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.

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

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

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.

CARE AFTER ENDOSCOPIC SINUS SURGERY

Endoscopic sinus surgery is a procedure that is performed to open up blocked sinuses. It entails using scopes which provide good visualization of the nasal cavity structures without having to make any external skin incisions. Compared to yesteryears of open sinus surgery, endoscopic sinus surgery allows shorter hospital stay and faster recovery.

Endoscopic sinus surgery is recommended when there is failure of medical therapy in treatment of sinus infections.  It is also performed when there are polyps or tumours within the nasal cavity. Correction of deviated nasal septum causing nasal blockage can also be performed by endoscopy.

What to expect when you wake up from the surgery?

Usually the nose will be blocked with nasal packing and a gauze dressing is placed at the front of the nostril to absorb any blood stained discharge and changed whenever soaked. There are two types of nasal packing; dissolvable and non-dissolvable. The non-dissolvable nasal packing which looks like nasal tampon is usually removed 24-48 hours after the operation. The dissolvable nasal packing is left in place and will dissolve within few days.  Patients may have to breathe through their mouth because of the nasal pack.

Patients will experience some pain over the nose area and mild headache is expected. Analgesics are prescribed for pain relief. Inform the surgeon if you still experience considerable pain.

Once the nasal pack is removed, the patient is advised to pinch the nose for at least 15 minutes to stop the bleeding. The patient is also propped up in a sitting forward position and a kidney dish/basin is placed in front so that the patient can spit out any blood discharge trickling at the back of the throat.

The patient is then observed for any serious bleeding before allowed home. A small amount of blood stained discharge is expected for the next few days.

Post op advice for patients

• When lying in bed, keep the head elevated to reduce bleeding from the operated site.
• Patients should not blow their nose for 1 week after surgery. When they sneeze, make sure the mouth is open to reduce pressure in the nasal cavity and prevent bleeding.
• Nasal douching will be prescribed by the surgeon using pre-prepared salts which are dissolved into cooled boiled water. Patients are expected to perform the douching twice a day until healing is complete. The nasal douching will prevent dry crusting in the nasal cavity and allows easy dislodgment of blood clots.
• Patients should also avoid straining, heavy lifting, swimming and flying for a few weeks.
• Patients should avoid allergies and any food known to cause an allergic reaction. Reduce intake of dairy products which can increase mucous production. Refrain from smoking and exposure to secondhand smoke. Patients should also avoid crowded places in case they may catch an infection.
• Patients must comply with the medications prescribed by the surgeon which often includes antibiotics.
• Patients are required to come for follow-up at 5-7 days post operation. During the follow-up visits, the surgeon will monitor the recovery process by endoscopic examination in the clinic and suction removal of blood clots or secretions will be performed.

What next?

The recovery period can take between 2-4 weeks. Patients are often given at least 1 week home rest after the operation. The recovery process varies from patient to patient.

Some patients require long term medication after the endoscopic sinus surgery to prevent recurrence of the disease such as polyps.

Follow up is necessary until the recovery is complete and in patients with polyps they may still need a 6-12 monthly checkup to monitor for recurrence.

Should the tonsils be removed?

The above question is often heard during consultation at the ENT clinic. The patient goes through a rollercoaster of thoughts when their doctor suggests an operation. What more when a parent has to make the decision on behalf of their child.

What are tonsils?

Tonsils are lymphoid tissues at the back of the throat which form a part of the immune system. It grows rapidly between the ages 2 to 6 years and then slowly regress with age. However it is not unusual for tonsils to get infected resulting in a condition called tonsillitis with symptoms of severe sore throat and fever.

When is tonsillectomy advised?
Common indications include
       Recurrent or Chronic tonsillitis; more than 3-5 episodes in a year
       Enlarged tonsils causing airway obstruction or snoring
       Suspicion of tumour; ulcerated tonsils or unilateral tonsil enlargement
       Peritonsillar abscess

How is tonsillectomy performed?
The patient is given general anaesthesia and the tonsils are removed via the mouth. At times other procedures are also indicated such as adenoidectomy depending on the patient's history and ENT examination.
Complications associated with tonsillectomy is minimal. Patients are informed of pain on swallowing and advised to take soft cold diet immediately after surgery. And return to normal diet till healing is complete. This normally takes about 7-10 days. Patients are also informed about the possibility of post tonsillectomy bleeding.

Tonsillectomy is a simple operative procedure. What is more important is the correct selection of patients. The immune function is not affected after tonsillectomy as there are other lymphoid tissue in the throat area.