NO MORE HEADACHES

Those arising out of neurological disorders are usually associated with symptoms like nausea, vomiting, blurred vision and fits. This type of headache may be a warning of increased intra cranial tension or intracranial tumours. Ophthalmic disorders like glaucoma and refractory errors may cause headaches. Dental caries and other disorders in the teeth may cause severe headache, which can mimic sinusitis. Migraines cause more trouble and are usually episodic associated with an aura. They are also one-sided.

Common cause

The commonest cause of headache, however, is Sinusitis. This may be associated with nasal obstruction, running nose, postnasal discharge, dry cough and other such factors. With the nose being subject to various environmental pollutants and infections, sinusitis has become an increasingly common problem.

Sinuses are normal spaces or cavities within our skull. Ventilation and drainage of their secretions is essential for proper functioning. Our nose acts as a common drainage point for all sinuses. When the sinus pathway is obstructed, secretions collect in sinuses leading to bacterial and fungal infections. The nasal obstruction may be caused by variations in the anatomy of the nose like deviation of the septum and formation of soft tissues like polyps.

Examination

Evaluation of patients with sinusitis requires a detailed examination. The advent of nasal endoscopes has revolutionised the treatment of sinusitis. This reveals the complex anatomy and the changes causing disease in the nose and sinuses. The patient can also see all this on the monitor. Blood tests, x-rays and a CT scan of the sinuses complement the endoscopy and play a vital role in evaluation.



The use of nasal endoscope has revolutionised treatment of sinusitis.

Patients are initially treated with appropriate antibiotic therapy. The use of nasal endoscopes has brought about a great change in the treatment of the disease and surgical aspects. The earlier surgical methods like puncturing and lavage, which did not establish adequate drainage, are all obsolete now.

The latest surgical procedure called Functional Endoscopic Sinus Surgery (FESS) uses the advanced nasal endoscope. This procedure precisely eliminates the blockage of natural pathways of the sinuses restoring the normal flow of secretions. It also has a cosmetic advantage in that it produces no external scar. The surgery can be performed as a day care procedure. Deviation of the septum, when present, is also corrected in the same sitting. There is no need for repetitions as in the older procedures.

Advanced surgical tools like Microdebrider help in adequate and efficient treatment making FESS a safe and advanced technique in the management of sinusitis. The use of Microdebrider provides good mucosal preservation, reduced complications like bleeding and hence good postoperative results. Microdebrider plays a vital role in polyp surgeries reducing the recurrence rate.

The nasal endoscope is also a great tool in performing other surgeries and its role in minimally invasive removal of orbital tumours and in neurosurgery has revolutionised these fields. With these advanced options available, sinusitis no longer needs to be a headache.

WE KNOW EARLY WARNINGS

THE tsunami that struck South Asia last December provided a salutary warning to all the countries around the Indian Ocean.

If only we had in place an effective early warning system, so many lives could have been saved. If we had been forewarned, I am sure people would not have suffered so much. Actually we were quite unprepared for the tragedy that struck us.

Similarly many medical tragedies can be prevented if we attune ourselves to the early warning signs that Nature gives us. Unfortunately, most of us are oblivious to these signs either due to ignorance or neglect. Among the tragedies that we can prevent or at least minimise are heart attacks, strokes and cancer.

Heart attack

A heart attack occurs because one of the coronary arteries (the blood vessels that carry blood to the heart muscles) gets blocked — whether by a sudden severe spasm or by a blood clot obstructing a narrowed vessel.

In an unfortunate few, the first indication that their arteries have narrowed is when they suffer a massive and fatal heart attack. Most people, however, get warning symptoms in the form of angina, which is the name for pain or discomfort originating from the heart muscle. This is usually felt as a tightening feeling in the centre of the chest, brought on by physical exertion, cold weather or severe emotion.

Angina is felt because the heart muscle gets less blood than it needs since enough blood is unable to reach it through the narrowed coronary artery.

Angina pain may not always be typical — some people describe it as heaviness in the chest, some feel the pain along the upper left arm or the throat but it is always an unusual symptom brought on by physical exertion or severe emotion.

If you experience such a symptom, there is no point in ignoring it or rubbing liniment in the belief that it is a muscle pain. See your doctor because central chest pain of this nature should be considered to originate from the heart unless proved otherwise.

Stroke

A stroke or a cerebrovascular accident (CVA) is a similar occurrence because the vessels supplying blood to the brain (cerebral arteries) are narrowed. A clot stuck in one of the important blood vessels can suddenly cut off blood flow to the brain.

Even if the area of the brain that has had its blood flow cut off suddenly is not large enough to cause death, strokes can damage the affected part of the brain resulting in paralysis, loss of memory, speech and other such problems.

Fortunately most people experience mini-strokes or Transient Ischaemic Attacks (TIAs) before they suffer a full-blown stroke. It is important that one knows the symptoms of a mini stroke so that it can be recognised for what it is — an early warning of imminent danger.

TIAs are felt as a momentary loss of brain function that lasts less than 24 hours — a slurring of speech. A feeling of paralysis in an arm or leg, an episode of blindness in one eye, numbness in a limb or loss of consciousness for a few minutes.

Risk factors

If you are at risk of a stroke — by virtue of age, smoking, high blood pressure, diabetes or if you have suffered a heart attack/stroke previously — then you should be aware of what a TIA feels like.

If you ever experience what feels like a mini stroke, see your doctor immediately and have a scan done so that effective preventive measures can be taken if it is proved that your cerebral arteries have narrowed.

Cancer is a group of diseases characterised by the abnormal rapid growth of cells and can affect various organs of the body. The symptoms can vary depending on the organ affected.

Symptoms

Any abnormal lump in the breast, testicle or surface of the body or a non-healing ulcer in the mouth, tongue or skin should be checked by the doctor. Do not hide the lump or ulcer hoping it will go away. If it is a cancer then it will grow and spread. Once a cancer has spread from the original site to other parts of the body, it is difficult to cure.

Unexplained weight loss is another symptom of cancer, which is often neglected. If you are not dieting, losing weight is a serious symptom as are tiredness and weakness.

Usually working too much, worrying too much or sleeping less than usual can explain being excessively tired. Not infrequently tiredness and malaise can also be caused by anaemia and blood loss resulting from a cancer in the bowel or stomach. Discuss any of these symptoms that you cannot readily explain with your doctor.

The important message is that we should recognise the warning signs and take preventive measures before we are struck down.

KNEE INJURIES

THE anterior crucaite ligament (ACL) is one of four ligaments that stabilise the knee. It runs within the joint cavity of the knee (intra-articular) from the top of the leg bone (tibia) to the thighbone (femur) in an outward direction. It prevents the leg bone from sliding off the thighbone during activities like running or climbing down stairs.

Bundle of collagen

The ACL is a bundle of collagen (connective tissue) about four cm long and one cm thick. It, perhaps, deserves to be termed as the most valuable piece of collagen in the human body as many a high-profile sportsperson's career can be jeopardised by injury to the ACL.

In the last 10 years, there has been tremendous growth of scientific literature on the management of this injury. It is common to sportspersons and in the West, women have a greater incidence than man. This has been attributed to the peculiar anatomy at the end of the thighbone. In India, there is an additional high incidence in men after accidents.

Although there are very few randomised trials concerning surgical management, there have been reasonable studies in the initial assessment, surgical techniques and rehabilitation. Public awareness of the impact of the injury has led many people to seek early surgical treatment.

This is called ACL reconstruction, as attempts to suture the torn ligament have been largely unsuccessful. In an ACL reconstruction, a piece of tissue from the neighbouring tendons and bone (graft) of the patient's own knee (auto graft) is borrowed and fixed with implants. The source of the graft is commonly the patellar (knee cap) or hamstring tendons.

Bone tunnels are drilled in the tibia and femur to site the graft; the graft is threaded through them and is fixed at both ends by some implant (metal or bio absorbable).

Surgical reconstruction is advised in young people who wish to remain active in sports and even in those in whom it is symptomatic even if they are not engaged in sports.

There is no strict age limit or any reason to withhold an ACL reconstruction in a symptomatic individual.

Accurate history

Even consultants miss many ACL injuries. An accurate history should be obtained from the patient. There will be a "popping" sound at the time of the injury.

Immediate swelling ensues after this injury (haemarthrosis or blood collection in the joint). A routine MRI study to support diagnosis in cases of suspected ACL injury is not justified.

MRI has been shown to be less sensitive and specific than an experienced examiner. A MRI is useful in chronic injuries to pick up associated resultant damage to the menisci (semi-lunar cartilages). Concomitant treatment of articular cartilage lesions can logically improve the long-term results after an ACL reconstruction.

Surgical techniques have been refined over the last 10 years. Most knee surgeons now use Arthroscopic or minimally invasive technique. There is some debate about the best source of the graft — patellar tendon or hamstring tendon.

Advances

There is no one answer to this and surgeons should decide on the basis of the patient's needs. Patients whose occupations involve kneeling are not suitable for patellar tendon graft, as there is an increased incidence of anterior knee pain.

New forms of fixing grafts have been developed. These include bio absorbable fixation devices and screws. Early ACL reconstruction is advisable to avoid likelihood of damage to the cartilages of knee and osteo-arthritis.

Ten years ago, it was common practice to splint the knee after an ACL reconstruction. It is now considered unwise to protect the knee and an early return to normal activities is advocated.

Regaining the straight position of the knee is the first goal and regain flexion is the next goal to be achieved progressively. The exercise regime is in an "accelerated" nature and not "aggressive" to avoid strain on the graft.

The physiotherapist needs to supervise the rehabilitation process only on an intermittent basis.