggi, bunyi bising melampau seperti bunyi tembakan atau letupan mercun.

APA PESAKIT AKAN RASA?

Simptom gegendang telinga pecah adalah sakit yang teramat sangat dirasai dalam telinga atau pesakit berasa tidak selesa. Pesakit juga merasa seperti telinga sumbat dan pendengaran mungkin berkurangan. Kadangkala terdapat cecair atau darah mengalir keluar dari dalam telinga. Pesakit juga mungkin berasa pening disebabkan oleh gegendang pecah.

RAWATAN GEGENDANG TELINGA BERLUBANG/PECAH

Rawatan bagi gegendang telinga berlubang bergantung kepada puncanya. Sekiranya ia disebabkan jangkitan kuman, pesakit perlu mendapat rawatan antibiotik dan ubat titis telinga. Pakar ENT juga akan mencuci telinga tersebut dengan menggunakan alat sedut di klinik ENT. Setelah jangkitan kuman dirawati, iaitu telinga tengah sudah tidak mengeluarkan nanah, gegendang telinga berlubang dapat ditampal dengan kaedah pembedahan (myringoplasty). Ada kalanya gegendang telinga tersebut dapat pulih dan tutup dengan sendiri jika jangkitan dapat ditangani dengan segera seperti dalam kes otitis media akut (acute otitis media, AOM)

Kadangkala jangkitan telinga tengah sudah berlarutan dan melibatkan mastoid. Ini berlaku sekiranya jangkitan telinga tengah adalah kronik dan melebihi 12 minggu (otitis media kronik atau chronic otitis media, CSOM). Bila ini berlaku jangkitan kuman menjadi sukar untuk dirawat dengan kaedah antibiotik sahaja dan pesakit mungkin memerlukan pembedahan mastoid. Dengan pembedahan ini tulang mastoid yang dijangkiti kuman dapat dicuci dan dinyahkan jangkitan. Gegendang telinga yang berlubang itu ditampal sekali.

Sekiranya gegendang telinga pecah atau berlubang disebabkan oleh trauma, kebanyakan kes gegendang pecah itu dapat pulih dengan sendiri bergantung kepada saiz lubang pada gegendang telinga. Saiz lubang yang kecil kemungkinan besar dapat pulih secara semulajadi adalah tinggi, 80-90%. Tetapi penting bagi pesakit menjaga kebersihan telinga dan mengelak air masuk ke dalam telinga. Ini supaya jangkitan kuman tidak berlaku dan gegendang tersebut dapat pulih dengan eloknya.

SEPTOPLASTY AND TURBINATE SURGERY

Septoplasty is a surgical procedure to correct a deviated or crooked nasal septum. Patients often complain of nasal block and congestion, which can disturb their sleep. They may also have symptoms of rhinitis such as runny nose, sneezing and postnasal drip. Some patients have a deviated nasal septum as a result of trauma or blow to the nose. 

Turbinate surgery refers to a procedure performed to reduce the size of the enlarged nasal turbinates, which often contribute to the nasal block and congestion. There are many methods how the ENT surgeon reduce the size of the turbinates. Regardless of the surgical method used, the turbinates may slowly increase back in size if patients do not take care of their allergies.

The ENT surgeon may put the patient on a trial of medication which include nasal sprays and antihistamine to control their allergies. If the nasal block is still not relieved or minimally relieved with medication then septoplasty and turbinate surgery should be considered. However in severely deviated nasal septum especially post trauma, medication often bring little improvement. Septoplasty can also be indicated for recurrent epistaxis.

Complications of septoplasty and turbinate surgery are uncommon however patients should be aware of the possible complications including bleeding, infection, nasal crusting, numbness and septal perforation.

General care after septoplasty and turbinate surgery

The nose may be packed after surgery and patients are warned to breathe through their mouth upon waking up from surgery. The nasal pack is usually removed the following day after surgery. Following nasal pack removal, patients should expect bloodstained nasal secretions for a few days. Patients should not blow their nose for about 10-14 days. When sneezing, patients should keep their mouth open to reduce built-up pressure in the nose.

Patients may also experience swelling and pain around the nose including numbness of the upper teeth; which usually resolve in a few weeks. 

Patients are advised to take light soft cool diet when awake after surgery. Hot food and drinks are to be avoided for a few days after surgery.

Patients should rest with their head elevated on 2-3 pillows to reduce swelling around the nose area. Patient should also avoid straining and lifting heavy objects to reduce risk of bleeding.

Medications that can thin the blood, such as Aspirin and Warfarin, should be avoided until advised by the ENT surgeon.

The ENT surgeon would often prescribe nasal douching where patients will flush the nasal cavities using saline irrigation for a few weeks. This will ensure good healing and prevent formation of dried crusts or blood clots. Patients will also be prescribed with a course antibiotic that should be completed.

Patients are also expected to take some time off until the doctor says it is safe to return back to work. Patient should refrain from smoking or exposure to smoky areas as this can impair healing and cause further irritation to the nose.

When should you see your ENT surgeon urgently?

• Continuous bleeding despite nasal compression and ice
• Increasing swelling over the nose and eyes 
• Persistent high grade fever >38 Celcius
• Severe pain or headache not relieved by the pain medication given.

Q&A on RAPI magazine Sept 2012

HOARSENESS

Hoarseness is a symptom when there is change in the voice. The voice may become raspy, strained, unable to reach certain pitch or breathy. Hoarseness happens when there is an abnormality of the vocal cords. The vocal cords act like string instruments that come together and vibrates as we speak. During breathing the vocal cords come apart to allow air to enter the lungs.

CAUSES OF HOARSENESS

Laryngitis

The most common cause of hoarseness is laryngitis; which is inflammation of the vocal cords. It is usually temporary and related to the common cold or upper respiratory tract infection. However voice abuse during bouts of laryngitis can further strain and injure the vocal cords. If the hoarseness lasts for more than 2 weeks the patient should seek the advice of an ENT surgeon who would examine the larynx to confirm the cause. Persistent hoarseness can be an early sign of cancer.

Voice abuse

Excessive straining of the voice can also cause damage to the vocal cords. Habits of screaming, excessive use or shouting in noisy environment can also lead to hoarseness. Public speaking for prolonged periods without use of amplification is also voice abuse.

If the hoarseness happens suddenly after shouting then there is a possibility that the patient has developed vocal cord hemorrhage. This occurs when the sudden increased pressure on shouting causes a blood vessel to rupture at the surface of the vocal cord. An assessment by an ENT surgeon can determine this and treatment is strict voice rest.

Vocal cord lesions

Prolonged hoarseness of more than 2 week should be assessed by an ENT surgeon as it can be an early sign of cancer.

There are also other benign (non-cancerous) vocal cord lesions that can present with persistent hoarseness such as vocal cord polyp and nodules.

Laryngopharyngeal reflux

This is condition when there is stomach acid reflux which goes all the way up till the larynx or vocal cords. The acidic juice will cause inflammation of the vocal cords and result in hoarseness.

Smoking

Both primary and secondary smoking can cause hoarseness. Smokers also have a high risk of developing cancer of the larynx. Therefore they should not delay consulting an ENT surgeon if they develop hoarseness.

Vocal cord paralysis or palsy

Any impairment of the vocal cords movement can result in hoarseness. The vocal cords come in a pair and move synchronously to produce voice, pitch and volume. If one or both the vocal cords are unable to move then the patients will experience change in voice. Depending on the position of the vocal cords patients amy also have difficulty breathing or choking episodes on drinking fluids. Vocal cord palsy/paralysis can occur due to neurological conditions, trauma, thyroid disease and other rare causes such as muscle tension dysphonia or spasmodic dysphonia.

Treatment of hoarseness

The treatment of hoarseness depends on the underlying cause. Usually doctors would advice voice rest, taking lots of fluids, avoid smoking and spicy food. Occasionally the help of a speech therapist would be sought. The therapist is able to teach patients on proper voice usage and how to avoid voice abuse especially for professional voice users such as singers, teachers, telephonists and public speakers.

Vocal cord lesions or vocal cord paralysis often need surgical intervention.

When should patients seek ENT advice?

Since the most common cause of hoarseness is laryngitis then the initial treatment is given by the family doctor or general practitioner when patients come in for their common cold. However there are certain signs and symptoms which should prompt early referral to the ENT surgeon:

1. Persistent hoarseness of more than 2 weeks especially in smokers

2. When there is no associated upper respiratory tract infection

3. Professional voice users

4. Presence of neck swelling

5. When patients experience difficulty swallowing

6. When patients experience difficulty breathing

7. When there is cough with blood stained sputum

Voice hygiene

This term refers to maintaining the health of the vocal cords which is mainly avoiding voice abuse. These measures can be practiced:

• Quit smoking
• Avoid secondhand smoke
• Drink plenty of fluids
• Avoid caffeinated drinks and alcohol which can dehydrate the body
• Avoid spicy and oily food
• Try not to use the voice for too long or too loudly
• Humidify the home
• Use of amplification such as microphones when speaking to a crowd

Useful links:

Guide for Voice hygiene by Marshfield Clinic

Panduan berpuasa untuk pesakit

Buku panduan berpuasa untuk pesakit oleh Jabatan Kemajuan Islam Malaysia cetakan 2009

BENGKAK LEHER (NECK LUMPS)

Gejala bengkak leher pasti akan membuat pesakit rasa gusar dan susah hati. Kebanyakan kes ia melibatkan bengkak kelenjar limfa yang berlaku apabila ada infeksi dan radang; dan ini bersifat sementara. Walaubagaimanapun ada beberapa gejala bengkak leher yang memerlukan rawatan selanjutnya dan pesakit harus peka dengan gejala-gejala lain yang merupakan tanda-tanda penyakit yang lebih serius.

Anatomi leher

Kedudukan kelenjar-kelenjar limfa di sekeling leher dan juga kelenjar air liur parotid di bahagian pipi dan kelenjar submandibular di bawah rahang.

Kelenjar limfa

Kelenjar limfa berperanan penting dalam sistem imunisasi badan. Cecair limfa mengalir dari organ dalaman manusia ke dalam system limfatik dan melalui kelenjar limfa. Sekiranya terdapat radang, infeksi, ketumbuhan atau kanser, kelenjar limfa boleh membengkak.

Selalunya radang dan infeksi merupakan penyebab utama bagi kelenjar limfa yang bengkak di bahagian leher. Contohnya seperti sakit kerongkong/tekak, tonsillitis, sakit gigi dan sebagainya. Dan kelenjar limfa yang bengkak ini akan surut apabila radang atau infeksi tersebut dirawat dengan antibiotik.

Kelenjar limfa leher yang terus membengkak melebihi tempoh 2 minggu dengan tanpa ada gejala lain berkaitan infeksi/radang sepatutnya diperiksa dengan lebih lanjut oleh doktor pakar ENT.

Sebab lain yang boleh menyebabkan kelenjar limfa leher yang bengkak adalah ketumbuhan/kanser pada bahagian dalam mulut, tekak dan hidung, tuberculosis, lymphoma (sejenis kanser sel darah) dan sebagainya.

Kelenjar air liur (Kelenjar submandibular dan parotid)

Kelenjar air liur juga boleh mengalami infeksi dan radang samada dari jangkitan bakteria atau sumbat saluran air liur disebabkan oleh batu karang. Jika begitu, pesakit akan mengadu rasa bengkak, sakit pada bahagian kelenjar dan mungkin demam. Jika terdapat batu karang selalunya kelenjar air liur tersebut akan lebih bengkak selepas makan dan surut sedikit beberapa jam kemudian.

Bengkak kelenjar air liur juga boleh disebabkan oleh ketumbuhan (tumor). Pesakit akan mengalami bengkak kelenjar air liur yang semakin membesar dan selalunya ia tidak merasa sakit. Kebanyakan ketumbuhan kelenjar air liur adalah jenis ketumbuhan ‘benign’ iaitu bukan kanser. Walaubagaimanapun sekiranya dibiarkan ia boleh berubah menjadi kanser.

Pakar ENT akan memeriksa punca sebenar bengkak kelenjar air liur. Sekiranya ia disebabkan oleh infeksi atau radang, pesakit perlu mengambil ubat antibiotik. Sekiranya ia disebabkan oleh batu karang atau ketumbuhan, pemeriksaan radiologi lanjutan seperti ‘ultrasound’ atau ‘CT scan’ perlu dijalankan sebagai persediaan untuk pembedahan.

Kelenjar tiroid

Kelenjar tiroid terletak di bahagian hadapan leher di bawah halkum (‘adam’s apple’). Kelenjar tiroid boleh membengkak ke bahagian tepi dan ke bawah. Selalunya kelenjar tiroid yang bengkak disebabkan oleh ‘multinodular goitre’ sejenis ketumbuhan yang ‘benign’. Tetapi ia juga boleh disebabkan oleh kanser tiroid seperti kanser tiroid papillary yang boleh berlaku pada mereka yang berusia muda. Oleh sebab itu mereka yang mengalami masalah bengkak kelenjar tiroid perlu pemeriksaan lanjutan oleh doktor pakar.

Cyst

Cyst merupakan bengkak yang terdiri daripada karung yang mengandungi cecair dan sel. Terdapat beberapa jenis cyst yang boleh terjadi di bahagian leher.

Thyroglossal cyst selalunya terjadi di bahagian tengah hadapan leher. Ia bergerak semasa pesakit menelan atau menjelirkan lidah. Kadangkala ia merasa sakit sekiranya berlaku infeksi di dalam cyst tersebut. Ia seeloknya dibedah kerana boleh dikaitkan dengan kejadian kanser.

Dermoid cyst juga terjadi di bahagian tengah hadapan leher tetapi ia tidak bergerak semasa pesakit menelan atau menjelirkan lidah. Ia selalunya berlaku pada kanak-kanak dan saiznya boleh membesar jika dibiarkan.

Branchial cyst pula merupakan bengkak di bahagian tepi leher dan berlaku pada pesakit remaja. Cyst ini hanya menjadi bengkak apabila berlaku infeksi dan ianya surut semula selepas infeksi tersebut reda.

Cystic higroma merupakan bengkak leher yang boleh terjadi pada bayi sejak lahir. Kadangkala saiznya menjadi sangat besar dan boleh menyukarkan pernafasan bayi tersebut. Rawatan cystic higroma selalunya melibatkan penggunaan suntikan ubat ke dalam karung (cyst) tersebut untuk mengecutkannya. Pembedahan pada cystic higroma selalunya adalah sukar kerana cystic higroma mempunyai ‘ekor-ekor’ yang meresap ke dalam tisu di sekelingnya.

Lain-lain punca bengkak leher

Kadangkala bengkak leher boleh berpunca dari bahagian lapisan kulit itu sendiri. Bengkak leher seperti ini terletak di bawah lapisan kulit dan senang dirasai dengan sentuhan jari. Bengkak dari lapisan kulit boleh terjadi disebabkan lipoma (ketumbuhan lemak), sebaceous cyst, dermoid cyst dan bisul.

Selain daripada itu, ada beberapa punca bengkak leher yang jarang berlaku. Contohnya seperti carotid body tumour, hemangioma, schwannoma, pharyngeal pouch dan sebagainya.

Bila bengkak leher perlu pemeriksaan pakar ENT

• Bengkak leher yang lebih dari 2 minggu walaupun setelah mendapat rawatan doktor klinik

• Saiz yang semakin membesar

• Terjadi beberapa bahagian bengkak leher

• Bengkak leher yang menganggu pernafasan, susah menelan atau perubahan suara

• Jika bengkak tersebut mengeluarkan nanah dan sakit (abscess; bisul yang besar)

• Sejarah keluarga untuk kanser

HERBAL SUPPLEMENTS AND SURGERY

Many patients are not aware of the possible adverse events that can happen during surgery if they consume herbal supplements. Patients are advised to disclose to their doctors of the types of herbal supplements they are taking prior to surgery. They are also advise to stop taking these herbal supplements about 2 weeks before surgery.

Some of these herbal supplements can cause significant bleeding, heart problems, blood pressure changes and drug interactions. This would have an effect on the possible surgical complications and surgical outcome. Therefore patients should also seek their doctor's advice if they wish to resume their herbal supplements after surgery.

LIST OF SUPPLEMENTS

Supplements that can cause bleeding
Ginkgo biloba
Ginseng
Garlic
Fish oils (Omega 3-fatty acids, doses more than 3gm/day)
Dong quai
Feverfew

Supplements that can cause cardiovascular effects
Ephedra
Garlic

Supplements that can cause drug interactions
Echinacea
Goldenseal
Licorice
St John's Wort
Kava
Valerian

Supplements that can have anaesthetic effects
Valerian
St John's Wart
Kava

Reference websites
http://plasticsurgery.about.com/od/beforesurgery/a/herbal_supp.htm
http://my.clevelandclinic.org/heart/prevention/alternative/herbals_theheart.aspx
http://my.clevelandclinic.org/heart/prevention/alternative/herbals_surgery.aspx
http://edition.cnn.com/HEALTH/library/herbal-supplements/SA00040.html
http://suite101.com/article/herbs-surgery-anesthesia-a15521

SUSAH BERNAFAS SEBAB HIDUNG TERSUMBAT

Hidung tersumbat boleh menyebabkan seseorang merasa sesak nafas, tidur berdengkur, bernafas melalui mulut, suara sengau, sakit kepala, berat kepala, letih dan lesu. Seringkali hidung menjadi tersumbat oleh sebab jangkitan virus atau bakteria semasa demam selsema dan ia akan pulih dalam masa yang singkat. Walaubagaimanapun ada sesetengah pesakit gejala hidung tersumbat ini berlaku pada bila-bila masa atau berpanjangan.

Ruang hidung manusia terbahagi kepada dua; belah kanan dan kiri. Ia dipisahkan oleh tulang tengah iaitu ‘septum’. Masalah hidung tersumbat boleh disebabkan oleh bentuk septum yang bengkok atau bengkakan pada selaput dalam hidung. Selaput hidung boleh menjadi bengkak disebabkan jangkitan kuman, alahan (alergi), polip hidung (nasal polyposis) atau ketumbuhan hidung (tumour). Pada peringkat umur kanak-kanak tisu adenoid yang besar seringkali menjadi punca hidung tersumbat. Terdapat juga insiden di mana bendasing menyebabkan sebelah hidung tersumbat dan berair pada kanak-kanak.

Apa lagi gejala lain berkaitan dengan hidung tersumbat?

Doktor akan bertanya beberapa soalan seperti berikut:

• Berapa lama masalah ini berlaku?
• Hidung sebelah mana atau kedua-duanya yang tersumbat?
• Adakah masalah ini semakin serius dalam jangka masa terdekat?
• Adakah tuan/puan mengalami sentiasa bersin, hidung gatal, hidung berair?
• Adakah tuan/puan mengalami masalah sakit kepala, tidur berdengkur?
• Bagaimana dengan deria bau dan rasa? Adakah ia berkurangan?
• Pernah mengalami hidung berdarah?
• Pernah mengalami trauma pada hidung?
• Adakah tuan/puan menggunakan ubat sembur hidung yang mengandungi pseudoephedrine atau mengambil ubat aspirin?
• Adakah tuan/puan mengalami masalah kesihatan yang lain seperti lelah, darah tinggi, masalah tiroid etc?

Bagaimana doktor pakar ENT mengenalpasti punca hidung tersumbat?

Setelah mendapat riwayat penyakit dengan teliti, pakar ENT akan memeriksa bahagian ruang hidung dengan menggunakan skop di klinik. Ini membolehkan pakar tersebut melihat dengan lebih jelas ruang dalam hidung dan mengenalpasti punca hidung tersumbat. Selalunya imej skop tersebut disambung kepada kamera dan dipaparkan di atas skrin TV agar pesakit juga dapat melihat dengan sendiri.

Kadangkala doktor akan mengesyorkan pemeriksaan lanjutan seperti ujian darah, ujian alahan atau CT scan. Tetapi ini bergantung kepada setiap kes pesakit dan bukan semua pesakit perlu pemeriksaan lanjutan tersebut.

Rawatan bagi hidung tersumbat

Rawatan hidung tersumbat bergantung kepada puncanya. Sekiranya ia berkaitan demam selsema, rawatan perubatan dapat memulihkan keadaan yang selalunya bersifat sementara.

Rawatan perubatan yang sering disyorkan termasuk ubat sembur hidung (intranasal steroids, nasal decongestant, saline wash/spray) dan pil (antihistamine, decongestant) dalam pelbagai kombinasi. Antibiotik juga perlu sekiranya ada jangkitan bakteria. Ia adalah penting bagi pesakit menggunakan ubat seperti yang disarankan oleh doktor yang merawat. Kadangkala ia mengambil masa beberapa minggu untuk hidung tersumbat menjadi lega.

Sekiranya rawatan perubatan gagal untuk memulihkan masalah hidung sumbat, pakar ENT mungkin mengesyorkan pembedahan (surgeri). Jenis pembedahan bergantung kepada punca masalah hidung tersumbat. Contohnya pembedahan septum (septoplasty) dinasihatkan sekiranya pesakit mengalami tulang septum yang bengkok. Ada juga pembedahan turbinat hidung untuk mengecutkan selaput yang bengkak. Endoscopic sinus surgery pula disyorkan bagi mereka yang bermasalah polip hidung dan sinusitis. Tisu adenoid yang bengkak juga boleh dibedah sekiranya rawatan perubatan gagal. Perlu diingatkan bahawa ada beberapa cara untuk mengatasi masalah hidung tersumbat dan doktor pakar akan menasihatkan rawatan yang paling sesuai bagi setiap pesakit.

Laryngopharyngeal reflux- the chronic cough

Have you experienced an irritating cough that doesn’t get better despite cough mixtures and antibiotics? If yes, then you may be suffering from laryngopharyngeal reflux (LPR); also known as ‘silent reflux’. Most patients may not have the typical symptoms of gastroesophageal reflux (GERD) such as heartburn.

LPR occurs when the acid contents of the stomach is washed up (refluxed) all the way up to the throat (larynx) and even the back of the nose. It may be due to laxity of the muscle sphincter or gatekeeper between the oesophagus and stomach. The mucosal lining of the throat gets inflamed when exposed to the acid.

Symptoms of laryngopharyngeal reflux (LPR)

• Chronic cough
• Frequent throat clearing
• Feeling of mucous at the back of the throat
• Hoarseness
• Foreign body sensation or feel of a ‘lump’ in the throat
• Difficulty swallowing
• Sore throat
• Difficulty breathing

Diagnosis of laryngopharyngeal reflux

Most of the time the ENT Surgeon would make a diagnosis of LPR from the medical history and throat examination with a 70 degree scope or flexible nasopharyngolaryngoscope. This will allow visualization of the larynx, showing inflammation of the vocal cord and surrounding areas.

Sometimes a double probe pH monitoring may be required. This involves inserting a small tube through the nose into the oesophagus to record the frequency and severity of the acid reflux. This would have to be worn for 24 hours. However this test is only necessary for certain cases.

Treatment of laryngopharyngeal reflux

The inflammation of the larynx due to acid reflux may take weeks to months to recover. The doctor would recommend some medication such as proton pump inhibitors, antacids, prokinetic agents.

However it is also important that the patient adhere to some lifestyle changes for better recovery and control of the reflux in the long run. Smoking habit and some food can aggravate the condition. Patients who are obese and overweight are also prone to LPR.

Most patients respond well to medication and lifestyle modification/ dietary change. Some may require prolonged treatment. Only a few patients may not respond to the above measures and require surgery; which involves wrapping around the muscle sphincter to improve its strength.

Home care measures for LPR

• Stop smoking
• Lose weight
• Avoid alcohol
• Avoid caffeinated drinks such as coffee, tea including cola fizzy drinks
• Avoid acidic fruit juices such as orange, grapefruit, tomato
• Avoid spicy and fatty foods such as curry, tomyam even tomato based sauces
• Do not wear tight fitting cloths especially at the waist
• Stop eating at least 3 hours before going to bed
• Elevate the head of the bed at least 4-6 inches
• Take the medications prescribed according to instructions. Proton pump inhibitors are taken 30 minutes before meals and most are given for twice a day.

·      

SINUSITIS

Article published in KPJ Klang Specialist Hospital website
Link to article Sinusitis authored by Dr Mazita Ami

Sinuses are air-filled spaces located within the skull bones.  These sinuses are situated behind the forehead, cheek, around the eyes and nasal bones. Sinusitis occurs when there is inflammation of the sinuses due to viral, bacterial or fungal infection.

These sinuses (frontal, maxillary, ethmoid and sphenoid) are usually lined with mucosal membranes and drain into the nasal cavities. The mucous clearance from the sinuses occurs by the sweeping mechanism of small hair like structures called cilia. This ciliary mechanism can be affected by certain medical conditions such as cystic fibrosis and Kartagener’s syndrome. Upper respiratory tract infection, allergies and deviated nasal septum can also cause blockage of the sinuses. Chronic smoking can also affect the ciliary function

and lead to sinusitis.

Symptoms of sinusitis

Sinusitis usually follows a cold that does not improve after 5-7 days. The symptoms include

• Nasal block
• Post nasal drip
• Nasal drip (rhinorrhoea)
• Headache
• Cough
• Bad breath or loss of smell
• Fever
• Fatigue

How is sinusitis diagnosed?

The doctor would obtain a complete medical history and ask for the above symptoms.

Nasal endoscopic examination can be performed which enables close inspection of the nasal cavities and the sinus openings. Features of sinusitis would include inflamed turbinates and nasal mucosa with yellowish discharge (mucopus). Presence of nasal polyps would also be inspected.

Computed tomography (CT scan) of the sinuses can further confirm the diagnosis and will show the extent of the sinuses involved. It can also show the anatomy of the sinuses and determine if surgery is necessary. Magnetic resonance imaging (MRI) may also be performed if there is suspicion of tumour or fungal infection.

Treatment

Treatment of sinusitis would be directed at decongesting the nose and treating the infection.

Broad-spectrum antibiotic is prescribed for 10-14 days. Oral decongestants are also given to help open up the blocked sinus openings. Nasal decongestant sprays are also beneficial. However caution is taken that it is not used for more than 3-5 days as it cause worsening of the nasal congestion. Other medications would include analgesics (painkillers), nasal saline sprays and mucolytics. Nasal corticosteroid sprays have also been shown to be beneficial in acute sinusitis, more so in patients with allergies and nasal polyps.

If fungal infection is suspected, treatment is more intensive and often surgery is advised. Invasive fungal infection is life threatening and would require inpatient treatment and immediate sinus surgery.

Is sinusitis a serious condition?

Sinusitis especially when acute can lead to life-threatening complications. Because of the close proximity of the sinuses to important structures, infections can easily spread with devastating effects. The complications include eye infections, eye abscess, blindness, meningitis, brain abscess and encephalitis.

Symptoms of possible complication are swelling or redness around the eyes, headache not relieved with over-the-counter medicine, nausea, vomiting or changes in vision. These symptoms require immediate medical attention.

Does sinusitis require surgical treatment?

Most cases of acute sinusitis would resolve with adequate medications. However patients with nasal polyps, anatomical blockage of sinuses and allergies are prone to get recurrent or chronic sinusitis. This category of patients would often require sinus surgery.

How is sinus surgery performed?

Sinus surgery is performed with the use of nasal endoscopes (Endoscopic sinus surgery). This enables the ENT Surgeon to perform the surgery via the nostrils without any external skin incisions. The surgery is aimed to open the blocked or narrowed sinus openings, correction of deviated nasal septum, removing nasal polyps and drainage of the sinuses.

Nowadays, balloon sinuplasty is also being performed to widen the narrowed or blocked sinus openings. The ENT Surgeon would be able to advise if this type of sinus surgery is suitable for the patient.

CHRONIC OTITIS MEDIA

Article published in KPJ Klang Specialist website
Link to website article: Chronic Otitis Media authored by Dr Mazita Ami

Chronic otitis media occurs due to chronic inflammation or infection of the middle ear mucosa and mastoid air cells.

It can occur from an acute otitis media infection that does not resolve completely or repeated infections. It usually presents as persistent ear discharge, reduced hearing and a perforated ear drum. Pain and fever are less common symptoms compared to patients with acute otitis media.

How does it occur?

It starts with an upper respiratory tract infection that causes nasal congestion and blockage of the Eustachian tube. This will lead to poor equalization of pressure in the middle ear thus causing fluid accumulation in the middle ear.

This fluid may get infected with bacteria and cause an acute infection.

If the Eustachian tube is continuously blocked or the infection not adequately treated the middle ear infection persists and lead to ear drum perforation and damage to the ossicles.

Treatment for chronic otitis media

Ear care is very important and patients are advised to prevent water entering the ears whilst bathing. Swimming is also discouraged when there is ongoing infection and perforated ear drums. This is to prevent the vicious cycle of repeated infections.

Antibiotic ear drops and oral antibiotics are prescribed. Nasal decongestants are often given to help alleviate the underlying nasal congestion.

If the infection resolve and the patient is left with a dry perforated ear drum, surgical repair of the ear drum (myringoplasty) can be performed. Sometimes there is need to repair the damaged ossicles at the same time.

However if the ear discharge and infection persists despite adequate medical treatment, mastoid surgery is advised to rid of the diseased mastoid bone and achieve a healthy ear.

When is it not just a ‘simple’ ear infection?

Otitis media or infection of the middle ear can spread to surrounding structures and cause complications. These complications include meningitis, brain abscess, inner ear infection and facial weakness. Symptoms to look out for are severe headache, nausea, vomiting, dizziness/spinning sensation with hearing loss.

HEARING LOSS

The ear is divided into three parts that is the external ear, middle ear and inner ear. The external ear consists of the pinna and external ear canal limited by the ear drum. The middle ear is an air-filled space deep to the ear drum which houses the ossicles, facial nerve and connected to the Eustachian tube and mastoid air cells. The inner ear is a fluid filled labyrinth surrounded by solid bone and contains the organ for hearing (cochlea) and balance (semicircular canals, saccule and utricle).

A person can hear when sound waves travel through the external ear canal and hits the ear drum whose vibrations are transmitted via the ossicles to reach the cochlea. Nerve impulses generated by the cochlea are then transmitted by the cochlea nerve to the brain which interprets the sound. Any disruption along this chain of events can lead to hearing loss.

Types of hearing loss

Hearing loss is divided into three types such as conductive hearing loss, sensorineural hearing loss or mixed hearing loss. The type of hearing loss can be determined by performing a pure tone audiometric test. This test can also assess the degree of hearing loss; mild, moderate, severe or profound. However the ENT surgeon would perform an ear examination to assess the condition of the ear before performing the hearing test.

Conductive hearing loss

Conductive hearing loss occurs when there is disruption of the conducting mechanism in the hearing pathway. It can be due to simple causes such as impacted ear wax, foreign body or external ear infection, otitis externa. Perforated ear drum, middle ear fluid and damaged ossicles due to otitis media or otosclerosis can also cause conductive hearing loss.

Sensorineural hearing loss

Sensorineural hearing loss occurs when there is damage to the inner ear structures such as the cochlea or the cochlear nerve. This often occurs due to aging and is called presbyacusis. It can also occur due to infection or less commonly tumours. If a patient has one-sided sensorineural hearing loss, an assessment by the ENT surgeon is necessary to exclude brain tumour (cerebellopontine angle). Sensorineural hearing loss can also be congenital; present since birth. And it is important to detect this early because it can affect the speech development of the child.

Mixed hearing loss

Mixed hearing loss means there is impairment in both the conductive and sensorineural components of the hearing mechanism. This usually occurs in patients with chronic otitis media which can cause damage to the ear drum, ossicles and cochlea.

Treatment of hearing loss

The treatment would depend on the type of hearing loss and if the cause is reversible. Most conductive hearing loss can be cured by treating the underlying cause. If there is impacted ear wax or foreign body then it only requires removal of the offending objects. Perforated ear drum, damaged ossicles and otosclerosis can be repaired surgically. Middle ear fluid can be resolved with medication and if that fails then myringotomy with grommet insertion is performed. The chances of surgical success of each of the procedures should be discussed with the ENT surgeon.

Patients with sensorineural hearing loss would be advised to use hearing aids. Nowadays, hearing aids are digitalized and can be programmed to the individual needs of patients. However in patients with severe to profound hearing loss, the benefits of hearing aids can be limited. In this group of patients, cochlear implants should be considered in suitable candidates.

On the other hand, patients with mixed hearing loss often have ongoing middle ear infection. The initial step is to treat the infection by medication including antibiotics. If the infection persists, mastoid surgery is performed to eradicate the infection and the perforated ear drum can be repaired at the same time. Often the patient requires hearing aid after surgery to achieve good hearing.

NEW CLINIC

It has been a while since my last entry. I have been busy moving to my new clinic. I would say that I finally know how much stuff I have accumulated over the years.

Packing and unpacking was only one part of the headache. The clinic renovation was the biggest headache. There are still minor works that need to be done but otherwise my clinic is up and running.

I am happy with how things have turned out. The clinic layout is practical and easy to maintain. Some may say it looks simple as compared to others. But the main thing is all the important features for patient care, safety and comfort are all in place.

Well, best if I get feedback from my patients.

POST TONSILLECTOMY CARE

TONSILLECTOMY

Tonsillectomy is a surgical procedure to remove the tonsils which are lymphoid tissues situated at the back of the throat. It is recommended when the patient has repeated tonsillitis, enlarged tonsils, suspicion of tumour or peritonsillar abscess. The surgeon would only advise for tonsillectomy when the benefits of the procedure outweigh the possible risks and complications. Tonsillectomy is performed under general anaesthesia via trans-oral approach; that is through the mouth opening.

Typical appearance of the back of the throat three days post tonsillectomy
(Wikipedia.org)

COMPLICATIONS OF TONSILLECTOMY

Bleeding- the tonsil area has a rich blood supply and care is taken to stop any bleeding intraoperatively. The risk of bleeding after tonsillectomy is very low and usually present with blood stained saliva. On rare occasions the bleeding can be severe and have to be managed in the operating theatre. Risk of bleeding is higher when there is infection.

Infection- it is a potential risk especially in patients with inadequate food and fluid intake after tonsillectomy. Patients with infection post tonsillectomy will have symptoms of severe throat pain and bleeding. Treatment is mainly antibiotics and may require re-admission.

Injury to lip/mouth- instruments are inserted to help open up the mouth during surgery. There is a small risk of injury to lip, mouth or teeth during this procedure.

POST OP CARE

• Pain post tonsillectomy can be severe and lasts up to 2 weeks. However in children the recovery is much faster usually within 1 week. Sometimes the pain can get worse between 3 to 5 days after the surgery before it gets better. Patients are advised to take their painkiller medication regularly.
• Swallowing can be difficult after surgery because of the pain. However patients are encouraged to drink and eat as soon as they wake up after surgery. It may be easier to take cold fluids and soft food initially. Taking small sips of fluids may be easier than big swallows. Avoid taking any spicy or hot food to reduce risk of bleeding. Eating well would also lead to better and faster healing of the operated area.
• Avoid going out to public places. Patients are advised to rest at home for about 1-2 weeks. This can prevent exposure to infection.
• Small amounts of blood stained saliva can be normal in the first 2 weeks and can be stopped with ice gargles. However if bleeding is continuous and increasing in amount, do seek immediate medical attention at the hospital where the surgery was performed.

Printable patient leaflet

http://www.entheadandneckclinic.com/web_documents/leaflet_tonsillectomy1_.pdf

EAR WAX- To Clean or Not To Clean?

Ear wax is a sticky material produced by sebaceous glands in the ear canal. These glands are situated at the hairy outer part of the ear canal. The earwax helps to lubricate, repel water and trap dirt from entering deep into the ear canal. It is also acidic in nature and has antibacterial properties

There are different types of ear wax- soft or hard, wet or dry. Ear wax do not usually cause any problems and will naturally fall out of the ear along with the debris. However sometimes it can get impacted and block the ear canal.

The most common cause of impacted ear wax is the habit of digging the ears with cotton bud, matchsticks or hairpins which push the ear wax deeper into the ear canal. Hearing aid or ear plug users would also tend to have similar problems. Other causes include narrow ear canal, hairy ear canal, certain skin conditions, hard wax and recurrent ear infections.

Symptoms of impacted ear wax are usually ear pain, ear block and tinnitus. Sometimes ear wax can present with ear infection and patients would have severe pain with ear discharge.

Treatment of impacted ear wax includes using ear drops to dissolve the wax. Patients need to apply a few drops into the affected ear canal, two to three times a day for up to 5 days. The softened ear wax will dislodge itself.

However if the above measures fail or there is severe pain or ear discharge; patients should seek medical attention. The ear wax can be removed by the doctor by other methods such as syringing, suction or using forceps.

STEPS ON HOW TO APPLY EAR DROPS

1. Patient should lie down on his/her side with the affected ear facing upwards
2. Then apply 5-10 drops into the ear canal as prescribed by your doctor, preferably someone else can help to do so. Pulling the pinna backwards can open up the ear canal.
3. Patient should maintain the position for 3-5 minutes
4. Some of the ear drops will flow out when patient sits up, just wipe the outer part of the ear with tissue.
5. Patient can then lie down again to apply to the opposite ear if needed.
6. Note: Good to warm up the ear drops by holding the bottle in the palm of your hands for few minutes before application.

KANSER TEKAK

Kanser tekak lebih tepat dikenali sebagai kanser laring (larynx) dari segi istilah perubatan. Anatomi laring melibatkan kawasan peti suara yang juga berdekatan saluran pemakanan iaitu esofagus (esophagus).
Di dalam kajian National Cancer Registry tahun 2006 terdapat 1.1 kes per 100,000 populasi di Malaysia di mana kaum lelaki mencatatkan kekerapan lebih 5 kali ganda berbanding kaum wanita. Ia juga menunjukkan peningkatan kes bagi pesakit yang berumur 40 tahun ke atas dengan yang tertinggi di kalangan pesakit yang berumur 60-69 tahun.

Kawasan tekak (larynx) melibatkan khususnya organ peti suara (glottis), supraglottis dan subglottis

Gejala kanser tekak seringkali timbul sebagai perubahan suara, suara garau atau masalah menelan makanan dan minuman. Pesakit juga kadangkala berasa seperti ada 'sesuatu yang sangkut' di bahagian tekak. Perubahan suara kerapkali merupakan gejala sakit tekak biasa yang disebabkan oleh jangkitan kuman. Akan tetapi sekiranya perubahan suara itu berlarutan lebih dari 2 minggu, pesakit seharusnya mendapatkan pemeriksaan tekak yang lebih terperinci.

Gejala-gejala lain yang berkaitan kanser tekak adalah bengkak pada leher yang disebabkan oleh kelenjar limpa, batuk berdarah, sesak pernafasan atau pernafasan berbunyi terutamanya di kalangan mereka yang merokok.

PEMERIKSAAN KLINIKAL

Pesakit yang mempunyai gejala- gejala tersebut perlu diperiksa dengan lebih lanjut menggunakan peralatan endoskopi semasa sesi rawatan di dalam klinik pakar. Sekiranya pemeriksaan endoskopi menunjukkan ketumbuhan di kawasan tekak pesakit perlu menjalani pemeriksaan selanjutnya.

Ketumbuhan pada tekak boleh disebabkan oleh pelbagai penyakit seperti tuberkulosis (batuk kering), polip, granuloma selain dari kanser. Untuk mengenalpasti punca sebenar sedikit tisu perlu diambil dari ketumbuhan tersebut. Kerapkali ini melibatkan pembedahan kecil.

Pesakit juga perlu menjalani pemeriksaan CT scan (computed tomography) untuk mengetahui sejauh mana kanser tersebut telah merebak.

RISIKO KANSER TEKAK

Terdapat beberapa faktor yang merupakan risiko tinggi untuk kanser tekak:
Faktor umur- Risiko meningkat semakin pesakit berumur
Alkohol- Tabiat pengambilan alkohol atau minuman keras merupakan faktor risiko yang tinggi terutamanya jika pesakit juga mengamalkan tabiat merokok
Merokok- Perokok tegar yang bertahun-tahun lamanya mempunyai risiko yang amat tinggi
Pesakit kanser tekak di kalangan ahli keluarga terdekat terutamanya ibubapa atau adik-beradik
Human papillomavirus- Jangkitan virus ini juga meningkatkan risiko kanser tekak
Faktor lain seperti Asid reflux, pencemaran Bahan kimia, Diet yang kurang sihat

RAWATAN KANSER TEKAK

Pelan rawatan penyakit kanser perlu pertimbangan antara pesakit dan doktor pakar bedah bersama pakar onkologi. Rawatan kanser tekak yang disyorkan oleh doktor pakar bergantung kepada tahap kanser tersebut.

Sekiranya tahap penyakit kanser tekak masih di peringkat awal rawatan secara pembedahan atau radioterapi perlu dijalankan. Ketumbuhan kanser yang lebih besar terutamanya yang melibatkan kelenjar limpa perlu kedua-dua pembedahan dan radioterapi. Kadangkala kemoterapi juga diperlukan bagi tahap kanser tekak yang lebih lanjut. Pelan rawatan penyakit kanser adalah khusus bagi setiap pesakit setelah mengambil kira tahap kanser, keadaan kesihatan pesakit dan jenis sel kanser.

PERINGATAN
Peringatan yang paling penting ialah pesakit harus cepat mendapatkan pemeriksaan lanjutan sekiranya mengalami gejala-gejala di atas. Kerana pemeriksaan awal dapat mengesan ketumbuhan pada peringkat awal. Sekiranya kanser tersebut dapat dikenalpasti pada peringkat awal, sudah tentu rawatannya kurang rumit dan peratusan kebarangkalian sembuh adalah amat tinggi.

NASAL POLYPOSIS

Nasal polyps are growths or masses in the nasal cavity which is not cancerous. It usually arises due to chronic inflammatory process and will continue to increase in size if not treated. It can even cause distortion in the shape of the nose and eventually bulge out through the nostrils in severe cases.

Nasal polyps usually occur in young and middle aged adults. It is uncommon in children. Nasal polyps are often bilateral (both nasal cavities involved). A unilateral polyp is called an antrochoanal polyp which usually arises from the maxillary sinus and affects teens and young adults.

The cause of nasal polyps is open to much debate but it is agreed that an ongoing inflammatory process is the main pathophysiology. There are however certain associated conditions which increase the risk of developing polyps.

These conditions include asthma which is an inflammatory condition of the airways triggered by allergens, chronic rhinosinusitis which is a chronic infection of the sinuses, aspirin sensitivity, allergic fungal sinusitis which is an allergy to airbone fungi, cystic fibrosis especially suspected in children with nasal polyps (rare disease in Malaysia) and other less common syndromes such as Churg Strauss syndrome, Kartagener’s syndrome and Young’s syndrome. Recent understandings have also shown the relevance of family history and certain genetic predisposition to nasal polyps.

SYMPTOMS

The symptoms or nasal polyps are similar to other inflammatory conditions of the nose such as runny nose, post nasal drip and pressure around the face. However when there is persistence in the symptoms especially when associated with unrelenting nasal block/stuffiness, loss of sense of smell or taste, headache, pain around face and teeth and snoring then possibility of nasal polyposis should be considered.

HOW TO DIAGNOSE NASAL POLYPS?

Diagnosis of nasal polyposis can only be confirmed with an endoscopic examination of the nose. A small rigid or flexible scope is inserted into the nose to fully inspect the nasal cavities. It is a simple procedure performed in the ENT clinic. Polyps appear as grapelike structures protruding into the nasal cavities.

Imaging studies are also performed to see the origin of the polyps and extent of the disease. A computed tomography (CT) or magnetic resonance imaging (MRI) is usually requested. The imaging studies can also reveal possible fungal disease or complications.

Other tests such as allergy test, test for cystic fibrosis or others may be indicated depending on a patient to patient basis.

TREATMENT

The treatment of nasal polyps is long term suiting its nature; underlying chronic ongoing inflammatory process. The aims of treatment are to shrink the size of polyps and prevent complications. Most polyps would respond to medical treatment however some would require surgical intervention.

Medical treatment would consist of topical intranasal steroids, oral corticosteroids, antihistamines and antibiotics in various combinations.

Endoscopic sinus surgery is considered when the polyps do not respond to optimal medical treatment. Surgical intervention is also recommended earlier if patients present with complications. Large nasal polyps often may not shrink considerably with medication alone. However patients have to be aware that nasal polyps do recur after surgery. Therefore adequate followup care and ‘maintenance’ medication is necessary to prevent recurrence.

NASOPHARYNGEAL CARCINOMA

Nasopharyngeal carcinoma (NPC) is a tumour of the nasopharynx which is situated at the deep end of the nose. It has the highest incidence amongst the Chinese of Southeastern region and Hong Kong.  It is one of the top 5 cancers affecting both male and female in Malaysia apart from breast, colorectal (bowel), lung and cervical cancer. The Malaysian National Cancer Registry in 2006 noted an incidence of 7.5 per 100,000 for males and 2.4 per 100,000 for females. Chinese men had the highest incidence rate of 15.9 per 100,000. The age specific incidence increased after 30 years old. 

The nasopharynx is situated at the deep end of the nose which makes it a blind spot to normal clinical examination. Tumors or the nasopharynx also often present late because of this anatomical position.

This disease has a multifactorial origin and is a result of interplay between genetic susceptibility, environmental factors and Epstein Barr virus. There is evidence to suggest that abnormalities in specific chromosomes may play a role in the pathogenesis. Cultural factors linked to NPC which have been observed include consumption of dried salted fish in childhood.

CLINICAL FEATURES

The symptoms of NPC are usually non obvious and only apparent when the tumor has spread, due to the anatomical location of the nasopharynx. More commonly patients present with neck swelling in 50-70% of cases followed by unilateral ear block or tinnitus and nasal obstruction. Other less common symptoms include blood stained nasal discharge or saliva and headache. Advanced disease may present with cranial nerve palsies, altered conscious level or distant tumour spread.

DIAGNOSIS

The diagnosis of NPC requires visualization of the nasopharynx region using nasal endoscopy. This endoscopic facility is readily available as an outpatient procedure in ENT clinics. The neck is also palpated to assess for enlarged lymph nodes. Patients with neck swelling and unilateral ear symptoms coupled with high risk ethnicity should always be examined with nasal endoscopy. Endoscopic examination findings in NPC would show as a growth/mass, swelling or obliteration of the Fossa of Rosenmuller. The diagnosis of NPC is confirmed by biopsy and examination of the tissue in the histopathological laboratory. In rare instances, nasal endoscopy may be normal. In these highly suspicious cases the ENT surgeon may suggest examination under general anaesthesia with deep multiple biopsies.

TUMOR STAGING

When diagnosis is confirmed, the tumour is then staged by imaging studies. The rationale for tumour staging is to give a true picture of the tumour extension and its related prognosis. Imaging studies include computed tomography (CT) scan of the head and neck area, chest radiograph, abdominal ultrasound and bone scan.

TREATMENT

The mainstay of treatment for NPC is radiotherapy with without concurrent chemotherapy.  Early small tumours will do well with radiotherapy alone. Often the radiotherapy is combined with chemotherapy. The oncologist will devise the treatment plan after discussing with the patient.

Nowadays advanced forms of radiotherapy such as intensity modulated radiation therapy (IMRT) can better target the tumour volume thus reducing radiation exposure to normal tissues. The side effects that patients may experience with radiotherapy include skin pigmentation and desquamation, oral ulcers and dryness, tiredness, restricted mouth movements, taste disturbance and hearing changes. These side effects would gradually occur during the course of the treatment and will slowly get better. However some of the side effects such as dry mouth and hearing changes are long term.

FOLLOW UP AFTER TREATMENT

After completing the treatment for NPC, the patient is reassessed to ensure good response to the treatment given. Patient is again reviewed by medical history, physical examination along with nasal endoscopy and imaging studies are performed to make sure that the tumour has been eradicated. These clinic reviews are also important to assess for tumour recurrence (return of the tumour), metastasis (distant spread of the disease) and any ongoing problems that the patient may have following treatment. The follow up consultation may be frequent, 3-4 monthly, in the first 2 years and then becomes a 6-12 monthly visit after that.

Useful links

National Cancer Society Malaysia 

National Cancer Registry 2006