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.