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 

HOLIDAY BUGS

It’s the school holidays and with the busy jammed packed holiday resorts the children especially can easily catch an infection such as the common cold. Public places are a constant source of germs and we pick them up in playgrounds, supermarket trolley handles, lift buttons, armrests, public transport, swimming pools etc. But bear in mind that it’s pretty normal for a child to have between 6-8 colds a year in the first three years.

The common cold gives rise to symptoms of nasal congestion, runny nose, sore throat and fever. It is caused by the adenovirus and coronavirus and usually runs a self limiting course.  These symptoms last between seven to ten days. Therefore patients rarely need antibiotics unless there is superadded bacterial infection. Treatment of the common cold is symptomatic ie paracetamol/brufen for the fever, oral decongestant/nasal decongestant spray for the blocked nose, cough syrup etc. Hence why a nice bowl of hot chicken soup makes the patient feels better. Symptomatic treatment only helps to ease the symptoms but it’s the patient’s immune system that will continue working against the infection. 

When do we need antibiotics?

Antibiotics are prescribed when there is superadded bacterial infection. Usually this occurs when there’s complication due to spread of the infection.

• Sinusitis- Patients will have badly congested nose, post nasal drip, yellow to greenish phlegm, headache, facial pain/fullness.
• Otitis media- Patients will complain of pain in the ear with high grade fever. The ear feels blocked and may have ear discharge.
• Throat infection such as tonsillitis or severe laryngopharyngitis- This is commonly due to the postnasal drip. In common cold, initial throat discomfort caused by the viral infection is common. However if the sore throat becomes severe and there is pain on swallowing, most likely there is superadded bacterial infection such as Streptococcus.
• Lung infection such as bronchitis or pneumonia- Patients will present with productive cough, shortness of breath and fever. 

Best remedy- prevention, prevention & prevention

Good hygiene can reduce the exposure and risk of catching a cold. However bear in mind that ‘too much’ hygiene or ‘living in a bubble’ is also not advisable because exposure to some germs are needed to mature and strengthen the immune system. So moderation is the key. (Look up articles on hygiene hypothesis)

1. Proper hand hygiene and handwashing technique
2. Avoid close contact with anyone having a cold and do not share utensils
3. Best to use tissues that can be disposed after use         
4. Keep the house/bedrooms well ventilated
5. Boost your immune system- many good habits such as taking supplements, adequate sleep, regular exercise, reduce stress and avoid smoking. There are many articles written on this topic and I leave it to individuals to find what’s best for them. I find this article apt at summarizing this topic Strengthen your immune system 

VERTIGO- I FEEL THE EARTH MOVE UNDER MY FEET

Vertigo refers to a symptom of spinning sensation; either patient feel themselves spinning or the room spinning around them. It is a very distressing symptom associated with nausea and vomiting.

It is foolhardy to determine the cause of vertigo with this short article. However there a few clues that the doctors will elicit from a patient with vertigo:

• How long does the vertigo lasts; seconds, minutes or hours?
• Is there sensation of ear fullness/block or tinnitus?
• Does a certain head position bring on the vertigo, such as looking left or right?
• Do you experience nausea or vomiting?
• Have you been feeling unwell or had fever in the last 2 weeks?
• Is there any ear discharge or ear pain?
• Did you bump your head or fell?
• Do you experience any weakness or numbness in other parts of your body?
• Did you faint or lose consciousness?
• Do you have any history of migraine, diabetes or hypertension?

What are the causes of vertigo?

There is an exhaustive list of possible causes of vertigo. Therefore it takes proper consultation and examination before the doctor can provide a possible cause and treat accordingly.

• Benign paroxysmal positional vertigo- The most common cause of vertigo. Patients experience a short duration of vertigo related to certain head positions. The doctor can reproduce this vertigo during Dix-Hallpike examination and confirm the diagnosis. The treatment is simply a manouvre that is done in the clinic which gives immediate relief. Sometimes the manouvre needs to be repeated for complete resolution.

• Meniere’s disease-Patient’s have vertigo lasting minutes to hours associated with tinnitus and reduced hearing. Often there is nausea and vomiting too.  In between episodes, patients are symptoms free.

• Vestibular neuronitis- It is a condition due to inflammation of the vestibular nerve.  It is hypothesized to be due to viral infection. Patients have vertigo symptoms with nausea and vomiting. There is no hearing loss or tinnitus.

• Labyrinthitis- This is another condition due to inflammation of the inner ear or labyrinth. Patients have vertigo with hearing loss and tinnitus. The hearing loss can be severe and permanent if not treated early. It is due to viral or bacterial infection.

• Middle ear disease such as otitis media or cholesteatoma. Cholesteatoma is a non tumour condition resulting in whitish debris seen within the middle ear. Treatment of cholesteatoma often require surgery.

• Cerebellar stroke or hemorrhage leading to disruption of oxygen supply and blood flow to the base of the brain area (cerebellum) which is an important central portion that controls balance.

• Head trauma can cause vertigo or dizziness which is often temporary.

• Vertebrobasilar insufficiency is related to cervical spine problems. This can lead to occlusion of blood supply to the inner ear especially when patient looks up or down.

Other causes of vertigo which are less common: Ototoxicity, Cerebellopontine angle tumour, Migraine

Treatment of vertigo

The treatment recommended for the patient will depend on the diagnosis. And recovery from the vertigo will also depend on the diagnosis and patient factors such as age and other co-morbidities.

The choice of treatment can be a combination of the following:

Medication- Betahistine is commonly used for vertigo. Other medications are also used during the acute attack of vertigo such as prochloperazine and metoclopramide. In the case of bacterial infections in labyrinthitis, antibiotics are prescribed as well.

Vestibular rehabilitation exercises which are a series of movements that can help patients regain their balance. Other similar exercises recommended include tai-chi.

Particle repositioning manouvres which is a manouvre that is performed in the doctor’s office for benign paroxysmal positional vertigo such as the Epley’s manouvre. There are other types of manouvres that can be performed depending on the semicircular canal involved.

Lifestyle advice which includes avoiding alcohol, reducing stress, low salt diet for Meniere’s disease, reducing caffeine intake, good adequate sleep and rest 

HEALTHY EATING AFTER CANCER TREATMENT

As ENT doctors we often deal with cancers involving the head and neck area, commonly the oral cavity, throat and nose (nasopharynx). Treatment of these cancers entail either surgery, radiotherapy, chemotherapy or a combination of them. Because of the location of the cancer itself and the treatment, patient often have problems related to the head & neck area such as chewing and swallowing. And yet nutrition is an integral part of treatment to combat the disease.

During the course of the treatment patients should seek the doctor's advice before taking any supplements because it can interfere with the therapy. The doctor would also inform patients of the possible side effects of treatment and how best to prepare and deal with the problems. With the advent of new radiation technology there is less severe side effects such as those seen many years ago.

But what about after treatment? When follow-up examination and scans show that the cancer was successfully removed or had responded well to treatment, is it important to continue with a healthy diet?

An article published in the Harvard's Medical School's consumer health journal advocates healthy lifestyle as the key for cancer survivors to decrease the likelihood of recurrence. Their advice includes healthy eating with at least 5 servings of fruits and vegetables per day, exercise, maintaining body mass index between 20-25, eat fatty fish two to three times a week and having normal vitamin D levels.

The American Cancer Society has produced an informative booklet which provides nutrition advice during and after cancer treatment. The list below is taken from their booklet on tips of healthy eating after cancer treatment.

Tips on Healthy Eating after Cancer Treatment (American Cancer Society Nutrition Guide)

• Check with your doctor for any food or diet restrictions.
• Create healthy balance meals. Choose a variety of food.
• Eat at least 5 to 7 servings a day of fruits and vegetables, including citrus fruits and dark-green and deep-yellow vegetables.
• Eat plenty of high-fiber foods, like whole-grain breads and cereals.
• Decrease the amount of fat in your meals by baking or broiling foods.
• Limit your intake of red meat to no more than 3 to 4 servings a week.
• Avoid salt-cured, smoked, and pickled foods (including bacon, sausage, and deli meats).
• Choose low-fat milk and dairy products.
• If you choose to drink alcohol, limit the amount.
• Maintain a healthy weight.
• Exercise. Ask your doctor before starting any exercise regime.

USDA update pyramid 2005

Reference
Stephanie Meyers, 2009. Does diet affect cancer recurrence?
Healthy Eating. National Cancer Institute
American Cancer Society. Nutrition

Image credits:
http://www.flickr.com/photos/calliope/4206360542
http://www.flickr.com/photos/62116165@N00/2461157879

APABILA TELINGA BERAIR…..

Apabila telinga menjadi berair dan mengeluarkan bau yang busuk, itu tandanya ia mengalami jangkitan kuman. Tetapi ada kalanya telinga yang ada jangkitan hanya berasa gatal dan sebu atau tersumbat. Selain dari jangkitan kuman, telinga juga boleh dijangkiti oleh kulat.

Fenoma berasa sakit pada telinga selalunya bermakna jangkitan yang lebih serius yang boleh membawa kepada komplikasi.  Pesakit juga selalunya merasa demam dan sakit kepala.

Jangkitan pada telinga boleh berlaku samada di bahagian telinga luar atau telinga tengah. Jika jangkitan melibatkan telinga tengah, gegendang telinga mungkin bocor atau bengkak.

Kenapa ia berlaku?

Jangkitan pada telinga luar berkait rapat dengan tabiat membersihkan telinga menggunakan putik kapas atau alatan lain. Tabiat ini boleh menyebabkan luka pada kulit yang kemudiannya dijangkiti bakteria. Ini amat merbahaya terutamanya pada pesakit diabetes. Jangkitan telinga luar juga boleh berlaku selepas pesakit berenang di kolam mandi ataupun di laut dan sungai. Air yang masuk ke dalam telinga mengandungi kuman yang boleh menyebabkan jangkitan.

Jangkitan telinga tengah pula berkait rapat dengan masalah hidung. Infeksi hidung seperti selsema atau sinusitis boleh menyebabkan jangkitan merebak ke telinga tengah melalui tiub Eustachian. Ia lebih kerap berlaku pada kanak-kanak kerana mereka seringkali mengalami selsema dan tiub Eustachian mereka senang tersumbat. Pesakit seringkali mengalami selsema dan kemudiannya mengadu sakit telinga atau telinga tersumbat.

Gambar sebelah menunjukkan gegendang telinga yang bengkak dengan nanah di dalam bahagian telinga tengah. Jangkitan ini dinamakan 'otitis media'. Sekiranya tidak dirawat ia boleh menyebabkan jangkitan yang lebih serius dan rosak pendengaran.

Rawatan

Pemeriksaan oleh doktor akan memastikan punca masalah yang menyebabkan telinga berair. Cecair atau kotoran di dalam telinga akan dibersihkan oleh doktor dan rawatan perubatan akan disusuli. Perubatan yang seringkali disyorkan merupakan ubat titis telinga dan kadangkala pil antibiotik. Doktor juga akan merawat  permasalahan hidung sekiranya dialami oleh pesakit.

Pesakit dinasihatkan agar mengelak air masuk ke dalam telinga dan berhenti membersihkan telinga dengan putik kapas di rumah. Pesakit juga disyorkan berhenti aktiviti berenang untuk sementara waktu.

Cara menggunakan ubat titis telinga

1. Pesakit perlu baring mengiring dengan telinga yang bermasalah menghadap ke atas
2. Ubat dititiskan ke dalam telinga, selalunya 5-10 titis, mengikut preskripsi doktor. Elok sekiranya ada orang lain yang membantu menitiskan ubat tersebut
3. Pesakit perlu mengekalkan posisi selama 3-5 minit.
4. Apabila bangun, sebahagian dari titisan akan mengalir keluar. Ini adalah normal dan pesakit hanya perlu mengelap di bahagian cuping telinga dengan tisu
5. Pesakit kemudiannya beralih ke posisi mengiring untuk telinga yang sebelah lagi dan ulangi proses tersebut jika perlu.

Sumber imej

http://en.wikipedia.org/wiki/File:HumanEar.jpg

http://en.wikipedia.org/wiki/File:Acute_Otitis_Media.jpg

MENGATASI MASALAH ALAHAN (RESDUNG)

Masalah resdung seringkali berkaitan dengan gatal hidung, bersin, hingus cair dan hidung sumbat. Dalam bahasa perubatan ia lebih sesuai dipanggil sebagai ‘Allergic Rhinitis’ atau alahan hidung. Pesakit juga boleh mengalami simptom gatal pada bahagian mata dan kulit muka. Gejala ini berlaku kerana pesakit alah kepada pelbagai bahan terutamanya hama, makanan laut, belacan dan sebagainya.

Perkara utama dalam menangani masalah alahan hidung adalah untuk mengelak dari bahan yang menyebabkan alahan atau ‘alergen’. Salah satu cara untuk mengenalpasti alergen adalah dengan mencatatkan dalam diari makanan yang diambil setiap hari dan juga keadaan persekitaran. Seringkali apabila diimbas kembali pesakit mungkin dapat meneka alahan mereka dengan tepat.

Selain daripada usaha pencegahan, para doktor mungkin mengesyorkan pengambilan ubat anti-alahan hidung samada dalam bentuk pil antihistamin atau pam/spray hidung. Ubat ini dapat membantu mengawal simptom alahan hidung dengan lebih berkesan, terutamanya bagi pesakit yang mengalami alahan yang teruk atau yang terpaksa terdedah kepada alergen seperti mereka yang bekerja di gudang yang berhabuk.

Langkah- langkah mengatasi alahan

Elak dari terdedah kepada alergen Pengambilan ubat yang disyorkan doktor apabila mengalami kes alahan teruk

Mengatasi masalah alergen utama iaitu HAMA

Ramai pesakit alahan hidung mempunyai alahan terhadap hama. Hama adalah binatang yang hanya dapat dilihat melalui kanta mikroskop. Sebenarnya alahan itu adalah terhadap najis hama tersebut. Hama hidup dengan memakan sel kulit mati yang terdapat pada katil dan perabot di dalam rumah kita. Ia suka kepada keadaan yang panas dan lembab.

Selain dari alahan hidung, alahan kepada hama juga boleh menyebabkan sakit asma (lelah) atau gatal kulit (eczema). Ciri utama dalam mengatasi alahan hama adalah pencegahan dan kebersihan.

Cara mengatasi hama

1. Elak penggunaan permaidani di dalam rumah terutamanya di bilik tidur
2. Elak mengunakan terlalu banyak kusyen atau perhiasan rumah yang dapat mengumpul habuk
3. Alat mainan seperti patung beruang seharusnya jenis yang boleh dibasuh dengan senang dan kerap
4. Basuh cadar dan selimut sekurang-kurangnya dua kali seminggu
5. Elok basuh cadar dan selimut dengan menggunakan air panas 60⁰C
6. Menggunakan hampagas untuk mengurangkan habuk. Penggunaan hampagas yang mempunyai filter yang bagus (high efficiency filter, HEPA) dapat mengurangkan habuk dan hama dengan berkesan
7. Mengelap perabot dengan kain lembap lebih berkesan dari menggunakan bulu ayam/plastik
8. Memakai 'face mask' terutamanya semasa mengemas rumah ataupun di tempat kerja yang berhabuk
9. Mengelakkan haiwan peliharaan seperti kucing atau anjing dari kawasan bilik tidur
10. Penggunaan lapik katil dan bantal yang anti-hama (anti-dust mite covers) juga dapat membantu

Apa yang boleh berlaku sekiranya masalah alahan hidung (resdung) tidak dikawal?

• Boleh menyebabkan masalah infeksi atau jangkitan kuman pada rongga hidung dan sinus (sinusitis)
• Boleh menyebabkan masalah polip hidung
• Gejala hidung yang sentiasa sumbat boleh mengurangkan daya konsentrasi dan menyebabkan pesakit merasa lesu
• Hidung tersumbat boleh mengganggu tidur yang berkualiti
• Alahan hidung juga berkait rapat dengan penyakit asma/lelah yang sukar dikawal
• Alahan hidung juga boleh menyebabkan pesakit mengalami masalah jangkitan telinga ‘otitis media’ terutamanya pada kanak-kanak