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 

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