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DOC I HAVE SIALADENITIS

What is Sialadenitis?

Sialadenitis is an inflammation of the salivary glands .

There are 3 salivary glands:

1.Parotid – the largest salivary gland is located at the cheeks in front of the ears. An inflammation of the parotid gland is called parotitis.

2.Submandibular – this salivary gland is located at the back of the cheek below the lower jaw.

3.Sublingual – this salivary gland is located below the jaw near the front of the mouth below the  front of the tongue.

Inflammation of the salivary glands are usually viral  (example mumps) or bacterial.

They are common in most people and can recur after infections.

What is the cause of Sialadenitis?

1.Viral (mumps) infection

2.bacterial infection such as staphylococcus or pneumococcus

3.It can be associated with the presence of salivary stones (sialothiasis) in the duct.

It can occur as a result of poor oral hygiene or debilitating disease

Acute post operative parotitis used to be a common problem caused by ascending infection from the mouth but has been avoided by appropriate fluid therapy following surgery.

What are the symptoms of Sialadenitis?
Symptoms are:

1.acute swelling of the involved salivary glands or entire side of face

2.abnormal tastes , often foul

3.fever, general toxemia and malaise

4.pus or purulent saliva may discharge from the Stensen’s duct(opening of the salvary duct )

5.dry mouth

6.Pain  on opening of the mouth or eating food

How is the diagnosis of  Sialadenitis made?

Diagnosis:
1.presence of swelling of salivary gland especially the parotid

2.Xrays may show the presence of stones in the salivary duct

3.CT Scan or ultrasound may be necessary if there is suspected abscess or stones causing obstruction to the saliva duct

What are the complications of Sialadenitis?

The complications of Sialadenitis Fever are:

1.pneumonia

2.abscess formation

3.cellulitis or spread of infection to other parts of the face or neck

What is the treatment of Sialadenitis?

Treatment may not be necessary in mild cases.

1.Viral infections may only require symptomatic treatment such as for bed rest. anti fever medicine, pain killer, mouth rinses , oral hygiene and lots of fluid (water).

2.If the infection is suspected to be bacterial, antibiotics are given according to culture and sensitivity to antibiotics.

3. If there is abscess or blockage of the salivary duct, surgical drainage of pus or removal of stone may be necessary

What is the prognosis of Sialadenitis?

Prognosis depends on extent of disease.

Most viral mild salivary gland infections will disappear with symptomatic treatment . Bacterial infections are cured with antibiotic treatment.  Rarely there are complications such as difficulty in breathing or swallowing.

How do you prevent sialadentis?

1.Proper oral hygiene

2.Avoid smoking

3.Drink adequate fluids.

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DOC I HAVE ACTINOMYCOSIS

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What is Actinomycosis?
Actinomycosis fever is a chronic infection caused by the Actinomycosis anaerobic gram positive bacteria (Actinomyces israeli) associated with multiple draining abscesses.

There are 4 forms of Actinomycosis:
1.General:

affects the whole body including skin, brain, bones, kidney, liver and female pelvic organs

2.Cervicofacial (neck and face) form arises in decayed teeth

3.Respiratory form is caused by aspiration of oral secretions

4.Abdominal form has transmucosal (through the mucosal lining of the intestine) spread.

Discharge from multiple communicating abscesses contain sulfur granules in the fluid.

They are yellowish granules made of clumped micro-organisms.

The most common location is in the neck and facial region.

The bacteria enters the tissues of the neck or face through injury, dental surgery and infection.

Very common cause of infection is a dental abscess or dental surgery.

Sometimes Intra uterine Device in the womb of women may also cause infection by the Actinomycosis bacteria.

Once inside the tissues of the neck or face it forms a lump (abscess) at the lower jaw. Once the abscess burst , pus pours out from a sinus tract in the skin of the jaw.

What are the symptoms of Actinomycosis?
Symptoms are:

A.Cervicofacial:
1.affects the cheeks, tongue, pharynx, salivary glands, skull bones, meninges and brain

2.small flat hard swellings which soften forming sinuses and fistula

B.Thoracic form:
same symptoms as tuberculosis
1.fever
2.pain
3.chronic cough
4.perforation of chest wall with sinuses

C.Abdominal form:

affects appendix and caecum
1.pain,
2.fever
3.constipation
4.diarrhea
5.palpable mass
6.draining sinuses and fistula

D.General:

has blood spread to the whole body including skin, brain, bones, kidney, liver and female pelvic organs

Diagnosis of Actinomycosis is by:
1.presence of Actinomyces israeli in sputum, pus or biopsy specimen

2.Examination of drained fluid under a microscope shows sulfur granules in the fluid

3.X rays of the chest and jaws

What are the complications of Actinomycosis?

The complications of Actinomycosis are:

1.pneumonia

2.neurological disturbances(seizures,cranial nerve signs and coma) may indicate bleeding in the brain

3.large abscesses which may lead to sepsis

What is the treatment of Actinomycosis?

Treatment of Actinomycosis:
1.antibiotic according to sensitivity
2.continuous antibiotic for months
3.surgical drainage of abscesses
4.laparotomy and surgical excision of abdominal forms

What is the prognosis of Actinomycosis?

Prognosis:
This depends on extent of disease
It is a slow progressive disease
The best prognosis is treatment of the cervicofacial form
The prognosis is poor in pulmonary, abdominal and generalized forms respectively.

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DOC I HAVE DIVERTICULOSIS

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Diverticulosis are pouches in the wall of the colon.

Main symptoms are abdominal pain and bloating and constipation.

Treatment is mainly by control of diet, prevention of constipation and antispasmodics for pain.

Rarely diverticulitis  a infection of the colon pouches may be needed to be treated with antibiotics.

Generally prognosis is good.

Diverticulosis is a disorder of the colon or large intestine where there are one or more sac-like pouches(called diverticula) in the walls of the colon.

It is more common in the descending and sigmoid colon.

Diverticulosis becomes more obvious with age.
50% of people over the age 0f 60 years have Diverticulosis.

The exact cause of Diverticulosis is not known.

It has been suggested that a low-fiber diet is the main cause of diverticular disease.

Diverticulosis is common in developed countries where low-fiber diets are common whereas it is rare in Asia and Africa where people eat high-fiber vegetable diets.

Fiber prevents constipation which can make the muscles strain and increase pressure in the colon.

This increased pressure makes the weak spots in the colon lining to bulge out like pouches and become diverticula.

Most cases of Diverticulosis have no or little symptoms.

In the more severe cases, the main symptoms of Diverticulosis are:

1.Abdominal pain or cramps-usually over the left side or over the lower abdomen

2.Bloating

3.constipation

The symptoms can range from mild to severe.

Diagnosis of Diverticulosis is made by:

1.A history of abdominal pain especially on the left lower abdomen, bloating and constipation

2.The physical exam consists of
a.palpation of the left abdomen for tenderness or masses
b.digital rectal exam to detect tenderness or blood.

3.stool may be tested for blood

4.blood tests(WBC,ESR,bood culture) are done for evidence of infection.

5.Xrays of the abdomen and barium enema may be done to show evidence of pouches in the colon

6.Colonoscopy is also done to confirm evidence of diverticulosis and exclude malignant tumours.

Complications of Diverticulosis are:

1.Diverticulitis
Diverticulitis occurs when diverticula become infected with bacteria, viruses or become inflamed.
Bacteria are caught in the pouches and develops into diverticulitis suddenly.

The symptoms and signs of diverticulitis are:
1.abdominal pain usually continuous in the lower left abdomen with tenderness

2.fever due to infection,

3.nausea, vomiting,

4.cramping,

5.constipation

6.rectal tenderness

Diverticulitis can lead to:

1.Bleeding,
rare.
Bleeding can be severe caused by a small blood vessel in a diverticulum that weakens and finally bursts.
Surgery may be needed to stop bleeding if bleeding continues.

2.Abscess, Perforation, and Peritonitis
Often a few days of treatment with antibiotics will cure the diverticulitis.
If the infection gets worse, an abscess which is an infected area with pus may form in the colon.

Small abscesses usually clear up with antibiotics.

More severe abscesses may require drainage of the pus using a catheter.

If pus leaks from perforations in the lining of the colon, then it can cause infection in the abdominal cavity and results in peritonitis.

This is an emergency and requires immediate surgery to clean up the pus in the abdominal cavity and removal of the damaged part of the colon.

3.Intestinal Obstruction
The infection of the diverticula can cause scarring of the lining of the colon resulting in partial or total blockage of the large intestine.

If the obstruction blocks the intestine completely, emergency surgery is required to allow faecal matter to pass through.

A temporary colostomy may be necessary.

4.Fistula
occurs as an abnormal connection between two organs or between an organ and the skin.

It results from the damaged tissues coming together and an opening is left between the two tissues.

Usually the bladder, small intestine, vagina, and skin are the organs involved.

The most common fistula occurs between the bladder and the colon especially in men. This can cause a long-lasting infection of the urinary tract.

Surgery may be necessary to remove the fistula as well as the damaged part of the colon.

5.Urinary tract infections occurs frequently due to the fistula and proximity of the bladder to the infected colon.

6.Discharge of faecal material may occur through a fistula between the colon and vagina in some women.

Treatment of Diverticulosis is by:

Medication:
1.pain medications will relieve any pain symptoms.

2.Antispasmotic medication for spams of the colon

3.Antibiotics may be needed in diverticulitis and complications such as urinary infection and peritonitis.

Diet:
1.high-fiber diet

a.whole grain breads and cereals;
b.fruit like apples and peaches;
c.vegetables like carrots, broccoli, spinach, carrots, cabbage, beans.

2.fiber product such as Metamucil once a day.

3.Avoid nuts, popcorn, pumpkin, and sesame seeds or any food which can cause discomfort in the abdomen

Diverticulitis
1.Antibiotics to treat the infection and inflammation,

2.resting the colon by bed rest, nasogastric suction and a liquid diet

3.hospital stay to prevent complications such as abscess.

4.surgery if the attacks are severe or there are complications.
The surgeon resects the affected part of the colon and then joins the remaining sections.

Surgery is also done for complications such as a fistula or intestinal obstruction.

Emergency surgery may be done for a large abscess, perforation, peritonitis, or continued bleeding.

Prognosis of Diverticulosis is fair.

About 1% develop diverticulitis.
70% of patients with acute attacks of diverticulitis can be treated with medical management and have no further attacks

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DOC I HAVE A PIN IN THE FOOT

This memorable case was a 8 year boy who was brought by the mother to see me because of pain and swelling in his right foot for 2 weeks.
The mother gave a history of the boy jumping on his bed which had small head pins left by his younger sister. 
The boy claimed one of the pin entered his right foot and caused pain in his foot. 
So the mother brought him to a nearby clinic where the young doctor examined his foot and told the mother there may be just a slight infection of his foot. 
He was given some antibiotic and painkiller and an antibiotic cream to apply to the sole of his foot. 

After 5 days the foot became more swollen and painful and the boy was brought to the same doctor again . He was given an injection and an another antibiotic.

After 2 weeks when the swelling of the foot did go down and remains red and painful she was recommended by a friend to bring the child to consult me.

The first thing after I heard the history of a possible pin entering his right foot was to examine the foot carefully. There was indeed a red painful swelling of  the dorsum or the top surface of his foot. 
The second thing that I did was to send him for an X-ray of his right foot.
As suspected the urgent x-ray showed the presence of a pin stuck in his foot in the flesh between the 3rd and 4th toes.

I had to do an urgent surgery to remove the pin. 
Luckily the boy was quite brave and although he cries a bit he knew it was for his own good. 
In an operation that lasted almost 1 hour I had to search for the pin guided by the x-ray and finally retrieved a small rusty pin which was surrounded by fibrous tissues from his foot.
The mother was so relieved to see the pin.
She said she was praying so hard for me to find the pin. 

As the mother did not know whether the boy was given a tetanus toxoid injection to prevent lockjaw in his 2nd visit to the doctor, I had to call the doctor to ask whether he had given the tetanus injection. 
He was shocked to hear that the boy had a rusty pin in his foot for 2 weeks. He said that he gave the boy only an antibiotic injection and not the tetanus toxoid injection which was to prevent lockjaw. 

Lockjaw( A Simple Guide to Tetanus) was a dangerous condition where a rusty nail or metal can cause the tetanus bacteria to grow in the foot resulting in the contraction of muscles including the the heart muscle and then death.

I gave the boy the tetanus toxoid injection and hoped that he will not get tetanus. 

Only once in my work as a family doctor, I have seen a lockjaw patient who had to be sent to hospital where her breathing stopped and had to be resuscitated back to life.

After another x-ray showed the pin was no longer in the foot, I gave him some antibiotics, painkiller and reviewed him the next day.

Happily he was well and he was given an antibiotic cream to apply to his surgery wound. 
After the stitches were removed and the pain and swelling was gone, I was satisfied that the boy was going to be all right.

Any body who has a possibility of a metal foreign body in his flesh should be sent for an x-ray. 
The x-ray can detect any metal in the body easily and knowledge of this can prevent any tragic consequences to the patient.

It was a lesson to all new young general practitioners.

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DOC I HAVE A PAIN ON MY FACE

Trigeminal Neuralgia ( A Simple Guide to

Sensory areas of the head, showing the general distribution of the three divisions of the fifth nerve. (Photo credit: Wikipedia)

Trigeminal Neuralgia)is pain in the face due to hypersensitivity of the fifth or trigeminal nerve which supply sensation to the facial muscle and skin. 

All nerve pain can be excruciating. 

This elderly gentleman had this condition on the right side of his face for about 12 years. 
He was on constant painkillers.

The pain was so bad that he had to ask an ENT surgeon to cut off the branch of the nerve that leads to his nose and lip about 10 years ago. 
After the surgery there was no pain for 3 years though he has a bit of facial muscle droop. 
However the pain recurred after the third year of surgery. 

This time he did not want surgery because of the cost and also because the recurrence occurred even with surgery. 
There was also the side effect of a drooped facial muscle.
He was seeing instead a neurologist and his pain was relieved not totally with pain killers and a nerve pain drug called tegretol. 
However he had some gastric problem because of the strong pain killer.

Hearing about my injection for osteoarthritis and rheumatism, he came to consult me. 
I told him that the injection only worked with joint pain and not nerve pain.
In his case he needed an injection which will kill the nerve. 
In those days there were no botox injection which could kill the nerve. 
So what I used was (as recommended by an old medical book) surgical spirit. 
This was mixed with a local anesthetic and injection was done  into the nerve branch between the nose and lips. 
There was a slight droop of the face after the nerve was injected. 
Together with some painkiller, antacid and his Tegretol, the pain was reduced considerably. 

Each time there was recurrence of pain another injection was given. 

He had a total of 4 injections of the surgical spirit before the pain disappear completely.

He still comes to see me together with his wife for rheumatic pain but not for the nerve pain.

Nowadays the new aesthetic or cosmetic physician will probably inject him with botox which can cost a few thousand dollars.
Sometime an old method worked equally well. 

This is the one and only case in which I had treated with the injection of surgical spirit and successfully too.

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A TALE OF 2 ANESTHETISTS

There are 2 types of anesthetists:
1.confident and hardworking

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2.relaxed and too easy going


The first group is
1.conscientious,
2.do a proper  pre-operation examination of the patient the day before,
3.check that he is the correct patient.
4.make sure that he is not taking medications which may clash with the anesthesia
5.check that he has not taken any food or fluid at least 6 hours before the operation
6.reassure the patient before putting under general or regional anesthesia
7.continue to check his vital signs(blood pressure, heart beat, respiratory rate) during his surgery
8.make sure that the levels of oxygen and nitrous oxide are correct
9.check the intravenous drip does not run dry
10.make sure the patient was safe during the surgery(there are times when patients wake up during the operation because the anesthesia was not deep enough)
11.reverse the anesthesia carefully
12.make sure that the patient was well after waking up


The second type of anesthetist is very easy going:
1.ask the patient a few questions just before the operation
2.induce the general anesthesia
3.leave the patient in the hands of his nurse during the operation to monitor the vital signs, gases and drip
while he goes for a break in the surgical tea room
4.when the operation is over, he will turn off the anesthetic gases and reverse the anesthesia
5.Once the patient is awake he will go for another break until the next operation


I was taught by both types of anesthetists.
I learn to be the first type of anesthetist because I want to be good doctor who takes care of his patient and not just do his work routinely.
Besides I do not wish any of my patients ends up as one of the fatality from anesthesia.
So I was constantly with the patient from induction of anesthesia to reversing the anesthesia.
The danger of general anesthesia has been greatly exaggerated.
There is always a risk of 3 fatalities in a million due to anesthesia not 1 per cent as sometimes stated.
It is very important that a proper examination is done before the general anesthesia as medication such as Viagra may clash with some anesthetic.
If the patient is not fit for general anesthesia, he should undergo some other form of anesthesia for the surgery instead of general anesthesia.
It is also important to have an empty stomach for at least 6 hours before general anesthesia because of the risk of vomiting or regurgitation of fluid or food entering the windpipe.
There is also the danger of muscle relaxant reversal where the patient’s anticholinesterase enzyme were insufficient to help reverse the muscle relaxant.


I remember a surgery where the anesthetist was a new trainee anesthetist. It was his first general anesthesia done under the instruction of the Head of the Anesthetic Department. Everything went well until after the surgery. When he tried to reverse the muscle relaxant, he was horrified to find that the patient was unable to wake up. She was one of the patient who had this enzyme insufficiency.She had to be put on a respirator and intravenous drip for 2 days in the ward until the muscle relaxant was flushed out of her body.

It was one of the complications of general anesthesia.


General anesthesia can be administered with endotracheal intubation or without intubation. For short operations of less than 30 minutes or diagnostic operations such as biopsy, general anesthesia may be given after sedation with a short dose of thiopentone using nitrous oxide and oxygen gases.
An oropharyngeal air way is inserted to prevent the tongue from falling back and blocking the passage.


Regional anesthesia is preferred to general anesthesia because of less risks of complications associated with general anesthesia.
Spinal anesthesia is given by a needle into the epidural space below the spinal cord for operations requiring paralysis of the lower half of the body such as appendicectomy, operation of lower intestine, ovaries and womb.
Epidural anesthesia is given to relieve pain during delivery of babies, caesarean section.


Caudal  anesthesia is given to paralyse the lower perineal region for operation of the cervix, womb, hemorrhoid and anal operations. It last for 1-2 hours.
In the Obstretic and gynecological hospital (KKMH)of Singapore, I had to do caudal anesthesia for almost 20 patients over a period of 3 hours straight in order for them to undergo dilation and curettage of their wombs.


Regional anesthesia of a particular limb allows the surgeon to operate in cases where general anesthesia is dangerous or unnecessary (in elderly people or uncontrolled diabetic patients who needs amputations or treatment of fractures of the hips, legs and feet).



All told, the Anesthetic department was a short stint of 3 months which I enjoyed and learned.
I also found out all I can about the operations done, the conduct of some surgeons in the operation theater and the use of the surgical tea room for sleep.

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A TALE OF 2 CANCERS
———————————————


NASOPHAYNGEAL CANCER (A Simple Guide to Nasophayngeal Cancer)


The Ear Nose and Throat Department treats all cancers of the ear nose and throat.
Some of the throat and mouth cancers are treated together with the Dental Surgery Department.
In the 1970s one of the most common and deadly cancer was the Nasopharyngeal Cancer which  now is known to be linked with Epstein-Barr virus.
Treatment was difficult because of the closeness of the nose cancer to the brain and the frequently late diagnosis.
Surgical treatment is usually not considered unless it was at an early stage.
The treatment of choice was deep X-ray radiation to the affected area followed by chemotherapy in all cases spread of the cancer to other organs.
The mortality rate was high compared to the present modern treatment today of gamma knife treatment.
At the time of my assignment, there was a woman patient in the ward who was in the advanced stage of nasopharyngeal cancer and undergoing chemotherapy.
She was a teacher of 32 years of age who was mostly sick during the time there.
She was emaciated with vomiting during her chemotherapy and loss of appetite.
She was always in pain because the cancer has spread to the brain.
We had to give painkillers and anti-vomiting injections every now and then in order to relieve her symptoms.
Because of the injections, she was also in a sleepy state most of the time.
She has quite a few visitors including her family and her students, most of whom were dejected at the state of her condition.
I tried talking to her on several occasions but she was most too tired to answer except in short sentences.
One morning her bed was cleared and we know that she has succumbed to her illness in the night.


It was sad but quite a lot of nasopharyngeal cancer patients had succumbed in this way including my father-in-law during my medical student days.


LARYNGEAL CANCER (A Simple Guide to Laryngeal Cancer)


In contrast to the dangerous nasopharyngeal cancer (which was usually detected late), the Laryngeal Cancer is usually detected much earlier .
The symptom of hoarseness of voice was one of the easily symptom which prompts the patient to see a doctor.
Even then, some patient then to delay their checkup by a ENT surgeon preferring to see Chinese Sinsehs (Traditional Chinese healers) for treatment hoping to be cured of their condition.
We had a elderly female patient of 70 years who had an advanced stage of Laryngeal cancer which fortunately grow very much slower than the nasophayngeal cancer.
Although it had spread just outside of her larynx or vocal box, surgical removal of her cancer was successful.
A tracheostomy(hole in her windpipe) was done in order that she could breathe through the hole.
Her vocal box was completely removed and closed so her only way of breathing was through the hole.
By covering the hole partially ,she was able to utter some gutterial sounds which required a speech therapist to teach her to talk again.
Nowadays there are mechanical and electronic devices which can placed in the vocal box area to help the patient to talk
In the meantime she was recovering from her surgery in the ward.
Strict instructions was given to made sure the tracheostomy hole was not blocked and free of infection.
In the meantime I used to communicate with her through hand gestures and some written words.
She was cheerful in spite of her illness and I used to try to ‘talk’ to her with hand gestures and written words to keep her in good spirits.
Her relatives were also helpful and kind to her.
Once her condition was well enough to return home, she was discharged.


She even send me a thank you card for taking good care of her.
This was the one of the satisfying things about being a doctor.
It is always important to treat a patient well as another human being rather than a medical case.
When you treat a patient well and kindly , even other patients, nursing staff ,and hospital ‘amahs’(helpers or assistants) also know about it and treat you just as well.

In all, the ENT department was one of the satisfying department to work in and very essential to learn about managing a patient in the family practice.

Not many family doctors know how to remove a fish bone from the throat, a small marble from the nose of a child, remove wax from the ears, bleeding from the nose or treat peritonsillar abscess

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IN THE BEGINNING
I have never planned on becoming a doctor.

Not as a Stranger (Morton Thompson's Not as a Stranger) (Image via RottenTomatoes.com)

I was looking forward to a career in mathematics or chemistry. Those were my favorite subjects. I like solving mathematical problems and I look forward to experiment with the chemicals bought from the drugstore.

Then one day I came upon a Reader Digest condensed novel ” Not as a stranger”.
It was all about a poor medical student who became an assistant to a Family Doctor and eventually took over the family doctor’s practice.
It was inspirational.

Then came medical TV serials such as Marcus Welby M.D
Ben Casey, Dr Kildare , Doctor in the House.
I resolve that I would try to be a good family Doctor.

My mother whose older brother was a doctor in China encouraged me to take up medicine.

So it was at the tender age of 18 years, I entered the medical faculty of the university of Singapore.

The first day was a nightmare. Entering the dept of Anatomy, I was presented with a large hall of corpses and the strong smell of formaldehyde.
Suddenly the dream of being a doctor became a nightmare of looking at & cutting up of a dry preserved corpse for the next 18 months.

In the meantime there were the endless lectures of anatomy, physiology and biochemistry.
Life became rather rushed. Unlike other undergraduates, we were studying through out the whole year with 4 semesters instead of the 3 semesters in the Arts and Science faculty and 2 weeks break in between.

There were daily taking notes of complaints of patients and examinations of patients. There were also procedures like drawing blood from patients, watching surgical procedure done by eminent surgeons, doing minor surgical procedures like removing small lumps and bumps, stitching of cuts and cleaning of wounds.

The most important assignment was the “catching” of 20 babies at the Kandang Kerbau Maternity Hospital (the biggest baby factory in the world in the 1970’s) or the delivery of 20 babies in the hospital by natural birth.

So it was after 5 years of tutorial and practical medicine that I finally graduated as a medical doctor.
Even then I had only 1 month rest before being called up for
my housemanship – a compulsory year of working in the hospital before becoming a fully registered doctor.

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