by Dr. Iain Corness
July 21, 2018 - July 27, 2018
Sore throat –
is it tonsillitis?
The crying child, tugging at its
ear and running a high temperature is a common occurrence, and can be
the signs of tonsillitis. Add to that a change in the child’s voice and
you have almost a 100 percent chance that this is tonsillitis.
It is such a common complaint that
most of us got our tonsils yanked when we were about three years old.
However, adults can get tonsillitis too.
The tonsils are interesting little
(or in some cases, not so little) glands. They live in the back of the
throat and can become acutely infected which we call Acute Tonsillitis,
or can carry a low grade infection for many months or even years, known
as Chronic Tonsillitis.
The infecting organism is also of
interest and can be a Virus, or Chlamydia, or bacteria such a
Streptococcus or Staphylococcus, Mycoplasma, Fungi or Parasites. Another
interesting snippet is that the most likely organism varies with the age
of the owner of the rotten tonsils. In the 2-7 year olds it is
Haemophilus influenzae which is the culprit, while in the 8-14 year olds
it is Staphylococcus aureus and after that it becomes a mixed bag.
With an acute tonsillitis, when you
look inside the mouth there will be two “strawberry” shaped masses in
the back of the throat. They may even have little white follicles on
them, like strawberries. They can get so big that they will even meet in
the midline, displacing the uvula, the little ‘clapper’ that hangs down
in the center of your throat. Pain radiating up to the ears is another
frequent symptom, and the younger ones can run temperatures over 40
degrees C which is a worry for most Mums. Another symptom of an acute
attack is bad breath, so if Junior can knock over the cat with one
breath, have a look at his tonsils!
An appropriate antibiotic settles
the acute attack fairly quickly, but it is very necessary to make sure
the child takes the full course of medicine. With the more chronic
attacks, the pain is less, the temperature is less, but the patient does
not feel well, and antibiotic treatment is usual. Of course, it is
necessary to identify the causative organism, and a tonsilar swab is
usually taken to identify the nasty little blighter. It is also
important to treat the other symptoms, such as pain and the elevated
temperature, and paracetamol is the drug of choice for this.
When I was a child (in the days of
hardship before ballpoint pens and cellophane paper) one good attack of
tonsillitis was enough to have you prostrate under the surgeon’s knife,
but these days we are a little more circumspect.
The US Center for Disease control
recommends if there have been fewer than seven episodes of recurrent
throat infection in the past year or fewer than five episodes per year
in the past 2 years or fewer than three episodes per year in the past 3
years, watchful waiting is preferred over tonsillectomy.
Tonsillectomy is indicated for
recurrent throat infection of at least seven episodes in the past year
or at least five episodes per year for 2 years or at least three
episodes per year for 3 years with documentation of one or more of the
following: temperature above 38.3°C, cervical glands enlarged, tonsillar
exudate, and/or positive test for Group A â-hemolytic streptococcus
Tonsillectomy may be considered in
children who do not meet the above criteria but have multiple antibiotic
allergies/intolerances, (periodic fever, aphthous stomatitis,
pharyngitis, and adenitis), or a history of peritonsillar abscess.
So despite all our advances in
pediatric medicine, tonsillitis is still with us, and will be for many
years to come yet.
July 14, 2018 - July 20, 2018
We are not positive all
the time. We do, and naturally I might add, get depressed. Depression is
unfortunately an integral part of life and living, and there cannot be many
people who can say they have never been depressed in their lifetime. Does
this mean we are all mentally disturbed? Fortunately, no!
The opposite of
depression is elation and whilst we all sail between depression and elation
(which we medico’s call Euphoria, just to be different), it is only when the
mood stays down in the depths that it becomes a problem. So how much of a
problem is it in the community?
When we begin to look
at the various incidence rates the whole situation can become quite
interesting. Did you know, for example, that women get depression twice as
much as men, but the suicide rate for men is five times that for women? Did
you also know that the World Health Organization (WHO) is predicting that by
the year 2020 depression will be the major contributing factor to the burden
of disease in the developing world (and that could be us, if the POTUS ever
stabilizes)! What a depressing thought.
Other interesting facts
emerging from the world-wide studies of depression in women, the highest
rates of depression occur in the 18-24 year age group, while in men it peaks
in the 35-44 year age group. Men really are from Mars and Women are from
Of course, the
statisticians have managed to come up with other associations, which may or
may not be relevant. Such as the statistic that 50 percent of people with
depression also suffer from some physical problem or illness. For me, it is
a case of the chicken and the egg. Which came first? Are these people
depressed because they have an illness or does the depression make them more
prone to illness, or does the illness cause the depression? The answer is
probably a bit of all of them. For example, the risk of Ischemic Heart
Disease (Angina and the like) is three times greater in men diagnosed as
having depression, and it has also been found that depression is present in
45 percent of patients admitted to hospital with a heart attack. Chicken and
the egg once more.
So what kind of person
gets depression? Is there an algorithm we can use to pinpoint the
depressives? The personality profile includes those who are “worriers”,
perfectionists, shy and socially anxious, and those with low self-esteem. It
also includes people with low thyroid function, infectious diseases,
cerebral (brain) blood vessel disease through to diabetes and increased
blood pressure, chronic pain and cigarette smokers. Smoking to settle
yourself down may be sowing the seeds of depression.
fact: The apparent differences between women and men may also be more
imagined than real. That females report twice as much depression as males
may be a reflection of the male upbringing, where boys are taught that it is
“weak” to show their emotions, which subsequently results in under-reporting
their symptoms, whereas women can express their emotions much better.
So what can be done
about this depression epidemic? Fortunately modern treatment is producing
some worthwhile drugs which can elevate the mood without making the person
into a zombie. However, medication should not be thought of as the only way
to go about it. A pocketful of pills and you are instantly better is not
what happens. There should also be careful psychological assessment which
takes time, and assistance given with the planning of activities, the sleep
cycle and structured problem solving.
Early intervention is
important too, so if you are getting depressed, now might be the time to do
something about it by seeking professional help.
July 7, 2018 - July 13, 2018
Sticks and stones may break my bones
My son fell over at school and when
I went to pick him up he was holding his right wrist tightly and said,
“Daddy it is the biggest pain I’ve ever had.” With that simple
presentation, I knew he had a fracture of his wrist. A visit to my
hospital’s X-Ray department confirmed my suspicion regarding a
‘greenstick fracture’ and so he was put in plaster to immobilize the
bone and its fracture.
Broken arms are always in vogue,
with two of my friends fracturing theirs, as well as number 1 son. One
fell off his bicycle, while pedaling to get fit, and the other managed
to get center-punched by another motorcycle while riding his to work.
Neither has relished the experience, and all three have suffered pain.
Now whilst all three suffered
breaks, or fractures as we medicos call them, there are various degrees
and types you can end up with. Son and friend number one were the
luckiest, suffering “hairline” fractures of the Radius (the larger of
the two bones in the forearm). This should be thought of as more of a
“crack” in the outer surface of the bone, just like you can pick up a
drinking glass and see that it is cracked, but not broken in half.
However, it is still a painful condition, and the extreme bruising that
came out on the arm over the following ten days showed the amount of
trauma involved in stepping ungracefully off a bicycle!
The treatment for this type of
fracture is fairly conservative. A splint for a couple of weeks to rest
the arm, some anti-inflammatories to reduce the swelling and some simple
pain killers. After three weeks, this type of fracture will be
satisfactorily healed, though it does take around six weeks for total
Friend number two was not so lucky.
Picking himself up off the road he noticed that there was the end of a
piece of bone sticking out through the skin on his forearm, and as he so
aptly said, “It’s a scary feeling seeing your own bones!” Now this is a
real fracture, with complete division of the bone, and when it sticks
through the skin we called it a “compound” fracture. Raw jagged ends
certainly “compound” the problem!
Treatment for one of these is more
than a simple case of immobilization. What is called an Open Reduction
under general anesthesia is required. In other words, you are put to
sleep, so that the orthopedic surgeon can get in and close the fracture.
In this case, as with most of these, it is also necessary to insert a
metal plate into the arm, which is screwed firmly to the two halves of
the bone. This internal fixation holds the bone ends together and a cast
over the outside of the arm then completes the physical treatment side
of it. Of course, after surgery it is necessary to have some fairly
potent pain killers, and generally we would prescribe some antibiotics
Around three weeks, the cast can be
thrown away, and after six weeks, the patient can usually use the
afflicted limb quite well. With many of these, we also go back in after
one to two years and remove the plate and screws.
Sometimes, we actually fix the two
halves of bone by screwing an external plate through the skin and into
the bone itself. This is called “external” fixation and you don’t need a
secondary operation to remove the plate - but it does mean you put up
with something that looks like scaffolding around your broken limb.
So what do you do when presented
with something that might be a fracture? The simplest and best first aid
you can do is to immobilize the fracture by splinting the limb involved.
Wrap a magazine around the arm and hold in place with a crepe bandage.
With compound fractures, a sterile
pad over the fracture and a gently applied crepe bandage over that and a
trip to hospital.
The elderly should try not to fall
as old bones are not as strong as young ones, and a fracture of the neck
of femur (thigh bone) may be dangerous.
June 30, 2018 - July 6, 2018
Appendicitis - a pain in the belly!
Since the appendix is a vestigial
organ, I often get asked why do we still have an appendix. Please note, the
appendix is singular, you don’t have “them” removed. My answer is that it is
actually a very important organ, as it is the first surgical procedure done
by new surgeons. Yes, my first was a Russian seaman in Gibraltar, and I
think I was much more worried and apprehensive than he was, but that is a
yarn for another time.
A few years ago now, one of my friends
was rushed to hospital with inflammation of the appendix, which we medico’s
call appendicitis (remember that “-itis” at the end of the word usually
means inflammation). He had noticed some pain previously and a watchful eye
was being kept upon him by the surgeon, waiting to see if it would “blow up”
(not in the bomber sense) or subside. It didn’t settle and as the pain
became acute he ended up on the table and sacrificed his inflamed organ (the
appendix, silly!) to the surgeon’s knife. If it makes you feel better, there
are no ‘apprentice’ surgeons at my hospital!
The appendix is a little “finger”
shaped appendage that hangs off the bowel and connects with it. Ruminants
such as cows have large ones, if size really matters! For us, it is also one
of those cute “vestigial” organs which has no apparent functional use these
days, but can give us lots of problems if things go wrong. And things often
do go wrong, with appendicitis being experienced by about 1 person in 500
every year. Males suffer from this more than females and it can strike at
any age, though under two is exceptionally rare. The most affected age group
is between fifteen and twenty-four.
So what causes Appendicitis? It is a
form of infection which is generally from the food passing through the gut
and can be bacterial or even viral. Sometimes the poo (nice medical term) in
the gut gets jammed into the appendix and causes the initial problem. Just
for the record, we call it inspissated feces, just to make it sound grander
than it really is.
While the signs and symptoms of
Appendicitis are straightforward, the diagnosis is not as easy as a number
of other abdominal conditions will mimic the symptoms of centro-abdominal
pain which radiates to the right iliac fossa, nausea, with a low grade fever
and occasional diarrhea. From my medical student days I can even remember
the last one being the Abdominal Crises of Porphyria! I must admit that in
50 years of medicine I’ve never met her!
There are some laboratory tests which
can be done, especially a blood test to see if the White Cell count has gone
up, and some centers will perform ultrasound to try to differentiate what is
going on inside the belly.
The definitive “cure” is to whip out
the offending organ, and as mentioned before, this is usually one of the
first operations a young first year surgeon does on his own.
My old surgical boss always told me to
make sure the skin incision was as small and as neat as possible, because
that was all the patient had to go by to judge one’s competency. It didn’t
matter what went on inside - just make sure the outside looked good! This
was particularly important with young females and a 2 cm scar level with the
top of the bikini bottom was the ideal.
However, these days most surgical
removals are done via “keyhole” surgery with three or four small incisions
only. The recovery time after this form of surgical procedure is also
quicker than “open” surgery.
Post-operatively the vast majority of
patients do well and are up and about in a few days, happily living without
their appendix, so if you’re having some grumbling gut pains, and you still
have your Appendix, perhaps you should let our doctors cast their practiced
eyes over it.