Month: September 2022

Are all sore throats the same?

/ Subash Rau / Leave a comment

Pain in the throat can happen from many reasons. Although people may refer to the neck as the throat, what doctors consider as throat is the pharynx and the tonsillar areas. Lets have a look at the anatomy of the throat and then see how things change in disease.

The throat or pharynx is a muscular tube that connects the mouth and the nose to the windpipe (trachea) in the front and the food pipe (Oesophagus) behind. It is divided into 3 parts, the upper Nasopharynx (the part behind the nose), the Oropharnx (the part behind the mouth) and the Laryngopharynx (the lower most part behind the larynx (the voice box).

The throat or the Oropharynx is bordered by the palate on the top, the pharyngeal pillars (tonsillar areas) on the sides and the tongue below. This is the most important gateway into both the Respiratory as well as the Gastrointestinal tract and is therefore a site for frequent infections.

A sore throat occurs whenever there is inflammation in the throat. Inflammation could be due to infection or a non-infectious cause. Lets look at some of the common and not so common causes for a sore throat.

1. Viral Pharyngitis – the most common cause for a sore throat after streptococcal infection is a viral pharyngitis. This season, the commonest cause is the Covid 19 infection which causes severe and painful sore throat. Unlike a bacterial infection, the patient will have a runny nose, the throat will be erythematous (reddened) and would not show any pus points. Infectious mononucleosis (kissing disease)is seen in young patients who catch infection from kissing. The pain is often out of proportion to the severity of the pharyngitis on examination. This infection can be associated with a rash, enlarged lymph nodes in the neck and an enlarged liver and spleen. The blood smear study would show typical large lymphocytes (increased Lymphocyte count) The treatment is essentially symptomatic.

2. Bacterial (streptococcal pharyngitis and tonsillitis)

The throat shows small petichiae (bleeding spots) on the palate. If tonsillitis coexists, the tonsils are enlarged and show pus oozing from them and the lymph nodes in the neck are enlarged. Streptococcal infection is the commonest cause for a sore throat even more common than viruses. Recurrent streptococcal infection may predispose patients to Rheumatic fever and cardiac disease. Bacterial pharyngitis may also be caused by Neisseria gonorrhoea, Mycoplasma and chlamydia species. Antibiotics would be needed in many cases.

3. Peri-tonsillar abscess (Quinsy)- when the infection spreads through the capsule of the tonsil, pus collects outsides the tonsil and displaces the tonsil inwards, nearly occluding the oral cavity.Peritonsillar abscess must be treated with antibiotics and may need a drainage procedure to remove the pus and to hasten

4. Diphtheria is a respiratory tract infection that cause severe pharyngitis with a thick membrane over the throat. This can be dangerous if left untreated. Prompt antibiotic therapy will be needed.

5.Oral thrush is causes by yeast like fungus called candida. This is also quite common. It is seen on those on broad spectrum antibiotics, diabetes, steroid therapy, immune compromising conditions including HIV infection. The white patches can easily be dislodged showing underlying erythema (redness) and inflammation. Anti-fungal lozenges will be very effective in its treatment along with treating the cause for the infection e.g., controlling the blood sugars and stopping the antibiotics.

Non- infective causes for a Sore throat

1. Acid Reflux with pharyngitis – this is a very common cause for chronic pharyngitis. Acid reflux is a lifestyle disease caused due to an incompetence of the gastro-oesophageal valve usually seen in obese individuals who overeat.

2. Oral aphthous ulcers, Lichen planus, pemphigus and pemphigoid, Behcets syndrome and drug reactions can also give severe sore throat. Rarely cancer can be a cause for a sore throat. The photo below shows large ulcers of pemphgus.
The photo below shows a larger ulcer from cancer of the mouth.

So if your throat is sore and you have difficulty swallowing food, please consult your doctor for advice. Once the cause for the sore throat is identified, specific treatments are given to hasten recovery. Most infective sore throats respond well to antiinflammatory medicines such as Brufen. Antibiotics will be given by your doctor as necessary. Specialist consultation may also be needed.

IF YOU MUST GO TO BANGKOK, TAKE YOUR SPOUSE ALONG!

/ Subash Rau / Leave a comment

The heading of this article must sound strange but I have been pushed to write this article after another of my patients came back from Thailand, all stressed out and looking depressed. This young man had gone to Thailand with a few of his friends and had had a “regrettable” encounter with a commercial sex worker! During the course of my 25 yrs as a doctor, I have seen many a good man being remorseful after coming to his senses and (out of his alcohol or drug induced fugue) filled with guilt and fear on returning to his wife and life in Chennai. I write this article for the benefit of someone planning on being naughty on a holiday and hopefully, to give you enough information to help you stay safe during your trip.

What are the common sexually transmitted infections?

Syphilis, Gonorrhoea, Chancroid (Bacterial infections), Lymphoma granuloma venereum (Chlamydial infection), HIV, Genital herpes (HSV), Genital warts (HPV) (viral infections) and Trichomonas vaginalis (protozoal). Hepatitis A, B, C and pubic lice can also be transmitted during sex. HIV chlamydia and gonorrhoea are transmitted by sexual (body) fluid, HIV and Hepatitis B are transmitted via blood and Genital herpes, papilloma viruses and Syphilis are transmitted by skin to skin contact. Except for HIV, all STIs are curable if detected.

What are the risks of transmission of STD after a single heterosexual encounter?

The risks for women are much higher than it is for men. Syphilis has a 50-65% risk per sexual act, Gonorrhoea has a 20% risk for men and 60-90% risk for women to catch an STI after a single unprotected sexual act. Chlamydia has a 4.5% risk per sexual act and Mycoplasma has a 20-65% risk. HPV and genital warts are transmitted 4% for men and 3.5% for women after a single sexual act. The risks for HIV transmission is 0.05-0.1% for men and 0.08-0.19% for women after a single act. Receptive anal and vaginal intercourse has a 10 fold increased risk of infection transmission compared to Insertive anal and vaginal intercourse. Luckily the risk of catching HIV is a lot lower than for other infections. You should consider all sexual encounters with people not known to you in a foreign country as a high risk (for infection) encounter. Receptive Anal/Vaginal sex is more dangerous for catching an STI compared to Insertive sex and oral sex!

How soon will you see the effects if you catch any of the common infections?

Different infections have different incubation periods ( the time taken for the first symptom after entry of the pathogen into the body i.e., infection).

So what symptoms should you look for in case you have had an unprotected sexual encounter?

Common symptoms to look out for are Genital ulcers, enlarged lymph nodes in the groin, urethral discharge with burning on urination, vaginal discharge and fever, body aches, joint aches, headaches and rash etc. Most symptoms would show up a few days to upto a month after unprotected intercourse.

What tests are useful in the diagnosis of STIs?

Swabs from ulcers, from mucous membranes of the penis, vagina and mouth. Serological tests (to check for antibodies to certain infections) can be done for Chlamydia, syphilis and for HIV.

For syphilis, TPHA and FTA-ABS can be done. Nuclear antigen amplification tests or PCR can be done for HIV, Chlamydia, Chancroid, Gonorrhoea, Herpes, Trichomonas, Candida and bacterial vaginosis can be done. Biopsy can be done for genital warts.

What antibiotics are useful after unprotected sexual intercourse?

Azithromycin 1gm stat will treat Chlamydial infections and Chancroid.

Doxycycline 100mg twice daily for 14 days for Syphilis and Donovanosis.

Valacyclovir 1gm twice daily for 10 days for Genital Herpes.

Fluconazole 200mg at night for 3 days for Candidal infections.

Metronidazole 500mg twice daily for 7 days for Trichomoniasis.

Inj. Ceftrioxone 500mg IM stat for Gonococcal infection.

Inj. Benzathine penicillin 2.4 MU IM stat for primary syphilis.

Taffic (Bictegravir 50/Emtricitabine 200/Tenofovir Alafenamide 25) once daily or Viropil (Dolutegravir 50/Lamivudine 300/Tenofovir Disoproxil fumarate 300) once daily for 28 days, to be started as soon as you suspect that you may have caught HIV infection.

How do you protect yourself from catching a STI/STD?

1. Avoid going to places of temptation in the first place. If you must, take your spouse along with you!

2. Avoid mixing alcohol and drugs with sex. These substance will reduce your inhibitions and fear and make you do things that you wouldn’t do if you were in your senses.

3. Limit the number of sexual partners.

4. Use barrier methods of contraception. Use condoms, oral dams etc and avoid skin on skin contact and exchange of body fluids. Oral sex isn’t safe!

5. Get to know your partner before hand and if possible have an honest talk about previous sexual contacts, sexual habits and preferences and history of previous STIs.

6. Get yourself vaccinated against all possible sexually transmitted infections such as Hepatitis A and B, Human Papilloma virus etc.

7. Test yourself regularly especially if you have had numerous sexual contacts with multiple partners.

To sex or not to sex, that is the question you need to ask yourself! (All pun intended) If you choose to have sex, take all necessary precautions. If you have had unsafe sex or if you can’t remember, see your doctor as soon as you return and start relevant prophylactic medicines (as no test will be positive in early infection especially when you are asymptomatic).

So plan now and don’t regret later.

Secrets of Centenarians – the 9 habits of successful Centenarians!

/ Subash Rau / Leave a comment

As a doctor I have always been interested in knowing the secrets to a long life. Many people who lives long lives have very few if any diseases, apart from an old body (if you can consider that a disease) and remain surprisingly sprightly even in their 90s. Many others bravely tackle their medical and age related challenges and live a long life aided by modern medical treatments. So it was extremely exciting to find an article in The National Geographic Traveller magazine (Indian edition -May June 2022) which spoke about food and lifestyle habits of people who had a greater chance of living long lives (Centenarians) in certain areas of the world. The article quoted from research done by Dan Buettner, a longevity researcher who called the 5 specific areas of the world, where people were more likely to live up to a 100 yrs, the BLUE ZONES. The article seemed to suggest that these elderly people were living long lives because they were healthy rather than because of modern medicine.

These geographic areas are the following:

1. Greece- Icaria

2. Italy – Ogliastra, Barbagia, Seulo of Sardinia.

3. Japan -Okinawa.

4. Costa Rica – Nicola peninsula

5. USA – Loma Linda, California (Seventh day Adventists)

While the article highlighted the various food cultures of the people in these areas, I was more interested in Buettners “Power of Nine”,the factors/cultural/societal habits that were common to the people who lived in these 5 areas. Lets have a look at these habits.

1. Moving naturally – daily walking and gardening.

2. Purpose – motivation to get up in the morning.

3. Down shift – activities like prayer, meditation and naps and evening drinks with friends)

4. The 80% rule – to always eat only until 80% full.

5. Plant slant – significant portions of beans and greens and small portions of meat.

6. Wine @5 – moderate drinking.

7. Belong – to be part of some faith based community.

8. Loved ones first – to have close family ties.

9. Right tribe – strong social circles.

Many of these points are what I suggest to patients who have clinical depression. It would seem that happiness could be the answer for a long life if one were to remain physically active and eat right ( if you have read about what my grandfather had told me mentioned in my earlier article on longevity). Stress release by exercise and being physically active, stress control by meditation and living in a supportive/encouraging and positive social environment and consuming moderate amounts of alcohol could hold the key to a long life.

I hope and pray that you will incorporate these factors into your life and live long!

SHANTAMANAM BHAVATI!

A Earache – what you need to know!

/ Subash Rau / Leave a comment

Most of us would have at some point had a severe ear ache or seen someone else (usually a child) crying out in severe ear pain. The article will provide you with some information on the common causes and what you can do if you have someone with a earache to look after. Of the common causes for ear ache the first 4 conditions are more common in children and the last few ones are commoner in adults. Before that, lets have a quick look at the anatomy of the ear to get a better understanding of the problem.

The external ear or the Pinna behaves like a funnel collecting the sound waves from outside the body and directing it inside the ear where they hit the eardrum and make it vibrate. The portion of the ear upto the eardrum (from the outside) is called the External ear. Touching the eardrum are bones that sequentially transmit the vibration to the snail like Cochlea which is the organ that converts the sound vibration to electrical impulse which is conducted by the auditory nerve to the brain where the electrical impulse is interpreted as meaningful sound/voice/music or noice. In the diagram above, the 3 bones that conduct sound waves to the cochlea (i.e., Malleus Incus and Stapes) lie in the middle ear and this chamber is connected to the back of the throat by the Eustachian tube (in pink). The Eustachian tube maintains equal pressure on both sides of the ear drum permitting free undampened vibrations of the ear drum to incident sound. The inner ear (found deep inside the bone) also contains the organs of balance – Utricle and saccule and the semicircular canals.

Therefore the ear has 2 functions – hearing and balance!

Conditions causing Ear ache

1. Otitis externa (External ear infection) – is usually caused by trauma or injury caused by over enthusiastic ear cleaning with the finger or the ear bud. Less frequently it can happen after a swim in the pool. The tissues of the outer ear are tightly attached to the underlying bone and therefore any infection or boil, produces severe pain. The ear lobe could be red and swollen. Looking into the ear with a torch may show the boil or if pressing on the tragus (the small prominence just in front of the opening into the ear) or pulling the ear give severe pain – this would also indicate external ear infection. This would need antibiotic ear drops prescribed by your doctor.

2. Shining a light into the ear may also show an insect that can be the cause for pain. Shining a bright light may draw the insect out. Please don’t put oil into the ear (especially if you know that the ear drum is perforated)

3. Eustachian tube dysfunction – When the person has a mild cold, the excess mucous secreted may occlude the Eustachian tube. The air in the middle year then get absorbed and this negative pressure would draw the eardrum insides and reduce its vibrations to sound. Therefore people may have a feeling of reduced hearing. This is very common during a aeroplane flight. Sudden changes in altitude can even cause rupture of the ear drum (Barotrauma). The ear could pop open on yawning or blowing out with a pinched nose giving some relief. Using a nasal decongestant drop or using Vicks inhaler might help. Eustachian tube dysfunction commonly occurs in those with respiratory allergies, dust exposure and infections. If this condition doesn’t resolve, persisting negative pressure may draw out the fluid into the middle ear from the blood vessels causing serous otitis media. If bacteria invade and proliferate here, it becomes Acute suppurative (pus producing) Otitis media (middle ear infection).

4. Acute Suppurative Otitis media (ASOM) – this often presents with severe ear pain, reduced hearing and often with fever. Pulling on the ear or looking into the ear would not give severe pain. Sometimes there could be a spontaneous rupture of the ear drum and release of copious pus from the ear, also relieving the pain to an extent. This condition requires specific antibiotics and requires you to go to the local ENT surgeon for advice. If inadequately treated, the infection could become chronic (CSOM) and also spread inwards to the bone and the brain.

5. Herpes Zoster Oticus – relapse of the chicken pox virus affecting the ear could be a cause for severe earache with a rash around the ear. It may also cause hearing loss, ringing in the ear, vertigo, difficulty in closing the eye and a dry mouth.

6. TMJ Dysfunction – Temperomandibular joint is formed between the jaw bone and the undersurface of the skull. People who have a habit of biting only on one side or grinding their teeth can develop pain around the ear. This pain would be worse on opening the mouth widely and on chewing.

7. Pain referred to the ear due to stimulation of commonly innervated body parts- The tonsil and the ear may be supplied by the same nerve (the glossopharyngeal Nerve) Therefore irritation of the nerve due to Tonsillitis would cause pain to be referred to the ear. Similarly other nerves such as the Trigeminal, Facial, Vagal and somatic cervical nerves may also in certain conditions cause an earache.

Take home points:

Any medicine that you have taken for pain before would work to relieve an ear ache. Paracetamol or any other anti-inflammatory medicine can be given until you see the doctor.