For Your Healthy

Acute Otitis Media

2009-02-09T02:58:00.001+07:00

DEFINITION

Acute otitis media is an infection of the middle ear, the area of the ear directly behind the tympanic membrane (ear drum). Acute otitis media is one of the most commonly diagnosed childhood illnesses and is responsible for more than 30 million clinic visits a year in the United States.

Acute otitis media usually starts when germs that cause colds or sore throats (either bacterial or viral infections) spread to the middle ear. Once in the ear, the infection can cause a buildup of pus or fluid behind the eardrum. The pressure on the eardrum can lead to significant pain in some children.

Physicians diagnose acute otitis media using an otoscope, an instrument placed in the opening of the ear that allows the doctor to look at the eardrum. Inflammation of the eardrum can indicate an infection. Lack of movement of the eardrum can also indicate infection. If there is fluid or pus behind the eardrum, it usually does not move easily.

SIGNS AND SYMPTOMS

- Fever
- Ear pain or pulling at one or both ears
- Irritability
- Decreased appetite
- Fluid coming from one or both ears

These symptoms can occur for other reasons, so it is important for children with these symptoms to be evaluated by a physician.

TREATMENT

Acute otitis media may be treated with antibiotics if there is a bacterial infection. When children have recurrent or chronic (persisting long-term) otitis media, it may be necessary to have a tympanostomy tube placed in the eardrum. The tube falls out naturally after several months and the hole heals naturally. Treatment depends on the characteristics of each child, so it is important for your child to have an evaluation if these symptoms develop.

WHEN TO CALL THE DOCTOR

Although quite rare, ear infections that don't go away or severe repeated middle ear infections can lead to complications, including spread of the infection to nearby bones. So kids with an earache or a sense of fullness in the ear, especially when combined with fever, should be evaluated by their doctors if they aren't improving.

Other conditions can also result in earaches, such as teething, a foreign object in the ear, or hard earwax. Consult your doctor to help determine the cause of the discomfort and how to treat it.
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Chronic Otitis Media

2009-02-07T14:29:00.003+07:00

The Middle Ear and Its Structures

The middle ear is a hollow chamber in the bone of the skull. It is separated from the outside world by a thin membrane about half-an-inch in diameter, the eardrum. The middle ear area is lined by the same kind of mucous membrane that lines nose and mouth. It is connected to the back of the nose, just above the soft upper portion of the mouth, by a narrow passage called the eustachian tube.

The eustachian tube lies closed until the swallowing movement pulls it open and allows fresh air to enter the middle ear. The fresh air is needed to replace oxygen that has been absorbed by the middle ear lining. The fresh air equalizes the middle ear pressure with the air pressure outside the head. Some people hear this burst of fresh air as a pop or click.

Suspended within the middle ear is a chain of three small bones, the ossicles, which conduct sound vibrations from the eardrum across the middle ear into the fluid-filled inner ear. Inside the inner ear these vibrations are converted to nerve signals that are carried by the auditory nerve to the brain.

The mastoid bone is an extension of the air space of the middle ear. It is made up of small interconnected air spaces similar to a honeycomb. Its function is not clear, but it is often involved in chronic ear infections. Within it lie the structures of the inner ear responsible for balance and facial expression.

What is Chronic Otitis Media?

Chronic Otitis Media (COM) is the term used to describe a variety of signs, symptoms, and physical findings that result from the long-term damage to the middle ear by infection an inflammation. This includes the following:

- Severe retraction or perforation of the eardrum (a hole in the eardrum)
- Scarring or erosion of the small, sound conducting bones of the middle ear
- Chronic or recurring drainage from the ear
- Inflammation causing erosion of the bony cover or the facial nerve, balance canals, or cochlea (hearing organ)
- Erosion of the bony borders of the middle ear or mastoid, resulting in infection spreading to the meninges (the coverings of the brain) or brain
- Presence of cholesteatoma
- Persistence of fluid behind an intact eardrum

How Does Chronic Otitis Media Occur?

If the eustachian tube becomes blocked by swelling or congestion in the nose and throat, by swelling of the mucous membrane in the middle ear, or by swelling of the mucous membrane of the eustachian tube itself, the air pressure in the middle ear cannot equalize properly. A negative pressure develops, and if the obstruction is prolonged, fluid may be drawn into the air space of the middle ear from the mucosa. This may occur with a cold or flu virus and is a common cause of ear infections in children (serous otitis media). Serous otitis media usually resolves without treatment, but may require a course of antibiotics or steroids. It is a common reason for placement of tubes in children and adults.

If the eustachian tube blockage persists, chronic changes in the tissue of the middle ear begin to occur. First, the mucous secretions become thicker, and therefore less likely to drain. Then the membranes themselves begin to thicken and become inflamed. The defense mechanisms of the eustachian tube and middle ear become compromised and bacteria normally present in the nose may enter the middle ear and cause a painful condition called acute otitis media. This responds to antibiotic treatment, but may require placement of tubes.

The negative pressure in the middle ear or alternating periods of negative, normal and positive pressure may deform the eardrum. In the long term, the eardrum may become severely distorted, thinned, or even perforated. These changes may cause hearing loss and a sensation of pressure. When there is a hole in the eardrum, the natural protection of the middle ear from the environment is lost. Water and bacteria entering the middle ear from the ear canal can cause inflammation and infection. Drainage from the ear is a sign of a perforation.

Inflammation and infection in time can cause erosion of the ossicles and the walls of the middle and inner ear. The patient may experience hearing loss, imbalance, or weakness of facial movement on the affected side. In rare instances, the infection may extend deeper into the head, causing meningitis or brain abscess.

A cholesteatoma, or skin cyst, is essentially skin in the wrong place. Epidermal skin from the ear canal or outside surface of the eardrum, like that on the back of the hand, does not belong in the middle ear. If it is trapped by a deformed eardrum or migrates through a perforation, it tends to grow out of control and can cause significant damage to the structures of the middle ear and mastoid.

How Do I Know If I Have Chronic Otitis Media?

Warning signs of chronic otitis media include:

- Persistent blockage of fullness of the ear
- Hearing loss
- Chronic ear drainage
- Development of balance problems
- Facial weakness
- Persistent deep ear pain or headache
- Fever
- confusion or sleepiness
- Drainage or swelling behind the ear

Chronic otitis media generally occurs gradually over many years in patients with longstanding or frequent ear trouble. However, it can occasionally develop over several months in a patient with no previous history of ear disease. Any of the above symptoms should prompt an evaluation by an ENT or otologist/neurotologist.

How is Chronic Otitis Media Treated?

The first step in treating otitis media is a thorough evaluation by a physician. This will include a history and examination of the ear, nose, and throat. Depending on the individual situation, further testing will include a hearing test, tympanometry (a test that measures the pressure in the middle ear) and CT or MRI scan.

Treatment depends upon the stage of the disease. Initially, efforts to control the causes of eustachian tube obstruction, such as allergies or other head and neck infectious problems, may prevent progression of chronic otitis media. Uncomplicated chronic ear fluid is treated with antibiotics, steroids, and/or placement of ventilation tubes. Many children with chronic or recurrent ear infections have ventilation tubes inserted in their eardrums to allow normal air exchange in the middle ear until the eustachian tube matures.

Once the disease has progressed to the point of significant damage to the eardrum or ossicles, more intensive treatment is needed. If active infection is present in the form of ear drainage, antibiotic eardrops are prescribed. Occasionally, these may be supplemented with oral antibiotics.

Once the active infection is controlled, surgery is usually recommended. There are three objectives of surgery for COM:

* Eradication of the disease
* Remodeling of the middle ear and mastoid bone, located just behind the external ear, to prevent recurrence
* Preservation or improvement in hearing

Surgeries to achieve these objectives include tympanoplasty, mastoidectomy, or typanomastoidectomy. The ENT doctor or otologist makes an incision within the ear canal or behind the external ear. Part of the mastoid bone is then drilled away to gain access to the middle ear space. The abnormal tissues are removed. If possible, efforts are made to rebuild the eardrum and the sound-conducting bones. It is sometimes necessary, however, to complete the hearing reconstruction at a later date (a second stage) rather than at the same time as removal of the infected or damaged parts. Patients are usually discharged from the hospital on the same day or one day after surgery.

Healing after surgery takes several months. In 90 percent of cases, surgery is successful in repairing the eardrum and a dry, healthy ear results. Hearing improvement is more difficult to predict and varies greatly depending on the severity of the disease, including the presence of cholesteatoma, ossicular erosion, mastoid disease, and eustachian tube function. If a hearing reconstruction was performed, it will take several weeks and months for hearing to begin improving. During this time middle ear packing and fluids are being reabsorbed and scar tissue is being formed to help stiffen the bones. In addition, the eardrum thins out. These factors contribute to a gradual hearing improvement. Routine checkups by the physician are recommended at least yearly after the healing is complete, and in some cases may be required two or more times yearly to maintain adequate local hygiene.

http://www.umm.edu

Hemoptysis

2009-02-04T16:21:00.002+07:00

Definition

Hemoptysis is the coughing up of blood or bloody sputum from the lungs or airway. It may be either self-limiting or recurrent. Massive hemoptysis is defined as 200-600 mL of blood coughed up within a period of 24 hours or less.

Description

Hemoptysis can range from small quantities of bloody sputum to life-threatening amounts of blood. The patient may or may not have chest pain.

Causes and symptoms

Hemoptysis can be caused by a range of disorders:

- Infections. These include pneumonia; tuberculosis; aspergillosis; and parasitic diseases, including ascariasis, amebiasis, and paragonimiasis.

- Tumors that erode blood vessel walls.

- Drug abuse. Cocaine can cause massive hemoptysis.

- Trauma. Chest injuries can cause bleeding into the lungs.

- Vascular disorders, including aneurysms, pulmonary embolism, and malformations of the blood vessels.

- Bronchitis. Its most common cause is long-term smoking.

- Foreign object(s) in the airway.

- Blood clotting disorders.

- Bleeding following such surgical procedures as bronchial biopsies and heart catheterization.

Diagnosis

The diagnosis of hemoptysis is complicated by the number of possible causes.

Patient history

It is important for the doctor to distinguish between blood from the lungs and blood coming from the nose, mouth, or digestive tract. Patients may aspirate, or breathe, blood from the nose or stomach into their lungs and cough it up. They may also swallow blood from the chest area and then vomit. The doctor will ask about stomach ulcers, repeated vomiting, liver disease, alcoholism, smoking, tuberculosis, mitral valve disease, or treatment with anticoagulant medications.

Physical examination

The doctor will examine the patient's nose, throat, mouth, and chest for bleeding from these areas and for signs of chest trauma. The doctor also listens to the patient's breathing and heartbeat for indications of heart abnormalities or lung disease.

Laboratory tests

Laboratory tests include blood tests to rule out clotting disorders, and to look for food particles or other evidence of blood from the stomach. Sputum can be tested for fungi, bacteria, or parasites.

X ray and bronchoscopy

Chest x rays and bronchoscopy are the most important studies for evaluating hemoptysis. They are used to evaluate the cause, location, and extent of the bleeding. The bronchoscope is a long, flexible tube used to identify tumors or remove foreign objects.

Imaging and other tests

Computed tomography scans (CT scans) are used to detect aneurysms and to confirm x-ray results. Ventilation-perfusion scanning is used to rule out pulmonary embolism. The doctor may also order an angiogram to rule out pulmonary embolism, or to locate a source of bleeding that could not be seen with the bronchoscope.

In spite of the number of diagnostic tests, the cause of hemoptysis cannot be determined in 20-30% of cases.

Treatment

Massive hemoptysis is a life-threatening emergency that requires treatment in an intensive care unit. The patient will be intubated (the insertion of a tube to help breathing) to protect the airway, and to allow evaluation of the source of the bleeding. Patients with lung cancer, bleeding from an aneurysm (blood clot), or persistent traumatic bleeding require chest surgery.

Patients with tuberculosis, aspergillosis, or bacterial pneumonia are given antibiotics.

Foreign objects are removed with a bronchoscope.

If the cause cannot be determined, the patient is monitored for further developments.

Prognosis

The prognosis depends on the underlying cause. In cases of massive hemoptysis, the mortality rate is about 15%. The rate of bleeding, however, is not a useful predictor of the patient's chances for recovery.

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Related Link :
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Pneumothorax

2009-02-04T16:03:00.003+07:00

A pneumothorax is air that is trapped next to a lung. Most cases occur 'out of the blue' in healthy young men. Some develop as a complication from a chest injury or a lung disease. The common symptom is a sudden sharp chest pain followed by pains when you breathe in. You may become breathless. In most cases, the pneumothorax clears without needing treatment. The trapped air of a large pneumothorax may need to be removed if it causes breathing difficulty. An operation is needed in some cases.

Definition

A pneumothorax is air that is trapped between a lung and the chest wall. The air gets there either from the lungs or from outside the body.

Causes

Primary spontaneous pneumothorax. This means that the pneumothorax develops for no apparent reason in an otherwise healthy person. This is the common type of pneumothorax. It is thought to be due to a tiny tear of an outer part of the lung - usually near the top of the lung. It is often not clear why this occurs. However, the tear often occurs at the site of a tiny 'bleb' or 'bullae' on the edge of a lung. These are like small 'balloons' of tissue that may develop on the edge of a lung. The wall of the 'bleb' is not as strong as normal lung tissue and may tear. Air then escapes from the lung but gets trapped between the lung and the chest wall.

Most occur in healthy young adults who do not have any lung disease. It is more common in tall thin people.

About 2 in 10,000 young adults in the UK develop a spontaneous pneumothorax each year. Men are affected about four times more often than women. It is rare in people over the age of 40. It is also much more common in smokers compared to non-smokers. Cigarette smoke seems to make the wall of any bleb even weaker and more likely to tear.

About 3 in 10 people who have a primary spontaneous pneumothorax have one or more recurrences sometime in the future. If a recurrence does occur it is usually on the same side and usually occurs within three years of the first one.

Secondary spontaneous pneumothorax. This means that the pneumothorax develops as a complication (a 'secondary' event) of an existing lung disease. This is more likely to occur if the lung disease weakens the edge of the lung in some way. This may then make the edge of the lung more liable to tear and allow air to escape from the lung. So, for example, a pneumothorax may develop as a complication of COPD (chronic obstructive airways disease) - especially where lung bullae have developed in this disease. Other lung diseases that may be complicated by a pneumothorax include: pneumonia, tuberculosis, sarcoidosis, cystic fibrosis, lung cancer, and idiopathic pulmonary fibrosis.

Other Causes

An injury to the chest can cause a pneumothorax. For example, a car crash or a stab wound to the chest. Surgical operations to the chest may cause a pneumothorax. A pneumothorax is also an uncommon complication of endometriosis.

Symptoms

- The typical symptom is a sharp, stabbing pain on one side of the chest which suddenly develops.
- The pain is usually made worse by breathing in (inspiration).
- You may become breathless. As a rule, the larger the pneumothorax, the more breathless you become.
- You may have other symptoms if an injury or a lung disease is the cause. For example, cough or fever.

A chest x-ray can confirm a pneumothorax. Other tests may be done if a lung disease is the suspected cause.

What happens to the trapped air and small tear on the lung?

In most cases of spontaneous pneumothorax the pressure of the air that leaks out of the lung and the air inside the lung equalises. The amount of air that leaks (the size of the pneumothorax) varies. Often it is quite small and the lung collapses a little. Sometimes it can be large and the whole lung collapses. If you are otherwise fit and well, this is not too serious as the other lung can cope until the pneumothorax goes. If you have a lung disease, a pneumothorax may make any existing breathing difficulty much worse.

The small tear that caused the leak usually heals within a few days, especially in cases of primary spontaneous pneumothorax. Air then stops leaking in and out of the lung. The trapped air of the pneumothorax is gradually absorbed into the bloodstream. The lung then gradually expands back to its original size. Symptoms may last as short as 1-3 days in cases of primary spontaneous pneumothorax. However, symptoms and problems may persist longer, especially in cases where there is an underlying lung disease.

Tension pneumothorax
This is a rare complication. This causes shortness of breath that quickly becomes more and more severe. This occurs when the 'tear' on the lung acts like a one way valve. In effect, each breath in (inspiration) 'pumps' more air out of the lung, but the valve action stops air coming back into the lung to equal the air pressure. The volume and pressure of the pneumothorax increases. This puts pressure on the lungs and heart. Emergency treatment is needed to release the trapped air.

Treatment

No treatment may be needed. You may not need any treatment if you have a small pneumothorax. A small pneumothorax is likely to clear over a few days. A doctor may advise an X-ray in 7-10 days to check that it has gone. You may need painkillers for a few days if the pain is bad.

Aspirating (removing) the trapped air is sometimes needed. This may be needed if there is a larger pneumothorax or if you have other lung or breathing problems. As a rule, a pneumothorax that makes you breathless is best removed. It is essential to remove the air quickly in a 'tension' pneumothorax. The common method of removing the air is to insert a very thin tube through the chest wall with the aid of a needle. (Some local anaesthetic is injected into the skin first to make the procedure painless.) A large syringe with a three way tap is attached to the thin tube that is inserted through the chest wall. The syringe sucks out some air, the three way tap is turned, and the air in the syringe is then expelled into the atmosphere. This is repeated until most of the air of the pneumothorax is removed.

Sometimes a larger tube is inserted through the chest wall to remove a large pneumothorax. This is more commonly needed for cases of secondary spontaneous pneumothorax when there is underlying lung disease. Commonly, the tube is left is left place for a few days to allow the lung tissue that has 'torn' to heal.

Note: it can be dangerous to fly if you have a pneumothorax. Do not fly until you have the 'all clear' from your doctor following a pneumothorax. Also, do not go to remote places where access to medical care is limited until you have the 'all clear' from a doctor.

Treating Recurrences

Some people have repeated episodes of spontaneous pneumothorax. If this occurs, a procedure may be advised with the aim of preventing further recurrences. For example, an operation is an option if the part of the lung that tears and leaks air out is identified. It may be a small 'bleb' on the lung surface that can be removed. Another procedure that may be advised is for an irritant powder (usually a kind of talc powder) that can be put on the lung surface. This causes an inflammation which then helps the lung surface to 'stick' to the chest wall better.

A lung specialist will be able to give the pros and cons of the different procedures. The procedure advised may depend on your general health, and whether you have an underlying lung disease.

If you are a smoker and have had a primary spontaneous pneumothorax, you can reduce your risk of a recurrence by stopping smoking.

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Pleural effusion

2009-02-04T15:53:00.002+07:00

A pleural effusion is a collection of fluid next to the lung. There are various causes. The effusion may cause you to become breathless. The fluid can be drained if necessary. Treatment is mainly aimed at the underlying cause.

Pleural Effusion

A pleural effusion means that there is a build up of fluid between a lung and the chest wall.

The pleura is a thin membrane that lines the inside of the chest wall and covers the lungs. There is normally a tiny amount of fluid between the two layers of pleura. This acts like lubricating oil between the lungs and the chest wall as they move when you breathe. A pleural effusion develops when this fluid builds up and separates the lung from the chest wall.

Symptoms

You may feel some chest pain but a pleural effusion is often painless. The amount of fluid varies. As the effusion becomes larger, it presses on the lung which cannot expand fully when you breathe. You may then become breathless.

You may also have symptoms of the condition that is causing the effusion. For example, cough, and fever if the cause is pneumonia.
What are the causes of a pleural effusion?

A pleural effusion is a complication of various conditions. The following are some of the more common causes of a pleural effusion (but there are other rarer causes too).

- Pneumonia (lung infection), tuberculosis, and tumours (cancers) may cause inflammation of the lung and pleura. This may cause fluid to build up into a pleural effusion.
- Some arthritic conditions may cause inflammation of the pleura in addition to joint inflammation. For example, pleural effusion is an uncommon complication of rheumatoid arthritis and systemic lupus erythematosis (SLE).
- Heart failure causes 'back pressure' in the blood vessels (veins) that take blood back to the heart. Some fluid may seep out of the blood vessels. Swelling of the legs with fluid is typical with heart failure, but a pleural effusion may also develop.
- A low level of protein in the blood also tends to allow fluid to seep out of the blood vessels. For example, cirrhosis of the liver and some kidney diseases may cause a low level of blood protein which allows a pleural effusion to develop.

Diagnose

A chest x-ray confirms a pleural effusion. If the cause of the effusion is known then no further tests may be needed. However, sometimes a pleural effusion is the first sign of an underlying condition. Further tests may then be advised to find the cause of the effusion. These may include lung tests, blood tests, and taking a sample of the fluid and pleura to examine in the laboratory.

Treatment

A large pleural effusion that makes you breathless can be drained. This is usually done by inserting a needle or tube through the chest wall. A local anaesthetic is injected into the skin and chest wall first to make the procedure painless.

A major part of treatment is usually directed to the underlying cause of the effusion. For example, antibiotics for pneumonia, chemotherapy or radiotherapy for cancers, etc. Therefore, treatment can vary greatly, depending on the cause of the effusion.

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Bronchiectasis

2009-02-04T15:32:00.002+07:00

Bronchiectasis is a disease that causes localized, irreversible dilation of part of the bronchial tree. It is classified as an obstructive lung disease, along with bronchitis and cystic fibrosis. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired clearance of secretions. Bronchiectasis is associated with a wide range of disorders, but it usually results from necrotizing bacterial infections, such as infections caused by the Staphylococcus or Klebsiella species or Bordetella pertussis.

Rene Theophile Hyacinthe Laënnec, the man who invented the stethoscope, used his creation to first discover bronchiectasis in 1819. The disease was researched in greater detail by Sir William Osler in the late 1800s; in fact, it is suspected that Osler actually died of complications from undiagnosed bronchiectasis.

Pathogenesis

Dilation of the bronchial walls results in airflow obstruction and impaired clearance of secretions because the dilated areas disrupt normal air pressure in the bronchial tubes, causing sputum to pool inside the dilated areas instead of being pushed upward[4]. The pooled sputum provides an environment conducive to the growth of infectious pathogens, and these areas of the lungs are thus very vulnerable to infection. The more infections that the lungs experience, the more damaged the lung tissue and alveoli become. When this happens, the bronchial tubes become more inelastic and dilated, creating a self-perpetuating cycle of further damage to the lungs.

There are three types of brochiectasis, varying by level of severity. Fusiform (cylindrical) bronchiectasis (the most common type) refers to mildly inflamed bronchi that fail to taper distally. In varicose bronchiectasis, the bronchial walls appear beaded, because areas of dilation are mixed with areas of constriction. Saccular (cystic) bronchiectasis is characterized by severe and irreversible ballooning of the bronchi peripherally, with or without air-fluid levels. Chronic productive cough is prominent, occurring in up to 90% of patients with bronchiectasis. Sputum is produced on a daily basis in 76% of patients.

Generally, persons suffering from bronchiectasis tend to be infected by Haemophilus influenzae early on in the disease course. Secondary infection is usually due to Staphylococcus aureus; followed by Moraxella catarrhalis and finally Pseudomonas aeruginosa.

Causes

There are both congenital and acquired causes of bronchiectasis. Kartagener syndrome, which affects the mobility of cilia in the lungs, aids in the development of the disease. Another common genetic cause is cystic fibrosis, in which a small number of patients develop severe localized bronchiectasis. Young's syndrome, which is clinically similar to cystic fibrosis, is thought to significantly contribute to the development of bronchiectasis. This is due to the occurrence of chronic, sinopulmonary infections. Patients with alpha 1-antitrypsin deficiency have been found to be particularly susceptible to bronchiectasis, for unknown reasons. Other less-common congenital causes include primary immunodeficiencies, due to the weakened or nonexistent immune system response to severe, recurrent infections that commonly affect the lung.

Acquired bronchiectasis occurs more frequently, with one of the biggest causes being tuberculosis. Endobronchial tuberculosis commonly leads to bronchiectasis, either from bronchial stenosis or secondary traction from fibrosis. An especially common cause of the disease in children is acquired immune deficiency syndrome, stemming from the human immunodeficiency virus. This disease predisposes patients to a variety of pulmonary ailments, such as pneumonia and other opportunistic infection. Bronchiectasis can sometimes be an unusual complication of inflammatory bowel disease, especially ulcerative colitis. It can occur in Crohn's disease as well, but does so less frequently. Bronchiectasis in this situation usually stems from various allergic responses to inhaled fungus spores. Recent evidence has shown an increased risk of bronchiectasis in patients with rheumatoid arthritis who smoke. One study stated a tenfold increased prevalence of the disease in this cohort. Still, it is unclear as to whether or not cigarette smoke is a specific primary cause of bronchiectasis.

Other acquired causes of bronchiectasis involving environmental exposures include respiratory infections, obstructions, inhalation and aspiration of ammonia and other toxic gases, pulmonary aspiration, alcoholism, heroin (drug use), and various allergies.

Diagnosis

The diagnosis of bronchiectasis is based on the review of clinical history and characteristic patterns in high-resolution CT scan findings. Such patterns include "tree-in-bud" abnormalities and cysts with definable borders. In one small study, CT findings of bronchiectasis and multiple small nodules were reported to have a sensitivity of 80%, specificity of 87%, and accuracy of 80% for the detection of bronchiectasis. Bronchiectasis may also be diagnosed without CT scan confirmation if clinical history clearly demonstrates frequent, respiratory infections, as well confirmation of an underlying problem via blood work and sputum culture samples.[18]

Treatment

Treatment of bronchiectasis is aimed at controlling infections and bronchial secretions, relieving airway obstruction, and preventing complications. This includes the prolonged usage of antibiotics to prevent detrimental infections, as well as eliminating accumulated fluid with postural drainage and chest physiotherapy. Surgery may also be used to treat localized bronchiectasis, removing obstructions that could cause progression of the disease.

Inhaled steroid therapy that is consistently adhered to can reduce sputum production and decrease airway constriction over a period of time, and help prevent progression of bronchiectasis. One commonly used therapy is beclometasone dipropionate, which is also used in asthma treatment. Use of inhalers such as albuterol (salbutamol), fluticasone (Flovent/Flixotide) and ipratropium (Atrovent) may help reduce likelihood of infection by clearing the airways and decreasing inflammation.

Mannitol dry inhalation powder, under the name Bronchitol, has been approved by the FDA for use in cystic fibrosis patients with or at risk for bronchiectasis. The original orphan drug indication approved in February 2005 allowed its use for the treatment of bronchiectasis. The original approval was based on the results of Phase II clinical studies showing the product to be safe, well-tolerated, and effective for stimulating mucus hydration/clearance, thereby improving quality of life in patients with chronic obstructive lung diseases like bronchiectasis. Long-term studies are underway as of 2007 to ensure the safety and effectiveness of the treatment.

Combination therapies, long acting bronchodilators and inhaled corticosteroids such as Symbicort and Advair Diskus are also commonly used inhaled medicines which has in many cases been effective in clearing the airways, reducing sputum and reducing inflammation.

Prevention

In order to prevent future development of bronchiectasis, an x-ray of the chest should be taken after any severe attack of measles, whooping cough or other acute respiratory infection in childhood. While smoking has not been found to be a direct cause of bronchiectasis, it is certainly an irritant that all patients should avoid in order to prevent the development of infections (such as bronchitis) and further complications.

A healthy body mass index, vaccination (especially against pneumonia and influenza) and regular doctor visits may have beneficial effects on the prevention of progressing bronchiectasis. The presence of hypoxemia, hypercapnia, dyspnea level and radiographic extent can greatly affect the mortality rate from this disease.

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Chronic Obstructive Pulmonary Disease (COPD)

2009-02-04T14:45:00.003+07:00

Chronic Obstructive Pulmonary Disease (COPD) is not one single disease but an umbrella term used to describe chronic lung diseases that cause limitations in lung airflow. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis.

The most common symptoms of COPD are breathlessness, or a 'need for air', excessive sputum production, and a chronic cough.
However, COPD is not just simply a "smoker's cough", but a under-diagnosed, life threatening lung disease that may progressively lead to death.

Key Facts

- Chronic obstructive pulmonary disease (COPD) is a life-threatening lung disease that interferes with normal breathing – it is more than a “smoker’s cough”.
- An estimated 210 million people have COPD worldwide.
- More than 3 million people died of COPD in 2005, which is equal to 5% of all deaths globally that year.
- Almost 90% of COPD deaths occur in low- and middle-income countries.
- The primary cause of COPD is tobacco smoke (through tobacco use or second-hand smoke).
- The disease now affects men and women almost equally, due in part to increased tobacco use among women in high-income countries.
- COPD is not curable, but treatment can slow the progress of the disease.
- Total deaths from COPD are projected to increase by more than 30% in the next 10 years without interventions to cut risks, particularly exposure to tobacco smoke.

Chronic obstructive pulmonary disease (COPD) is a lung ailment that is characterized by a persistent blockage of airflow from the lungs. It is an under-diagnosed, life-threatening lung disease that interferes with normal breathing and is not fully reversible. The more familiar terms of chronic bronchitis and emphysema are no longer used; they are now included within the COPD diagnosis.

Symptoms

The most common symptoms of COPD are breathlessness (or a "need for air"), abnormal sputum (a mix of saliva and mucus in the airway), and a chronic cough. Daily activities, such as walking up a short flight of stairs or carrying a suitcase, can become very difficult as the condition gradually worsens.

Diagnosis And Treatment

COPD is confirmed by a simple diagnostic test called "spirometry" that measures how much air a person can inhale and exhale, and how fast air can move into and out of the lungs. Because COPD develops slowly, it is frequently diagnosed in people aged 40 or older.

COPD is not curable. Various forms of treatment can help control its symptoms and increase quality of life for people with the illness. For example, medicines that help dilate major air passages of the lungs can improve shortness of breath.

Treatment

A. Stable COPD
1. Education : to understand the disease, stop smoking,
able to overcome the critical situation
2. Drugs : Decrease & complaints complications :
a. Br.dilator (Beta2 agonis, antikolinergik, methyl-xantin)
- Tx inhalation more better
- Options tx: the availability of drugs, response examination, Drugs side effect
- The provision of: continuously or when necessary
- Combination drugs: increase efikasi & decrease Drugs side effect
b. Kortikosteroid inhalation, when given:
- Response (+)
- FEV1 <50% pred
- Eksaserbasi repeated
- Long-term oral K.steroid not recommended
c. Mukolitik, given the thick sputum
d. Antioxidants - N-acethyl cistein:
- Decrease frequency weight eksaserbation

3. Oxygen:
- Long-term (> 15 hrs / day) failed on COPD with respiratory distress chronic increase survival
- Indications:
- Pao2 <55 mmHg or SaO2 <88% ± hiperkapni
- Pao2 55-60 mmHg or SaO2 89% but have hypertension pulmonal, edema perifer, CHF, polisitemia (Hct> 55%)
4. Ventilator
5. Medical rehabilitation
comprehensive -> exercise training, nutrition consultation,
education -> improvement of exercise tolerance and shortness of breath complaint
6. Operation -> Bulektomi and transplant tuberculosis

Who Is At Risk?

At one time, COPD was more common in men, but because of increased tobacco use among women in high-income countries, and the higher risk of exposure to indoor air pollution (such as solid fuel used for cooking and heating) in low-income countries, the disease now affects men and women almost equally.

Almost 90% of COPD deaths occur in low- and middle-income countries, where effective strategies for prevention and control are not always implemented or accessible.

Risk Factors

COPD is preventable. The primary cause of COPD is tobacco smoke (including second-hand or passive exposure). Other risk factors include:

- indoor air pollution (such as solid fuel used for cooking and heating);
- outdoor air pollution;
- occupational dusts and chemicals (vapors, irritants, and fumes);
- frequent lower respiratory infections during childhood.

Total deaths from COPD are projected to increase by more than 30% in the next 10 years unless urgent action is taken to reduce underlying risk factors, especially tobacco use.

According to the latest WHO estimates (2007), currently 210 million people have COPD and 3 million people died of COPD in 2005. WHO predicts that COPD will become the third leading cause of death worldwide by 2030.

The most important risk factors for COPD are:

- Tobacco smoking
- Indoor air pollution (such as biomass fuel used for cooking and heating)
- Outdoor air pollution
- Occupational dusts and chemicals (vapors, irritants, and fumes)

WHO Response

WHO’s work on COPD is part of the organization's overall efforts to prevent and control chronic diseases. WHO aims to:

- raise awareness about the global epidemic of chronic diseases;
- create more healthy environments, especially for poor and disadvantaged populations;
- decrease common chronic disease risk factors, such as tobacco use, unhealthy diet and physical inactivity;
- prevent premature deaths and avoidable disabilities from major chronic diseases.

The WHO Framework Convention on Tobacco Control (WHO FCTC) was developed in response to the globalization of the tobacco epidemic, with the aim to protect billions of people from harmful exposure to tobacco. It is the first global health treaty negotiated by World Health Organization, and has been ratified by more than 140 countries.

WHO also leads the Global Alliance against Chronic Respiratory Diseases (GARD), a voluntary alliance of national and international organizations, institutions, and agencies working towards the common goal of reducing the global burden of chronic respiratory diseases. Its vision is a world where all people breathe freely. GARD focuses specifically on the needs of low- and middle-income countries and vulnerable populations.

http://www.who.int

Asma Bronchiale

2009-02-04T14:11:00.005+07:00

Asma bronkial, atau lebih populer dengan sebutan asma atau sesak napas, telah dikenal luas di masyarakat. Namun pengetahuan tentang asma bronkial hanya terbatas pada gejala asma bronkial saja, diantaranya dada terasa tertekan, sesak napas, batuk berdahak, napas berbunyi (mengi), dll.

Asma bronkial merupakan salah satu Penyakit Paru Obstruktif Kronis (PPOK) yakni penyakit paru yang memiliki kumpulan gejala klinis (sindrom) seperti yang telah disebutkan di atas. PPOK terdiri dari:

- Asma Bronkial (asma/bengek)
- Bronkitis kronis (radang saluran napas bagian bawah)
- Emfisema paru (penurunan daya elastisitas paru)

Faktor penyebab PPOK salah satunya adalah polusi udara yang berasal dari asap rokok, cerobong pabrik/industri, asap kendaraan bermotor. Semakin tua usia seseorang akan semakin lama menghisap udara yang berpolusi dan semakin besar kecenderungan untuk menderita sindrom PPOM.

Definisi

Penyakit asma bronkial secara umum adalah penyakit saluran pernapasan yang ditandai dengan:

- Sesak napas/sukar bernapas yang diikuti dengan suara “mengi” (bunyi yang meniup sewaktu mengeluarkan udara/napas)
- Rasa berat dan kejang pada dada sehingga napas jadi terengah-engah
- Biasanya disertai batuk dengan dahak yang kental dan lengket
- Perasaan menjadi gelisah dan cemas

Sedangkan berdasarkan ilmu kedokteran, penyakit asma bronkial adalah penyakit saluran pernapasan dengan ciri-ciri saluran pernapasan tersebut akan bersifat hipersensitif (kepekaan yang luar biasa) atau hiperaktif (bereaksi yang berlebihan) terhadap bermacam-macam rangsangan, yang ditandai dengan timbulnya penyempitan saluran pernapasan bagian bawah secara luas, yang dapat berubah derajat penyempitannya menjadi normal kembali secara spontan dengan atau tanpa pengobatan.

Kelainan dasar penyempitan saluran pernapasan yang berakibat timbulnya sesak napas adalah gabungan dari keadaan berikut:

- Kejang/berkerutnya otot polos dari saluran pernapasan
- Sembab/pembengkakan selaput lendir
- Proses keradangan
- Pembentukan dan timbunan lendir yang berlebihan dalam rongga saluran pernapasan

Mekanisme Terjadinya Kelainan Pernapasan

Baik orang normal maupun penderita asma, bernapas dengan udara yang kualitas dan komposisinya sama. Udara pada umumnya mengandung 3 juta partikel/mm kubik. Partikel-partikel itu dapat terdiri dari debu, kutu debu (tungau), bulu-bulu binatang, bakteri, jamur, virus, dll.

Oleh karena adanya rangsangan dari partikel-partikel tersebut secara terus menerus, maka timbul mekanisme rambut getar dari saluran napas yang bergetar hingga partikel tersebut terdorong keluar sampai ke arah kerongkongan yang seterusnya dikeluarkan dari dalam tubuh melalui reflek batuk. Pada penderita asma bronkial karena saluran napasnya sangat peka (hipersensitif) terhadap adanya partikel udara ini, sebelum sempat partikel tersebut dikeluarkan dari tubuh, maka jalan napas (bronkus) memberi reaksi yang sangat berlebihan (hiperreaktif), maka terjadilah keadaan dimana:

- Otot polos yang menghubungkan cincin tulang rawan akan berkontraksi/memendek/mengkerut
- Produksi kelenjar lendir yang berlebihan
- Bila ada infeksi, misal batuk pilek (biasanya selalu demikian) akan terjadi reaksi sembab/pembengkakan dalam saluran napas

Hasil akhir dari semua itu adalah penyempitan rongga saluran napas. Akibatnya menjadi sesak napas, batuk keras bila paru mulai berusaha untuk membersihkan diri, keluar dahak yang kental bersama batuk, terdengar suara napas yang berbunyi yang timbul apabila udara dipaksakan melalui saluran napas yang sempit. Suara napas tersebut dapat sampai terdengar keras terutama saat mengeluarkan napas. Serangan asma bronkial ini dapat berlangsung dari beberapa jam sampai berhari-hari dengan gejala klinik yang bervariasi dari yang ringan (merasa berat di dada, batuk-batuk) dan masih dapat bekerja ringan yang akhirnya dapat hilang sendiri tanpa diobati.

Gejala yang berat dapat berupa napas sangat sesak, otot-otot daerah dada berkontraksi sehingga sela-sela iganya menjadi cekung, berkeringat banyak seperti orang yang bekerja keras, kesulitan berbicara karena tenaga hanya untuk berusaha bernapas, posisi duduk lebih melegakan napas daripada tidur meskipun dengan bantal yang tinggi, bila hal ini berlangsung lama maka akan timbul komplikasi yang serius.

Yang paling ditakutkan adalah bila proses pertukaran gas O2 dan CO2 pada alveolus terganggu suplainya untuk organ tubuh yang vital (tertutama otak) yang sangat sensitif untuk hal ini, akibatnya adalah: muka menjadi pucat, telapak tangan dan kaki menjadi dingin, bibir dan jari kuku kebiruan, gelisah dan kesadaran menurun.

Pada keadaan tersebut di atas merupakan tanda bahwa penderita sudah dalam keadaan bahaya/kritis dan harus secepatnya masuk rumah sakit/minta pertolongan dokter yang terdekat.

Pengenalan Jenis Serangan Asma Bronkial

Pengenalan jenis serangan asma berkaitan erat dengan cara pengobatannya. Serangan asma/bengek ada 2 macam, yaitu:
1. Serangan asma bronkial karena otot polos saluran napas yang berkerut (Asma Episodik)
Serangan asma bronkial/bengek hanya sekali-sekali, ada periode bebas sesak napas, serangan “mengi” mungkin terjadi misalnya sewaktu jogging, makan suatu makanan yang kebetulan alergi, mencium binatang piaraan, dsb.

Jenis ini memberikan respon yang baik terhadap pemberian obat pelonggar nafas hirup (inhaler) dimana merupakan obat yang paling aman dengan sedikit efek samping yang minimal. Dapat juga diberikan obat pelonggar napas dalam bentuk tablet maupun sirup.

2. Serangan asma bronkial karena proses peradangan saluran pernapasan (Continuing Asma/Asma Berkelanjutan)
Penderita asma bronkial/bengek ini tidak pernah merasakan benar-benar bebas sesak, jadi hampir setiap hari menderita “mengi”. Saluran pernapasannya mengalami keradangan sehingga mempunyai resiko untuk terjadi serangan lebih sering, walaupun telah diberikan obat pelonggar napas.

Oleh karenanya, penderita memerlukan obat tambahan berupa anti keradangan (biasanya keluarga steroid).

Pengobatan Penyakit Asma

Asma tidak bisa disembuhkan, namun bisa dikendalikan, sehingga penderita asma dapat mencegah terjadinya sesak napas akibat serangan asma.

Kurangnya pengertian mengenai cara-cara pengobatan yang benar akan mengakibatkan asma salalu kambuh. Jika pengobatannya dilakukan secara dini, benar dan teratur maka serangan asma akan dapat ditekan seminimal mungkin.

Pada prinsipnya tata cara pengobatan asma dibagi atas:
1. Pengobatan Asma Jangka Pendek
2. Pengobatan Asma Jagka Panjang

Pengobatan Asma Jangka Pendek

Pengobatan diberikan pada saat terjadi serangan asma yang hebat, dan terus diberikan sampai serangan merendah, biasanya memakai obat-obatan yang melebarkan saluran pernapasan yang menyempit.

Tujuan pengobatannya untuk mengatasi penyempitan jalan napas, mengatasi sembab selaput lendir jalan napas, dan mengatasi produksi dahak yang berlebihan. Macam obatnya adalah:

A. Obat untuk mengatasi penyempitan jalan napas
Obat jenis ini untuk melemaskan otot polos pada saluran napas dan dikenal sebagai obat bronkodilator. Ada 3 golongan besar obat ini, yaitu:
- Golongan Xantin, misalnya Ephedrine HCl (zat aktif dalam Neo Napacin)
- Golongan Simpatomimetika
- Golongan Antikolinergik

Walaupun secara legal hanya jenis obat Ephedrine HCl saja yang dapat diperoleh penderita tanpa resep dokter (takaran < 25 mg), namun tidak tertutup kemungkinannya penderita memperoleh obat anti asma yang lain.

B. Obat untuk mengatasi sembab selaput lendir jalan napas

Obat jenis ini termasuk kelompok kortikosteroid. Meskipun efek sampingnya cukup berbahaya (bila pemakaiannya tak terkontrol), namun cukup potensial untuk mengatasi sembab pada bagian tubuh manusia termasuk pada saluran napas. Atau dapat juga dipakai kelompok Kromolin.

C. Obat untuk mengatasi produksi dahak yang berlebihan.

Jenis ini tidak ada dan tidak diperlukan. Yang terbaik adalah usaha untuk mengencerkan dahak yang kental tersebut dan mengeluarkannya dari jalan napas dengan refleks batuk.

Oleh karenanya penderita asma yang mengalami ini dianjurkan untuk minum yang banyak. Namun tak menutup kemungkinan diberikan obat jenis lain, seperti Ambroxol atau Carbo Cystein untuk membantu.

Pengobatan Asma Jangka Panjang

Pengobatan diberikan setelah serangan asma merendah, karena tujuan pengobatan ini untuk pencegahan serangan asma.

Pengobatan asma diberikan dalam jangka waktu yang lama, bisa berbulan-bulan sampai bertahun-tahun, dan harus diberikan secara teratur. Penghentian pemakaian obat ditentukan oleh dokter yang merawat.

Pengobatan ini lazimnya disebut sebagai immunoterapi, adalah suatu sistem pengobatan yang diterapkan pada penderita asma/pilek alergi dengan cara menyuntikkan bahan alergi terhadap penderita alergi yang dosisnya dinaikkan makin tinggi secara bertahap dan diharapkan dapat menghilangkan kepekaannya terhadap bahan tersebut (desentisasi) atau mengurangi kepekaannya (hiposentisisasi).

http://www.infoasma.org

Tuberculosis

2009-02-04T13:37:00.005+07:00

Infection and transmission

Tuberculosis (TB) is a contagious disease. Like the common cold, it spreads through the air. Only people who are sick with TB in their lungs are infectious. When infectious people cough, sneeze, talk or spit, they propel TB germs, known as bacilli, into the air. A person needs only to inhale a small number of these to be infected.

Left untreated, each person with active TB disease will infect on average between 10 and 15 people every year. But people infected with TB bacilli will not necessarily become sick with the disease. The immune system "walls off" the TB bacilli which, protected by a thick waxy coat, can lie dormant for years. When someone's immune system is weakened, the chances of becoming sick are greater.

- Someone in the world is newly infected with TB bacilli every second.
- Overall, one-third of the world's population is currently infected with the TB bacillus.
- 5-10% of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life. People with HIV and TB infection are much more likely to develop TB.

Global and regional incidence

The World Health Organization (WHO) estimates that the largest number of new TB cases in 2005 occurred in the South-East Asia Region, which accounted for 34% of incident cases globally. However, the estimated incidence rate in sub-Saharan Africa is nearly twice that of the South-East Asia Region, at nearly 350 cases per 100 000 population.

It is estimated that 1.6 million deaths resulted from TB in 2005. Both the highest number of deaths and the highest mortality per capita are in the Africa Region. The TB epidemic in Africa grew rapidly during the 1990s, but this growth has been slowing each year, and incidence rates now appear to have stabilized or begun to fall.

In 2005, estimated per capita TB incidence was stable or falling in all six WHO regions. However, the slow decline in incidence rates per capita is offset by population growth. Consequently, the number of new cases arising each year is still increasing globally and in the WHO regions of Africa, the Eastern Mediterranean and South-East Asia.

HIV and TB

HIV and TB form a lethal combination, each speeding the other's progress. HIV weakens the immune system. Someone who is HIV-positive and infected with TB bacilli is many times more likely to become sick with TB than someone infected with TB bacilli who is HIV-negative. TB is a leading cause of death among people who are HIV-positive. In Africa, HIV is the single most important factor contributing to the increase in incidence of TB since 1990.

WHO and its international partners have formed the TB/HIV Working Group, which develops global policy on the control of HIV-related TB and advises on how those fighting against TB and HIV can work together to tackle this lethal combination. The interim policy on collaborative TB/HIV activities describes steps to create mechanisms of collaboration between TB and HIV/AIDS programmes, to reduce the burden of TB among people and reducing the burden of HIV among TB patients.
Drug-resistant TB

Until 50 years ago, there were no medicines to cure TB. Now, strains that are resistant to a single drug have been documented in every country surveyed; what is more, strains of TB resistant to all major anti-TB drugs have emerged. Drug-resistant TB is caused by inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period because they start to feel better, because doctors and health workers prescribe the wrong treatment regimens, or because the drug supply is unreliable. A particularly dangerous form of drug-resistant TB is multidrug-resistant TB (MDR-TB), which is defined as the disease caused by TB bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-TB are high in some countries, especially in the former Soviet Union, and threaten TB control efforts.

While drug-resistant TB is generally treatable, it requires extensive chemotherapy (up to two years of treatment) with second-line anti-TB drugs which are more costly than first-line drugs, and which produce adverse drug reactions that are more severe, though manageable. Quality-assured second-line anti-TB drugs are available at reduced prices for projects approved by the Green Light Committee.

The emergence of extensively drug-resistant (XDR) TB, particularly in settings where many TB patients are also infected with HIV, poses a serious threat to TB control, and confirms the urgent need to strengthen basic TB control and to apply the new WHO guidelines for the programmatic management of drug-resistant TB.
The Stop TB Strategy, the Global Plan to Stop TB, 2006–2015 and targets for TB control

In 2006, WHO launched the new Stop TB Strategy. The core of this strategy is DOTS, the TB control approach launched by WHO in 1995. Since its launch, more than 22 million patients have been treated under DOTS-based services. The new six-point strategy builds on this success, while recognizing the key challenges of TB/HIV and MDR-TB. It also responds to access, equity and quality constraints, and adopts evidence-based innovations in engaging with private health-care providers, empowering affected people and communities and helping to strengthen health systems and promote research.

The six components of the Stop TB Strategy are:

1. Pursuing high-quality DOTS expansion and enhancement. Making high-quality services widely available and accessible to all those who need them, including the poorest and most vulnerable, requires DOTS expansion to even the remotest areas. In 2004, 183 countries (including all 22 of the high-burden countries which account for 80% of the world's TB cases) were implementing DOTS in at least part of the country.
2. Addressing TB/HIV, MDR-TB and other challenges. Addressing TB/HIV, MDR-TB and other challenges requires much greater action and input than DOTS implementation and is essential to achieving the targets set for 2015, including the United Nations Millennium Development Goal relating to TB (Goal 6; Target 8).
3. Contributing to health system strengthening. National TB control programmes must contribute to overall strategies to advance financing, planning, management, information and supply systems and innovative service delivery scale-up.
4. Engaging all care providers. TB patients seek care from a wide array of public, private, corporate and voluntary health-care providers. To be able to reach all patients and ensure that they receive high-quality care, all types of health-care providers are to be engaged.
5. Empowering people with TB, and communities. Community TB care projects have shown how people and communities can undertake some essential TB control tasks. These networks can mobilize civil societies and also ensure political support and long-term sustainability for TB control programmes.
6. Enabling and promoting research. While current tools can control TB, improved practices and elimination will depend on new diagnostics, drugs and vaccines.

The strategy is to be implemented over the next 10 years as described in The Global Plan to Stop TB, 2006–2015. The Global Plan is a comprehensive assessment of the action and resources needed to implement the Stop TB Strategy and to achieve the following targets:

1. Millennium Development Goal (MDG) 6, Target 8: Halt and begin to reverse the incidence of TB by 2015
2. Targets linked to the MDGs and endorsed by the Stop TB Partnership:
- by 2005: detect at least 70% of new sputum smear-positive TB cases and cure at least 85% of these cases
- by 2015: reduce TB prevalence and death rates by 50% relative to 1990
- by 2050: eliminate TB as a public health problem (1 case per million population)

Progress towards targets

In 2005, an estimated 60% of new smear-positive cases were treated under DOTS – just short of the 70% target.

Treatment success in the 2004 DOTS cohort of 2.1 million patients was 84% on average, close to the 85% target. However, cure rates in the African and European regions were only 74%.

The 2007 WHO report Global TB Control concluded that both the 2005 targets were met by the Western Pacific Region, and by 26 individual countries (including 3 of the 22 high-burden countries: China, the Philippines and Viet Nam.

The global TB incidence rate had probably peaked in 2005, and if the Stop TB Strategy is implemented as set out in the Global Plan, the resulting improvements in TB control should halve prevalence and death rates in all regions except Africa and Eastern Europe by 2015.

http://www.who.int

Pict : Pharyngitis

2009-01-27T05:04:00.002+07:00

commons.wikimedia.org

Description

Viral pharyngitis.
* Author : Dake
* Patient : Dake

Symptoms :
* Runny nose
* Sore throat
* Red oropharynx (swollen area in the middle of the picture)
* Headache
* Low-grade fever

Pict : Otitis Externa

2009-01-27T04:29:00.008+07:00

www.globalrph.com

Otitis Externa

2009-01-27T03:47:00.008+07:00

Otitis externa ("swimmer's ear") is an inflammation of the outer ear and ear canal. Along with otitis media, external otitis is one of the two human conditions commonly called "earache". It also occurs in many other species. Inflammation of the skin of the ear canal is the essence of this disorder. The inflammation can be secondary to dermatitis (eczema) only, with no microbial infection, or it can be caused by active bacterial or fungal infection. In either case, but more often with infection, the ear canal skin swells and may become painful and/or tender to touch.

Acute

In contrast to the chronic otitis externa, acute otitis externa is predominantly a microbial infection, occurs rather suddenly, rapidly worsens, and becomes very painful and alarming. The ear canal has an abundant nerve supply, so the pain is often severe enough to interfere with sleep. Wax in the ear can combine with the swelling of the canal skin and any associated pus to block the canal and dampen hearing to varying degrees, creating a temporary conductive hearing loss. In more severe or untreated cases, the infection can spread to the soft tissues of the face that surround the adjacent parotid gland and the jaw joint, making chewing painful. In its mildest forms, external otitis is so common that some ear nose and throat physicians have suggested that most people will have at least a brief episode at some point in life. While a small percentage of people seem to have an innate tendency toward chronic external otitis, most people can avoid external otitis altogether once they understand the mechanisms of the disease.

The skin of the bony ear canal is unique, in that it is not movable but is closely attached to the bone, and it is almost paper thin. For these reasons it is easily abraded or torn by even minimal physical force. Inflammation of the ear canal skin typically begins with a physical insult, most often from injury caused by attempts at self-cleaning or scratching with cotton swabs, pen caps, finger nails, hair pins, keys, or other small implements. Another causative factor for acute infection is prolonged water exposure in the forms of swimming or exposure to extreme humidity, which can compromise the protective barrier function of the canal skin, allowing bacteria to flourish; hence the name, "swimmer's ear". Densely impacted wax, usually caused by enthusiastic use of cotton swabs, can put enough pressure on the ear canal skin to injure it and initiate infection. A sensation of blockage or itching can prompt attempts to clean, scratch, or open the ear canal, which potentially worsens and perpetuates the condition. The cotton fibers of a swab are abrasive to the thin, fixed canal skin. Self-manipulative measures to improve the condition often make it worse and are to be discouraged, since it is a blind exercise that can result in significant injury to the ear. Production of wax by glands in the canal may be hindered by external otitis. The exact function(s) of cerumen (earwax) is a subject that is open to speculation, since there is very little research regarding its function. Some caretakers feel strongly that earwax has a protective function with respect to infection and that a little earwax in the ear canal is a good thing. A natural question is, "How can I clean my ears, then?" It is well established that in most people the top layer of the ear canal skin normally migrates toward the ear opening, essentially sweeping the canal on a continuing basis. In other words, a normal ear canal is self-cleaning. This self-cleaning physiologic feature fails in some patients, especially in late life, and periodic cleaning by a physician can be necessary. The most controlled and least painful means of cleaning impacted wax or dead skin from the ear canal is by using a binocular surgical microscope, which frees the examiner's hands to instrument the ear and provides the magnification and depth perception needed to avoid traumatizing the delicate canal skin and eardrum.

Symptoms

Pain is the predominant complaint and the only symptom directly related to the severity of acute external otitis. Unlike other forms of ear infections, the pain of acute external otitis is worsened when the outer ear is touched or pulled gently. Pushing the tragus (that tablike portion of the auricle that projects out just in front of the ear canal opening) so typically causes pain in this condition as to be diagnostic of external otitis on physical examination. Patients may also experience ear discharge and itchiness. When enough swelling and discharge in the ear canal is present to block the opening, external otitis may cause temporary conductive hearing loss.

Due to the fact that the ear and throat are often interconnected, irritation (whether it be in inflammation or a scratching sensation) is normal. However, excessive throat symptoms may likely point to the throat as the cause of the pain in the ear rather than the other way around.

Because the symptoms of external otitis promote many people to attempt to clean out the ear canal (or scratch it) with slim implements, and self-cleaning attempts generally lead to additional trauma of the injured skin, rapid worsening of the condition often occurs.

Causes, incidence, and risk factors

Swimming in polluted water is a common way to contract swimmer's ear, but it is also possible to contract swimmer's ear from water trapped in the ear canal after a shower, especially in a humid climate. Saturation divers have reported Otitis externa during occupational exposure. Even without exposure to water, the use of objects such as cotton swabs or other small objects to clear the ear canal is enough to cause breaks in the skin, and allow the condition to develop. Once the skin of the ear canal is inflamed, external otitis can be drastically enhanced by either scratching the ear canal with an object, or by allowing water to remain in the ear canal for any prolonged length of time.

The two factors that are required for external otitis to develop are the presence of germs that can infect the skin and impairments in the integrity of the skin of the ear canal that allow infection to occur. If the skin is healthy and uninjured, only exposure to a high concentration of pathogens, such as submersion in a pond contaminated by sewage, is likely to set off an episode. However, if there are chronic skin conditions that affect the ear canal skin, such as atopic dermatitis, seborrheic dermatitis, psoriasis or abnormalities of keratin production, or if there has been a break in the skin from trauma, even the normal bacteria found in the ear canal may cause infection and full-blown symptoms of external otitis.

Fungal ear canal infections, also known as otomycosis, range from inconsequential to very severe. Fungus can be saprophytic, in which there are no symptoms and the fungus simply co-exists in the ear canal in a harmless parasitic relationship with the host, in which case the only physical finding is presence of the fungus. If for any reason the fungus begins active reproduction, the ear canal can fill with dense fungal debris, causing pressure and ever-increasing pain that is unrelenting until the fungus is removed from the canal and anti-fungal medication is used. Most antibacterial ear drops also contain a steroid to hasten resolution of canal edema and pain. Unfortunately such drops make fungal infection worse. Prolonged use of them promotes growth of fungus in the ear canal. Antibacterial ear drops should be used a maximum of one week, but 5 days is usually enough. Otomycosis responds more than 95% of the time to a three day course of the same over-the-counter anti-fungal solutions used for athlete's foot.

The incidence of otitis externa is high. In the Netherlands, it has been estimated at 12-14 per 1000 population per year, and has been shown to affect more than 1% of a sample of the population in the United Kingdom over a 12 month period.

Pathogens

The greenish coloration is characteristic of Pseudomonas aeruginosa, which was verified by laboratory bacteriological culture. This gram-negative bacillus has been reported as the predominant microorganism in otitis externa, exacerbated in hot, humid climates.www.rcsullivan.com

The bacterial pathogens at the top of the list are Pseudomonas aeruginosa and Staphylococcus aureus, followed by a great number of other gram-positive and gram-negative species. Candida albicans and Aspergillus species are the most common fungal pathogens responsible for the condition.

Diagnosis

When the physician looks in the ear, the canal appears red and swollen in well-developed cases of acute external otitis. The ear canal may also appear eczema-like, with scaly shedding of skin. Touching or moving the outer ear increases the pain, and this maneuvre on physical exam is very important in establishing the clinical diagnosis. It may be difficult for the physician to see the eardrum with an otoscope at the initial examination because of narrowing of the ear canal from inflammation and the presence of drainage and debris. Sometimes the diagnosis of external otitis is presumptive and return visits are required to fully examine the ear. Culture of the drainage may identify the bacteria or fungus causing infection, but is not part of the routine diagnostic evaluation. In severe cases of external otitis, there may be swelling of the lymph node(s) directly beneath the ear.

The diagnosis may be missed in early cases because the examination of the ear, with the exception of pain with manipulation, is normal or nearly normal. In some cases of early external otitis, the most striking visual finding in the ear canal is the lack of cerumen. As a moderate or severe case of external otitis resolves, weeks may be required before the ear canal again shows a normal amount of cerumen.

Treatment

The goal of treatment is to cure the infection and to return the ear canal skin to a healthy condition. When external otitis is very mild, in its initial stages, simply refraining from swimming or washing hair for a few days, and keeping all implements out of the ear, usually results in a cure. For this reason, external otitis is called a self-limiting condition. However, if the infection is moderate to severe, or if the climate is humid enough that the skin of the ear remains moist, spontaneous improvement may not occur.

Topical solutions or suspensions in the form of ear drops are the mainstays of treatment for external otitis. Some contain antibiotics, either antibacterial or antifungal, and others are simply designed to mildly acidify the ear canal environment to discourage bacterial growth. Some prescription drops also contain anti-inflammatory steroids, which help to resolve swelling and itching. Although there is evidence that steroids are effective at reducing the length of treatment time required, fungal otitis externa (also called otomycosis) may be caused or aggravated by overly prolonged use of steroid-containing drops. In addition to topical antibiotics, oral anti-pseudomonal antibiotics can be used in case of severe soft tissue swelling extending into the face and neck and may hasten recovery.

Removal of debris (wax, shed skin, and pus) from the ear canal promotes direct contact of the prescribed medication with the infected skin and shortens recovery time. This is best accomplished using a binocular microscope. When canal swelling has progressed to the point where the ear canal is blocked, topical drops may not penetrate far enough into the ear canal to be effective. The physician may need to carefully insert a wick of cotton or other commercially available, pre-fashioned, absorbent material called an ear wick and then saturate that with the medication. The wick is kept saturated with medication until the canal opens enough that the drops will penetrate the canal without it. Removal of the wick does not require a health professional. Antibiotic ear drops should be dosed in a quantity that allows coating of most of the ear canal and used for no more than 4 to 7 days. The ear should be left open. Do note that it is imperative that there is visualization of an intact tympanic membrane. Use of certain medications with a ruptured tympanic membrane can cause tinnitus, vertigo, dizziness and hearing loss in some cases.

Although the acute external otitis generally resolves in a few days with topical washes and antibiotics, complete return of hearing and cerumen gland function may take a few more days. Once healed completely, the ear canal is again self-cleaning. Until it recovers fully, it may be more prone to repeat infection from further physical or chemical insult.

Effective medications include ear drops containing antibiotics to fight infection, and corticosteroids to reduce itching and inflammation. In painful cases a topical solution of antibiotics such as aminoglycoside, polymyxin or fluoroquinolone is usually prescribed. Antifungal solutions are used in the case of fungal infections. External otitis is almost always predominantly bacterial or predominantly fungal, so that only one type of medication is necessary and indicated.

The pain of acute otitis externa is often severe enough to interfere with sleep. Topical analgesic drops often prescribed by primary care providers for pain relief are almost never adequate and should not be relied upon. A brief course of oral narcotic pain medication is often necessary to maintain comfort while the antibiotic drops are working. Improvement with appropriate initial treatment (cleaning of the canal, wick insertion if necessary, and antibiotic drops in adequate amount) is fairly rapid, with pain improvement occurring within one day and resolution within 2-4 days. Heat application using a heating pad, can also aid in pain relief, although it may increase the bacteria growth.

Non-prescription remedies

Provided it is not too severe, recurrent otitis externa can often be successfully treated by non-prescription means, at low cost. When symptoms recur in an individual who has had a previous diagnosis made, the use of non-prescription drops along with precautions to keep water out of the ear is generally effective. Self-treatment with non-prescription remedies is dangerous in individuals who have not been previously evaluated for the condition, because the tympanic membrane may not be intact, and because the true condition may be otitis media with drainage. Drops and water precautions may actually resolve otitis media with drainage for a period of time, while allowing an undiagnosed cholesteatoma to progress, or complications of otitis media to develop.

Effective solutions for the ear canal include acidifying and drying agents, used either singly or in combination. When the ear canal skin is inflamed from the acute otitis externa, the use of dilute acetic acid may be painful.

Burow's solution is an effective remedy against both bacterial and fungal external otitis. This is a buffered mixture of aluminium sulfate and acetic acid, and is available without prescription in the United States.

Prevention

The strategies for preventing acute external otitis are similar to those for treatment.

* Avoid inserting anything into the ear canal; use of cotton buds or swabs is the most common event leading to acute otitis externa.
* Most normal ear canals have a self-cleaning and self-drying mechanism, the latter by simple evaporation.
* After prolonged swimming, a person prone to external otitis can dry the ears using a small battery-powered ear dryer, available at many retailers, especially shops catering to watersports enthusiasts. Alternatively, drops containing dilute acetic acid (vinegar diluted 3:1) or Burow's solution may be used. It is especially important NOT to instrument ears when the skin is saturated with water, as it is very susceptible to injury, which can lead to external otitis.
* Avoid swimming in polluted water.
* Avoid washing hair or swimming if very mild symptoms of acute external otitis begin
* Although the use of earplugs when swimming and shampooing hair may help prevent external otitis, there are important details in the use of plugs. Hard and poorly fitting ear plugs can scratch the ear canal skin and set off an episode. When earplugs are used during an acute episode, either disposable plugs are recommended, or used plugs must be cleaned and dried properly to avoid contaminating the healing ear canal with infected discharge. One simple method of fabricating soft waterproof disposable ear plugs is with cotton balls and petroleum jelly. These jelly coated cotton balls are NOT inserted into the ear canal, but pressed into the auricle to cover the opening of the canal. Poorly fitted head sets can also bring on an episode caused by friction between the ear and phone muffs. It is important to wear small head phones that do not cover the whole ear.

Prognosis

Otitis externa responds well to treatment, but complications may occur if it is not treated. Individuals with underlying diabetes or disorders of the immune system are more likely to get complications, including malignant otitis externa. In these individuals, rapid examination by an otolaryngologist (ear, nose, and throat physician) is very important.

Complications

* Chronic otitis externa
* Spread of infection to other areas of the body
* Necrotizing External Otitis

Necrotizing External Otitis (Malignant otitis externa)

This uncommon form of external otitis occurs mainly in elderly diabetics, being somewhat more likely and more severe when the diabetes is poorly controlled. Even less commonly, it can develop due to a severely compromised immune system. Beginning as infection of the external ear canal, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. The hallmark of malignant otitis externa (MOE) is unrelenting pain that interferes with sleep and persists even after swelling of the external ear canal may have resolved with topical antibiotic treatment.

Natural History

MOE follows a more chronic course than ordinary acute otitis externa. There may be granulation involving the floor of the external ear canal, most often at the bony-cartilaginous junction. Paradoxically, the physical findings of MOE, at least in its early stages, are often much less dramatic than those of ordinary acute otitis externa. In later stages there can be soft tissue swelling around the ear, even in the absence of significant canal swelling. Also it can hurt the tip of your throat, causing pain when touched.

Treatment

Unlike ordinary otitis externa, MOE requires oral or intravenous antibiotics for cure. Diabetes control is also an essential part of treatment. When MOE goes unrecognized and untreated, the infection continues to smolder and over weeks or months can spread deeper into the head and involve the bones of the skull base, constituting skull base osteomyelitis (SBO). The infecting organism is almost always pseudomonas aeruginosa, but it can instead be fungal (aspergillus or mucor). MOE and SBO are not amenable to surgery, but exploratory surgery may facilitate culture of unusual organism(s) that are not responding to empirically used anti-pseudomonal antibiotics. The usual surgical finding is diffuse cellulitis without localized abscess formation. SBO can extend into the petrous apex of the temporal bone or more inferiorly into the opposite side of the skull base.

Complications

As the skull base is progressively involved, the adjacent exiting cranial nerves and their branches, especially the facial nerve and the vagus nerve, may be affected, resulting in facial paralysis and hoarseness, respectively. If both of the recurrent laryngeal nerves are paralyzed, shortness of breath may develop and necessitate tracheotomy. Profound deafness can occur, usually later in the disease course due to relative resistance of the inner ear structures. Gallium scans are sometimes used to document the extent of the infection but are not essential to disease management. Skull base osteomyelitis is a chronic disease that can require months of IV antibiotic treatment, tends to recur, and has a significant mortality rate.
source : http://en.wikipedia.org

Rhinitis Allergy

2009-01-19T22:25:00.008+07:00

Do you suffer from nasal congestion, runny nose, sneezing, and itching in the nose, roof of the mouth, throat, eyes, or ears? These are all symptoms of rhinitis, a condition affecting more than 50 million Americans, in which the lining of the nose becomes inflamed or irritated.

Allergic vs. Non-Allergic Rhinitis
There are two types of rhinitis: allergic rhinitis (sometimes called a "sinus allergy") and non-allergic rhinitis. If you have allergic rhinitis, your body produces IgE (or immunoglobulin E) antibodies to certain substances you are allergic to, called allergens. When you come into contact with these allergens, IgE triggers the allergic reaction and your immune system releases substances called histamine and leukotriene that cause the lining of your nose to become inflamed. "In allergic rhinitis, you can identify IgE antibodies to various proteins," explains Julie McNairn, MD, an allergist/immunologist in Cincinnati.

An allergist can help identify what allergens are causing your allergic rhinitis by administering skin or blood tests. People who suffer from seasonal allergic rhinitis — known as hay fever — may be allergic to trees, grasses, weed pollens, or mold spores that are more common during a particular season of the year. Those who experience symptoms year-round, a condition called "perennial allergic rhinitis," are usually allergic to dust mites, pet dander, mold spores, or foods.

If your allergist is not able to identify an allergen that is causing your rhinitis, you may have non-allergic rhinitis. One in three people with rhinitis don’t seem to have a specific allergen that triggers the problem. "In non-allergic rhinitis, there are no identifiable IgE antibodies against a specific protein," says Dr. McNairn, noting that irritants such as cigarette smoke, odors, weather changes, and dust are common culprits for people with non-allergic rhinitis. "Anything that is irritating to the mucus membranes can cause non-allergic rhinitis," she adds. These irritants are thought to lead to inflammation of the sinuses.

Non-allergic rhinitis can also be caused by long-term use of nasal decongestant sprays. People who have non-allergic rhinitis usually suffer from their symptoms all year long.

Treatment Options for Rhinitis
How you and your doctor decide to treat your rhinitis will depend on your preferences, symptoms, and the cause of your rhinitis. Treatment options for rhinitis are many, and include:

* Reducing allergens in your home
* Antihistamines
* Decongestants
* Leukotriene inhibitors
* Corticosteroid nasal sprays
* Ipratropium nasal spray
* Allergen immunotherapy (allergy shots)

Living With Rhinitis
"People tend to underestimate just how much of a problem rhinitis is," says McNairn. Rhinitis contributes to a lot of missed school and work, and people who are suffering from rhinitis may function poorly in their daily activities because they are probably not sleeping well.

If you have prolonged sneezing, runny nose, or nasal congestion, you should consider seeing an allergist, who can determine if you have rhinitis. If you do, the allergist can identify the allergens — if any — triggering your symptoms and help you find the best way to treat your condition.

Source : http://www.everydayhealth.com/allergies/allergic-rhinitis-nose

Pharyngitis

2009-01-18T22:27:00.006+07:00

is an inflammation of the throat or pharynx. In most cases it is painful, and thus is often referred to as a sore throat. Inflammation of the tonsils (tonsillitis) and/or larynx (laryngitis) may occur simultaneously, which can make eating difficult or painful.

Most cases are caused by viral infections (40%-60%), with the remainder caused by bacterial infections, fungal infections, or irritants such as pollutants or chemical substances.

Treatment of viral causes are mainly symptomatic while bacterial or fungal causes may be amenable to antibiotics and antifungals respectively.

Pharyngitis is very common but rarely serious. Most cases clear up on their own after three to ten days and require no therapy other than pain relievers to ease the discomfort. Rarely, though, tissues may swell considerably and obstruct breathing - a life-threatening condition.

In addition, strep throat (caused by streptococcal bacteria) requires antibiotics to prevent complications, including rheumatic fever, a condition that can permanently damage the heart valves.

Diphtheria is a rare but serious bacterial variety of pharyngitis.

The pharynx is a common site of infection. This is because viruses and bacteria often settle in this part of the body after a person inhales dust or water vapour containing the microorganism. Infection can also arise when a person touches their nose or mouth after having touched an object shared with another person with the disease. The foreign invader reproduces rapidly after settling on the body tissue.

Symptoms of Pharyngitis
The most common symptoms are:

* Sore or red, raw throat

* Difficulty speaking or swallowing

* Tender, swollen lymph nodes (glands) in the neck

* Fever

* Headache

* Earache

Treatments supported by research

* Analgesics such as NSAIDs and acetaminophen can help reduce the pain associated with a sore throat.
* Steroids: A single dose of dexamethasone reduces symptoms. This can either be given by mouth or intra-muscularly.
* Viscous Lidocaine can be obtained by prescription from a Physician and relieves pain by numbing the mucus membranes of the throat. Follow physician instructions when using this remedy as Viscous Lidocaine can affect the user's ability to swallow increasing the risk of choking or biting the tounge.
* Throat sprays such as Cepacol and Chloraseptic.
* Throat lozenges and cough medicine are often used for short-term pain relief.

Alternative treatments

Many alternative treatments are promoted and used in sore throats. They are however poorly supported by evidence and Uptodate recommends that they not be used to treat pharyngitis. Some include gargling with a warm salt solution, eucalyptus, and chamomile.

Remedial treatments

* Antibiotics are useful if a bacterial infection is the cause of the sore throat. For viral sore throats, antibiotics have no effect. These infections are treated by controlling or relieving symptoms until the virus runs its course.
* Antiviral drugs do not decrease the length of illness and are not used except in cases when the patient's immune system is compromised.