Treatment and Diagnosis:

Types of Hodgkin Lymphoma:

If you have swollen lymph nodes or another symptom that suggests Hodgkin lymphoma, your doctor will try to find out what’s causing the problem. Your doctor may ask about your personal and family medical history.

You may have some of the following exams and tests:

Physical exam: Your doctor checks for swollen lymph nodes in your neck, underarms, and groin. Your doctor also checks for a swollen spleen or liver.
Blood tests: The lab does a complete blood count to check the number of white blood cells and other cells and substances.
Chest x-rays: X-ray pictures may show swollen lymph nodes or other signs of disease in your chest.
Biopsy:A biopsy is the only sure way to diagnose Hodgkin lymphoma. Your doctor may remove an entire lymph node (excisional biopsy) or only part of a lymph node (incisional biopsy). A thin needle (fine needle aspiration) usually cannot remove a large enough sample for the pathologist to diagnose Hodgkin lymphoma. Removing an entire lymph node is best.

The pathologist uses a microscope to check the tissue for Hodgkin lymphoma cells. A person with Hodgkin lymphoma usually has large, abnormal cells known as Reed-Sternberg cells. They are not found in people with non-Hodgkin lymphoma. See the photo of a Reed-Sternberg cell.

You may want to ask your doctor these questions before having a biopsy:

How will the biopsy be done?
Will I have to stay in the hospital?
Will I have to do anything to prepare for it?
How long will it take? Will I be awake? Will it hurt?
Are there any risks? What are the chances of swelling, infection, or bleeding after the procedure?
How long will it take me to recover?
How soon will I know the results? Who will explain them to me?
If I do have cancer, who will talk to me about next steps? When?

Types of Hodgkin Lymphoma

When Hodgkin lymphoma is found, the pathologist reports the type. There are two major types of Hodgkin lymphoma:

Classical Hodgkin lymphoma: Most people with Hodgkin lymphoma have the classical type. The Reed-Sternberg cell looks like the photo.
Nodular lymphocyte-predominant Hodgkin lymphoma: This is a rare type of Hodgkin lymphoma. The abnormal cell is called a popcorn cell. It may be treated differently from the classical type.

Staging

Your doctor needs to know the extent (stage) of Hodgkin lymphoma to plan the best treatment. Staging is a careful attempt to find out what parts of the body are affected by the disease.

Hodgkin lymphoma tends to spread from one group of lymph nodes to the next group. For example, Hodgkin lymphoma that starts in the lymph nodes in the neck may spread first to the lymph nodes above the collarbones, and then to the lymph nodes under the arms and within the chest.

In time, the Hodgkin lymphoma cells can invade blood vessels and spread to almost any other part of the body. For example, it can spread to the liver, lungs, bone, and bone marrow.

Staging may involve one or more of the following tests:

CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your chest, abdomen, and pelvis. You may receive an injection of contrast material. Also, you may be asked to drink another type of contrast material. The contrast material makes it easier for the doctor to see swollen lymph nodes and other abnormal areas on the x-ray.
MRI: A powerful magnet linked to a computer is used to make detailed pictures of your bones, brain, or other tissues. Your doctor can view these pictures on a monitor and can print them on film.
PET scan: You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Lymphoma cells use sugar faster than normal cells, and areas with lymphoma look brighter on the pictures.
Bone marrow biopsy: The doctor uses a thick needle to remove a small sample of bone and bone marrow from your hipbone or another large bone. Local anesthesia can help control pain. A pathologist looks for Hodgkin lymphoma cells in the sample.

Other staging procedures may include biopsies of other lymph nodes, the liver, or other tissue.
The doctor considers the following to determine the stage of Hodgkin lymphoma:

The number of lymph nodes that have Hodgkin lymphoma cells
Whether these lymph nodes are on one or both sides of the diaphragm (see picture)
Whether the disease has spread to the bone marrow, spleen, liver, or lung.

The stages of Hodgkin lymphoma are as follows:

Stage I: The lymphoma cells are in one lymph node group (such as in the neck or underarm). Or, if the lymphoma cells are not in the lymph nodes, they are in only one part of a tissue or an organ (such as the lung).
Stage II: The lymphoma cells are in at least two lymph node groups on the same side of (either above or below) the diaphragm. Or, the lymphoma cells are in one part of a tissue or an organ and the lymph nodes near that organ (on the same side of the diaphragm). There may be lymphoma cells in other lymph node groups on the same side of the diaphragm.
Stage III: The lymphoma cells are in lymph nodes above and below the diaphragm. Lymphoma also may be found in one part of a tissue or an organ (such as the liver, lung, or bone) near these lymph node groups. It may also be found in the spleen.
Stage IV: Lymphoma cells are found in several parts of one or more organs or tissues. Or, the lymphoma is in an organ (such as the liver, lung, or bone) and in distant lymph nodes.
Recurrent: The disease returns after treatment.

In addition to these stage numbers, your doctor may also describe the stage as A or B:

A: You have not had weight loss, drenching night sweats, or fevers.
B: You have had weight loss, drenching night sweats, or fevers.

Treatment

Chemotherapy
Radiation Therapy
Stem Cell Transplantation

Your doctor can describe your treatment choices and the expected results. You and your doctor can work together to develop a treatment plan that meets your needs.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat Hodgkin lymphoma include hematologists, medical oncologists, and radiation oncologists . Your doctor may suggest that you choose an oncologist who specializes in the treatment of Hodgkin lymphoma. Often, such doctors are associated with major academic centers. Your health care team may also include an oncology nurse and a registered dietitian.

The choice of treatment depends mainly on the following:

The type of your Hodgkin lymphoma (most people have classical Hodgkin lymphoma)
Its stage (where the lymphoma is found)
Whether you have a tumor that is more than 4 inches (10 centimeters) wide
Your age
Whether you’ve had weight loss, drenching night sweats, or fevers.

People with Hodgkin lymphoma may be treated with chemotherapy, radiation therapy, or both.

If Hodgkin lymphoma comes back after treatment, doctors call this a relapse or recurrence. People with Hodgkin lymphoma that comes back after treatment may receive high doses of chemotherapy, radiation therapy, or both, followed by stem cell transplantation.

You may want to know about side effects and how treatment may change your normal activities. Because chemotherapy and radiation therapy often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them. The younger a person is, the easier it may be to cope with treatment and its side effects.

You may want to talk to your doctor about taking part in a clinical trial, a research study of new treatment methods. See the Taking Part in Cancer Research section.
You may want to ask your doctor these questions before you begin treatment:

What type of Hodgkin lymphoma do I have? May I have a copy of the report from the pathologist?
What is the stage of my disease? Where are the tumors?
What are my treatment choices? Which do you recommend for me? Why?
Will I have more than one kind of treatment?
What are the expected benefits of each kind of treatment?
What are the risks and possible side effects of each treatment? What can we do to control the side effects?
How long will the treatment last?
What can I do to prepare for treatment?
Will I need to stay in the hospital? If so, for how long?
What is the treatment likely to cost? Will my insurance cover the cost?
How will treatment affect my normal activities?
Would a clinical trial be right for me?
How often should I have checkups after treatment?

Chemotherapy

Chemotherapy for Hodgkin lymphoma uses drugs to kill lymphoma cells. It is called systemic therapy because the drugs travel through the bloodstream. The drugs can reach lymphoma cells in almost all parts of the body.

Usually, more than one drug is given. Most drugs for Hodgkin lymphoma are given through a vein (intravenous), but some are taken by mouth.

Chemotherapy is given in cycles. You have a treatment period followed by a rest period. The length of the rest period and the number of treatment cycles depend on the stage of your disease and on the anticancer drugs used.

You may have your treatment in a clinic, at the doctor’s office, or at home. Some people may need to stay in the hospital for treatment.

The side effects depend mainly on which drugs are given and how much. The drugs can harm normal cells that divide rapidly:

Blood cells: When chemotherapy lowers the levels of healthy blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team gives you blood tests to check for low levels of blood cells. If levels are low, there are medicines that can help your body make new blood cells.
Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may be somewhat different in color and texture.
Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Ask your health care team about medicines and other ways to help you cope with these problems.

Some types of chemotherapy can cause infertility:

Men: Chemotherapy may damage sperm cells. Because these changes to sperm may be permanent, some men have their sperm frozen and stored before treatment (sperm banking).
Women: Chemotherapy may damage the ovaries. Women who may want to get pregnant in the future should ask their health care team about ways to preserve their eggs before treatment starts.

Some of the drugs used for Hodgkin lymphoma may cause heart disease or cancer later on. See the Follow-up Care section for information about checkups after treatment.
You may want to ask your doctor these questions before having chemotherapy:

Which drugs will I have? What are the expected benefits?
When will treatment start? When will it end? How often will I have treatments?
Where will I go for treatment? Will I be able to drive home afterward?
What can I do to take care of myself during treatment?
How will we know the treatment is working?
What side effects should I tell you about? Can I prevent or treat any of these side effects?
Will there be lasting side effects?

Radiation Therapy

Radiation therapy (also called radiotherapy) for Hodgkin lymphoma uses high-energy rays to kill lymphoma cells. It can shrink tumors and help control pain.

A large machine aims the rays at the lymph node areas affected by lymphoma. This is local therapy because it affects cells in the treated area only. Most people go to a hospital or clinic for treatment 5 days a week for several weeks.

The side effects of radiation therapy depend mainly on the dose of radiation and the part of the body that is treated. For example, radiation to your abdomen can cause nausea, vomiting, and diarrhea. When your chest and neck are treated, you may have a dry, sore throat and some trouble swallowing.

In addition, your skin in the area being treated may become red, dry, and tender. You also may lose your hair in the treated area.

Many people become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise people to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, they can usually be treated or controlled. You can talk with your doctor about ways to ease these problems.

It may also help to know that, in most cases, the side effects are not permanent. However, you may want to discuss with your doctor the possible long-term effects of radiation treatment. After treatment is over, you may have an increased chance of developing a second cancer. Also, radiation therapy aimed at the chest may cause heart disease or lung damage.

Radiation therapy aimed at the pelvis can cause infertility. Loss of fertility may be temporary or permanent, depending on your age:

Men: If radiation therapy is aimed at the pelvic area, the testes may be harmed. Sperm banking before treatment may be a choice.
Women: Radiation aimed at the pelvic area can harm the ovaries. Menstrual periods may stop, and women may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger women. Women who may want to get pregnant after radiation therapy should ask their health care team about ways to preserve their eggs before treatment starts.

You may want to ask your doctor these questions before having radiation therapy:

Why do I need this treatment?
When will the treatments begin? When will they end?
How will I feel during treatment?
How will we know if the radiation treatment is working?
Are there any lasting side effects?

Stem Cell Transplantation

If Hodgkin lymphoma returns after treatment, you may receive stem cell transplantation. A transplant of your own blood-forming stem cells (autologous stem cell transplantation) allows you to receive high doses of chemotherapy, radiation therapy, or both. The high doses destroy both Hodgkin lymphoma cells and healthy blood cells in the bone marrow.

Stem cell transplants take place in the hospital. Before you receive high-dose treatment, your stem cells are removed and may be treated to kill lymphoma cells that may be present. Your stem cells are frozen and stored. After you receive high-dose treatment to kill Hodgkin lymphoma cells, your stored stem cells are thawed and given back to you through a flexible tube placed in a large vein in your neck or chest area. New blood cells develop from the transplanted stem cells.

Article by
HCG cancer centre

Cartilage Injury Treatments

In some cases arthroscopy can be used to ‘smooth’ the cartilage. Although new cartilage cannot grow to take its place, scar tissue appears.
It is also possible to transplant some cartilage from an uninjured part of the knee. Another option is to remove some normal cartilage cells, reproduce them in a lab and then later reimplant them into the damaged area so that new cartilage will grow.

Know More

Detached Cartilage of Bone in the Knee Joint

If the injury is fairly recent, it is possible to put the piece back in place. More commonly, the loose body may be removed by arthroscopy.
Cartilage Restoration

Cartilage Restoration is a procedure where a patient’s knee is resurfaced, realigned and stabilized thereby avoiding a joint replacement. Cartilage restoration is especially effective in patients who are under 50 and active.

Articular cartilage is a firm, smooth and slippery covering on the ends of bones that protects and cushions the bone joint. Injuries to this cartilage can cause pain and swelling. If partially or fully detached injured cartilage can cause mechanical symptoms such as “locking up or “catching.” If various non-operative treatments fail, surgery may be required. One of the surgical options is cartilage restoration.

There are two types of cartilage restoration:
ACI (Autologous Chondrocyte Implantation)

ACI is indicated for larger areas of full thickness cartilage loss, and requires two surgeries. First we arthroscopically harvest normal cartilage cells from one area of the knee not needed. The second surgery is an open surgery where we implant the cartilage cells back into knee to repair the damaged area.The cells in a gel form which solidify when placed in the cartilage defect area within 10 minutes.
Microfracturing

Microfracturing is a technique in which arthroscopically multiple small holes are put in the sub chondylar bone so that bone marrow can bring in blood supply and bent the cartilage defect with fibro cartilage.
Visscosupplementation

In order to provide optimum environment for cartilage to heal Visscosupplementation is injecting a solution of hyaluronic acid. It is used in association with Microfracturing.
Osteochondral Transplant

Cartilage and bone transplants are indicated when the damaged area is very large, if there is failure of one of the other techniques, or if bone is also injured along with the cartilage. This is when cartilage and bone plugs are harvested from either an uninjured non-weight bearing area of the knee, or from a donor (cadaver), and then transplanted to cover the injured area of bone and cartilage.

Cartilage restoration surgery can take 1-4 hours depending on the injury.

Recovery varies but can take 2-3 months before weight-bearing activities can be pursued

Article by
Apollo Hospitals

Microdermabrasion- Deparment of Dermatology

Microdermabrasion is used to treat. Enlarged pores. Hyperpigmentation. Superficial creases. Mild non-inflammatory acne scarring, sun damaged skin, dull and blemished skin, Stretch marks, Scar revision, face and body peeling.

During Microdermabrasion, aluminiumoxide crystals are blown into the skin through a sterile tipped tube at half to one atmosphere, pressure and vacuumed out under the same pressure through an adjoining aperture. The crystals remove a very superficial layer of the upper half of the skin called epidermis.

This is an outpatient training, and is best done by trained dermatologists. Each session lasts from 5 to 15 minutes, and one can go back to work after the treatment session.

Article by apollo Hospitals
Bangalore

Abrasion Arthroplasty with High Tibial Osteotomy

Abrasion Arthroplasty with High Tibial Osteotomy for
treatment of sever osteoarthritis – a follow up subjective
study.
Since 1980 we have started treatment of advanced osteoarthritis knee
by abrasion under arthroscopic guidance. But since 1985 we have started the
combination of Arthroscopic Abrasion Arthroplasty (AAA) and High Tibial
Osteotomy (HTO).
Aim of the study
To present the follow up results of AAA and HTO performed to patients
with advanced varus osteoarthritis knee; who are candidates for Total Knee
Replacement (TKR) or Unicompartmental Knee Replacement (UKR)
Materials and methods
All patients in this study were those suffering from advanced (severe)
knee joint varus osteoarthritis. The patients were of any age, any gender, and
the most important point is that the patient must accept the 6-8 weeks nonweight
bearing rehabilitation program. The patient also my be obese (mild) but
not morbid obesity. All our patient were candidate for artificial prosthesis (they
mentioned they had already date for TKR & UTKR), they search about an alternative
to prosthesis.
Since 1985 till 2006 more than 1.500 patients with advanced osteoarthritis
of medial knee compartment; underwent AAA with HTO at the clinic of Dr
Witwity, and Oxford score was sent to 946 patients till 2003 as we are concerning
with patients more than three years follow up-also some patient come for
metal removal and second look also was included. The Oxford 12 points questionnaire
is reliable and used by many surgeons to evaluate the patients with
TKR &UKR.509 patients sent their answers, 246 females and 263 males, 260
Lt knee, 249 Rt knee and 19 were bilateral. Average age 60 years (29 – 84
year).

Technique of the operation
Arthroscopic Abrasion Arthroplasty with High Tibial Osteotomy done
for all patients with grade IV chodromalacia and sclerotic lesion medial compartmental
knee osteoarthritis (bare bone).
AAA is multiple tissue debridement procedure and it is consisted of
Abrasion, which must be strictly intra-cortical, preserving the tide mark as a
vital bearing zone for the expected newly formed fibrocartlige. Only 1-3 mm is
abraded till the appearance of the superficial blood vessels which take the salt
and pepper appearance (minute dark red tinny vessels against pale white background
of abraded bone). In few number patients Micro-fracture technique is
done using special sharp knife to reach the deep cortical layers without disturbing
the tide-mark line

Hypospadias Repair

We feel that parents should be involved in decision making at every stage. This is an overview of the pathophysiology of hypospadias and possible treatment options.
What is hypospadias?

Hypospadias is abnormal growth and development of the tissues on the ventral (under-surface) aspect of the penis. This may cause abnormal opening of the urine tube anywhere from the scrotum up to the penile tip, curvature of the penis and problems while passing urine in standing position.
Why does it happen?

The exact cause is not known but many factors including genetic factors may contribute.

When the penis is being formed the urine tube initially is open sulcus that later on closes to form a tube. This closure begins from the base of the penis and progresses to its normal location at the tip. If this process gets interrupted in-between then the opening may remain at an abnormal place.
What are the types of hypospadias?

Hypospadias can be of various types depending on the location of this opening of urine tube (urethra). It can be glanular (on glans), coronal (at the sulcus between the glans and the body of penis), on the penile shaft (this type is divided in to 2 subgroups proximal and distal shaft) and peno-scrotal at the junction of penis and scrotum. Very rarely the scrotal halves remain separate and it opens directly on the perineum (perineal)
Can there be other associated problems?

This condition is rarely associated with malformations of kidney and other parts of genitourinary system
What is correct age for surgery?

Surgery can be performed at any age after 6 months of age. When it is corrected early, child will have no memory of it. Even older boys usually do not have problems with the surgery. After complete healing there are little noticeable marks of the operation. A successful repair lasts lifetime; including periods of rapid penile growth.
What operation will correct the problem?

Hypospadias repair transfers the location of urine tube from more proximal one (abnormal) to its normal position at the tip. It is done under general anaesthesia, meaning that he will be sound asleep during the surgery. This surgery takes between 1 to 2 hours.
What Is Hypospadias Repair?

Penis acts as a conduit for the urine and sperms while they leave the body. Both these are expelled out through a tube called urethra (referred as urine tube elsewhere for understanding) which opens at the end of the penis. Most of the children will also have ventral bending of the penis (when erect). The hypospadias repair surgery will reposition the opening and correct the bending to give the penis a more normal appearance.

The surgery will deal with following things

Creating the urine tube that has failed to form
Relocating its opening to the tip of the penis
Straightening the penile shaft if curved
Removal/ reshaping the abnormal foreskin
In complicated cases more extensive or stages repair may be necessary.

Which anaesthesia will be used?

This operation is usually performed under general anaesthesia. General anaesthesia will make the child go into deep sleep. General anaesthesia makes the surgery easier and safer as the child will not feel any pain or have any memory of it.

Caudal block is given along with general anaesthesia. It has two advantages; it blocks pain in the low back and trunk during and following the surgery and will reduce the requirements of GA medicines.
After the operation

Child can start eating and drinking a little at a time within 2 hours of surgery and can resume normal eating and drinking as early as he feels.

There will be a tube coming out from the tip of the penis connected to urine bag. Staff will teach you regarding empting the bag. Child carries the bag to home and it will be removed after a week or 10 days.

If a dressing was used, you will be told how to care for it. An ointment may be recommended or prescribed for you to use with the dressing.

If you notice a fever higher than 101.4˚F, bleeding or foul smelling drainage from the area around the repair, call the hospital.
Special needs

If your child has any special needs or health issues you feel the doctor needs to know about, please call your doctor’s office before the surgery and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

Article by
Sparsh Hospirals,
Bangalore

Salivary gland cancer surgery hospitals in India

A salivary gland tumor is an uncontrolled growth of cells that originates in one of the many saliva-producing glands in the mouth. Salivary gland cancer surgery in India is now days performed in most prominent cities of India at Hyderabad, Mumbai, Delhi and Bangalore. Salivary gland cancer surgery hospitals in India are highly equipped with best treatment facilities. Salivary gland cancer is a cancer that occurs in one of the salivary glands in your mouth, neck or throat. Salivary gland cancer may not cause any symptoms and is found during a regular dental check-up or physical exam. Symptoms caused by salivary gland cancer also may be caused by other conditions. Because of most advanced treatment facilities and most expert cancer surgeons, the success rate of surgical treatment in salivary gland cancer surgery in HCG Cancer centre, Bangalore in India is very good.

Treatment Facilities.

Now it is possible to cure salivary gland cancer with a surgical treatment, as most advanced cancer surgery techniques are available in salivary gland cancer surgery hospitals in India and are being successfully used for patients’ treatment. Surgery is not a solution of all cancers; it always depends on the stage of cancer, requirements, and health. But if surgery is required then it is very important to get it done as early as possible because any delay in getting treatment spreads cancer. In most cases, surgery is done to remove the cancer and some of the nearby tissue. If the cancer is a high grade or if it has spread to the lymph nodes, the doctor may suggest removing the nodes as well. Since salivary gland tumors often start in the parotid gland, that operation will be described first. The facial nerve, which controls movement of the face, passes through the parotid gland. This makes the surgery complicated. If it looks like the surgeon will need to remove the facial nerve, ask about ways to repair the nerve and ways to treat the side effects. If your cancer is in the submandibular or sublingual glands, the surgeon will remove the entire gland and perhaps some of the nearby tissue or bone. Several important nerves pass through or near these glands. These nerves control tongue movement, as well as feeling and taste. The surgeon may need to remove some of these nerves. If your cancer is in the minor salivary glands, the surgeon usually removes some tissue around the cancer along with the cancer. The exact details depend on the size and place of the cancer. There can be side effects from each of the different kinds of surgery, especially if facial nerves or other nerves need to be removed. Talk to your doctor about what to expect after your surgery and what measures you can take to help reduce any side effects.

Medical tourism in India would make your travel and medical stay in India more comfortable by providing you the best medical hospitalization and patient care during your salivary gland cancer surgery in India. Indian cancer surgeons are reliable persons that would provide you health recovery within the shortest span of time at an affordable cost.

Epistaxis is an important otorhinolaryngological emergency, which usually has an apparent etiology, frequently local trauma in children. Here we present a case report wherein the epistaxis was recalcitrant, and proved to have a psychiatric disorder as an underlying basis. The child was diagnosed with Attention Deficit/Hyperactivity Disorder, hyperactive type, which led to trauma to nasal mucosa due to frequent and uncontrolled nose picking. Treatment with atomoxetine controlled the patient’s symptoms and led to a remission of epistaxis.

Introduction

Children commonly present with nosebleed and these episodes are rarely life threatening. The majority of nosebleeds are mild, spontaneous and self-limited. However some children suffer from repeated nosebleeds or, to use its clinical name, ‘recurrent idiopathic epistaxis’. These nosebleeds often cause significant parental concerns and remain a challenging problem to patients and physicians alike [1,2].

Initiating factors include local inflammation, mucosal drying, and local trauma (including nose picking). Most of the studies have emphasized the fact that there are no apparent causes in habitual nose bleeders. However, there may be some underappreciated factors that place many children at risk for injury [3]. One of these factors may be the presence of attention-deficit/hyperactivity disorder (ADHD), which is now believed to be the most common neurobehavioral disorder in children[4]. The purpose of this case report is to describe the case of the child with a diagnosis of ADHD who suffered severe recurrent epistaxis, and to highlight the possible importance of this co-morbidity and its treatment in the context of paediatric trauma.

History:

A 12 year old boy presented with a 2 month history of recurrent epistaxis to the emergency department for his fourth episode. The first episode had occurred 2 months back and was treated by local pressure and a haemostatic drug. The second episode occurred 2 weeks later and was treated similarly. A week later, the patient had another bout of nose bleed, heavier this time, which had to be treated with an anterior nasal pack, and silver nitrate cauterization of the wound later on. The current episode was from the same site and needed nasal packing again.

On all occasions there was no history of an apparent physical trauma to the nose, nor were there any symptoms to suggest an upper respiratory infection or allergic rhinitis. There was no bleeding from any other site in the body. The patient was not using any medicines. The patient was not suffering from any diagnosed medical condition. There was no family history of a similar illness.
Physical Examination

On arrival the patient was awake, alert and fully oriented. He was bleeding moderately from left nostril. On physical examination his vital signs were stable. ENT examination showed active bleeding from left anterior nares. Rest of physical examination was normal. All through the examination, the child acted fussy and had difficulty remaining focused on a given task. He continuously rocked and fidgeted in the examination chair. Even frequent reprimanding couldn’t discipline the child. This prompted the attending resident to seek a psychiatric consultation.

Psychiatric Screening
History:

A detailed evaluation revealed a child who had no problems in preschool. In kindergarten, he seemed to learn alphabets and numbers normally. The parents had noticed that he seemed more disorganized and inattentive than his older brother was at the same age. They often had to repeat instructions, and he left tasks half-finished. In primary school the patient had mild difficulty with mathematics, and the teacher use to be concerned about his not listening much of the time. The patients’ school work was inconsistent and he often failed to finish his assignments. The parents also admitted a frequent nose picking behavior of the patient, which they couldn’t correct with even punitive methods.
Mental Status Examination

When the patient was seen in the child and adolescent psychiatry department, he appeared as an attractive teenager who looked his stated age and was of average build but he showed grossly conspicuous behaviour. During interview he constantly shifted position, folded arms behind his head or leaned over the table in front of him and at times fiddled with his nose. He also got out of his seat frequently, played with buttons on clothes and couldn’t sit still. His attitude was over familiar, pushy, demanding and lacking distance. He showed difficulty in sustaining attention and concentration which was elicited in writing and reading task given to him in interview. He was oriented in time, place and person. Intelligence was normal

Diagnostic Inventory:

A diagnosis of Attention Deficit/Hyperactivity Disorder, hyperactive type was suggested.

Investigation:

The patients hemoglobin was decreased at 10.2 gm/dl (11-13 gm/dl), platelet count was normal at 230,000 per microliter (150,000 to 400,000 per microliter). The coagulation profile was normal. TLC & DLC, ESR, RBC indexes were normal. Serum chemistry, TFT, urine exam and X-ray chest were also normal. ECG only showed sinus tachycardia (HR: 108/min).

Management and Course:

The patient was started on atomoxetine at 9 mg/bd, and weekly behavioral therapy sessions (including habit-reversal therapy), aimed at decreasing the nose picking behavior. The dose of atomoxetine was raised two weeks later to 18 mg/bd (calculated @ 0.5 mg/kg/d), while the behavior therapy was continued. The patient was sent for ENT follow-up as well, who after evaluation referred the patient the back, with no alteration in the treatment. The patient was followed up at weekly intervals. At 4 (Four) weeks, the patient’s hyperactive behavior, including nose picking, was much controlled. ENT checkup confirmed healing of the nasal wound. The drug treatment was continued at the same dose and patient continues to follow up on a monthly basis with no further episode of nosebleed.

Narcolepsy is a condition that causes patients to fall asleep uncontrollably throughout the day for periods lasting less than a minute to more than half an hour. These “sleep attacks” occur even after getting enough sleep at night. The unusual sleep pattern that people with narcolepsy have can affect their schooling, work, and social life. Falling asleep during activities like walking; driving, cooking, or talking can have dangerous results, both professionally and personally.

People with narcolepsy may also have one or more of the following signs and symptoms : –

Sudden loss of muscle tone and control (muscle weakness) over parts or all of the body while awake (cataplexy)
Sudden inability to move or speak while falling asleep or waking up (sleep paralysis)
Vivid dreams while falling asleep or waking up (hallucinations

Narcolepsy can occur in both men and women at any age, although its symptoms are usually first noticed in teenagers or young adults. There is strong evidence that narcolepsy may run in families; 8 to 12 percent of people with narcolepsy have a close relative with the disease.

Narcolepsy usually is a genetic (inherited) disorder, although it may be associated with brain damage or neurological disease

Diagnosis of Narcoplepsy

Epworth Sleepiness Scale : – During the test, you will be asked to answer 8 questions using a scale from 0 (not at all likely to fall asleep) to 3 (very likely to fall asleep). The resulting total score is between 0 and 24. Scores of 0 to 10 are normal. Total scores above 10 generally warrant further investigation.

Nocturnal polysomnogram : – This test will measure the electrical activity of your brain (electroencephalogram) and heart (electrocardiogram), and the movement of your muscles (electromyogram) and eyes (electro-oculogram), and usually requires an overnight stay at a sleep clinic for observation purposes.

Multiple sleep latency test (MSLT) This test measures how long it takes for you to fall asleep during the day, plus the kind of sleep you get during such a nap. Sleep specialists analyze your brain waves (EEG), heart rate (EKG), muscle activity, and eye movements

Spinal fluid analysis : – The lack of hypocretin in the cerebrospinal fluid may be a marker for narcolepsy. Examining spinal fluid is a new diagnostic test for narcolepsy

Narcolepsy is usually treated with amphetamine or amphetamine-like stimulants and a couple new pharmacologically different drugs. The most common amphetamine-like drugs are dextroamphetamine, pemoline methamphetamine, and methylphenidate.

In addition to drug therapy, an important part of treatment is scheduling short naps (10 to 15 minutes) two to three times per day to help control excessive daytime sleepiness and help the person stay as alert as possible. Daytime naps are not a replacement for nighttime sleep
Article by
BGS Hospitals

What is a Laryngectomy ?

The surgical procedure is performed to remove the voice box (larynx) and the separation of the airway from the esophagus, nose and the mouth. A part or all of the larynx can be removed. Owing to its location, larynx (voice box) plays a crucial role in swallowing, speaking and breathing. The larynx is located in the front of the esophagus (food pipe) and above on the trachea (windpipe). Larynx consists of two small bands of muscle (vocal cords) that helps in preventing the food from entering into the lungs and it vibrates to generate the voice. Laryngectomy is performed to remove the cancerous or tumor tissues.
Throat Cancer Symptoms

Location and size of the tumors are the two important factors for determining the symptoms-

While coughing the blood comes out
Constant cough
A mass or lump either in the throat or in the neck
Persistent or constant sore throat
Difficulty in breathing
The pain from the throat can result in ear pain

Laryngectomy Procedure

The surgical procedure is performed under general or local anesthesia. The surgeon in total laryngectomy will make cuts in the neck in order to open up the area. The crucial parts of the surgery

The first step is the removal of lymph nodes
The surgeon then removes the tissues and the larynx around it.
An opening is made in the patient’s trachea along with a hole in front of the neck.
The patient’s trachea is brought up and is then attached to stoma (hole)
After the surgical procedure, the patient will breathe from the stoma and the stoma is never removed.
Clips or stitches are used to thoroughly close the skin and the muscles.
Tracheoesophageal puncture (TEP) is a little hole in the trachea (windpipe) and the tube which is responsible for sending food from the throat into the stomach (esophagus).
Prosthesis (a little man-made part) will be placed into the opening. With the help of Prosthesis, the patient is able to speak after the removal of the voice box.

Minimally Invasive Surgery for Laryngectomy

The less invasive surgeries works for specific people and largely depends upon the type of the cancer and also on how much the cancer has spread. Some of the procedures are vertical partial laryngectomy, supracricoid partial laryngectomy, supraglotticor horizontal partial laryngectomy and endoscopic surgery.
Partial Laryngectomy

The procedure of removing a part of larynx instead of the whole is a very rare case. In this, a part of the voice box is left in order to be able to speak. But this results in the hoarse and weak voice. A temporary tracheotomy may be present that enables one to breathe.

Treatments for Laryngeal Cancer
What is a Laryngectomy ?

The surgical procedure is performed to remove the voice box (larynx) and the separation of the airway from the esophagus, nose and the mouth. A part or all of the larynx can be removed. Owing to its location, larynx (voice box) plays a crucial role in swallowing, speaking and breathing. The larynx is located in the front of the esophagus (food pipe) and above on the trachea (windpipe). Larynx consists of two small bands of muscle (vocal cords) that helps in preventing the food from entering into the lungs and it vibrates to generate the voice. Laryngectomy is performed to remove the cancerous or tumor tissues.
Throat Cancer Symptoms

Location and size of the tumors are the two important factors for determining the symptoms-

While coughing the blood comes out
Constant cough
A mass or lump either in the throat or in the neck
Persistent or constant sore throat
Difficulty in breathing
The pain from the throat can result in ear pain

Laryngectomy Procedure

The surgical procedure is performed under general or local anesthesia. The surgeon in total laryngectomy will make cuts in the neck in order to open up the area. The crucial parts of the surgery

The first step is the removal of lymph nodes
The surgeon then removes the tissues and the larynx around it.
An opening is made in the patient’s trachea along with a hole in front of the neck.
The patient’s trachea is brought up and is then attached to stoma (hole)
After the surgical procedure, the patient will breathe from the stoma and the stoma is never removed.
Clips or stitches are used to thoroughly close the skin and the muscles.
Tracheoesophageal puncture (TEP) is a little hole in the trachea (windpipe) and the tube which is responsible for sending food from the throat into the stomach (esophagus).
Prosthesis (a little man-made part) will be placed into the opening. With the help of Prosthesis, the patient is able to speak after the removal of the voice box.

Minimally Invasive Surgery for Laryngectomy

The less invasive surgeries works for specific people and largely depends upon the type of the cancer and also on how much the cancer has spread. Some of the procedures are vertical partial laryngectomy, supracricoid partial laryngectomy, supraglotticor horizontal partial laryngectomy and endoscopic surgery.
Partial Laryngectomy

The procedure of removing a part of larynx instead of the whole is a very rare case. In this, a part of the voice box is left in order to be able to speak. But this results in the hoarse and weak voice. A temporary tracheotomy may be present that enables one to breathe.

Treatments for Laryngeal Cancer

Radiotherapy : It is the most common treatment and is used for treating early stage cancers. The therapy helps in shrinking a large tumor of the larynx that makes it easy to remove.
Chemotherapy : Both radiotherapy and chemotherapy can be performed simultaneously to treat the cancer. Chemotherapy is also used when the cancer of the larynx again occurred after radiotherapy. The advanced cancer can be treated before with the help of chemotherapy (induction therapy).
Biological Therapy : This type of treatment is made up of natural body substances. The patient may opt for biological therapy which is also called as cetuximab. In this, radiotherapy can also perform for locally advanced squamous cell laryngeal cancer.

What is Throat Cancer ?

The throat (pharynx) is a cancer that develops in the throat. The throat is a five inch long tube that connects from the nose to the neck. The two major places of the throat cancer forms are pharynx and larynx. Head and neck cancer is the type of throat cancer that includes the salivary glands, nose, neck lymph nodes, mouth, tonsils and sinuses. Throat cancer is of two types –

Adenocarcinoma : This type of cancer starts in the glandular cells of the throat.
Squamous Cell Carcinoma : This type of cancer occurs in the flat and thin cells which lines the throat.

Pharyngeal cancer and Laryngeal cancer are the two most common forms of throat cancer.
Throat Polyps

The condition where there is an abnormal growth of the tissue which grows in the throat is known as throat polyps. Throat polyps may become cancerous and that is why a biopsy is performed. The symptoms include a feeling of having something at the back of the throat or can also be a feeling of sensation while swallowing.
Head and Neck Cancer

The cancers of head and neck usually starts in the squamous cells which lines the moist and mucosal surfaces in the head and neck. They are referred to as Squamous cell carcinomas of the head and neck. The cancers can also start in the salivary glands and that is a very uncommon situation. Salivary glands consist of a large number of cells which can become cancerous and ultimately leads to many types of salivary gland cancer.

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Radiotherapy : It is the most common treatment and is used for treating early stage cancers. The therapy helps in shrinking a large tumor of the larynx that makes it easy to remove.
Chemotherapy : Both radiotherapy and chemotherapy can be performed simultaneously to treat the cancer. Chemotherapy is also used when the cancer of the larynx again occurred after radiotherapy. The advanced cancer can be treated before with the help of chemotherapy (induction therapy).
Biological Therapy : This type of treatment is made up of natural body substances. The patient may opt for biological therapy which is also called as cetuximab. In this, radiotherapy can also perform for locally advanced squamous cell laryngeal cancer.

What is Throat Cancer ?

The throat (pharynx) is a cancer that develops in the throat. The throat is a five inch long tube that connects from the nose to the neck. The two major places of the throat cancer forms are pharynx and larynx. Head and neck cancer is the type of throat cancer that includes the salivary glands, nose, neck lymph nodes, mouth, tonsils and sinuses. Throat cancer is of two types –

Adenocarcinoma : This type of cancer starts in the glandular cells of the throat.
Squamous Cell Carcinoma : This type of cancer occurs in the flat and thin cells which lines the throat.

Pharyngeal cancer and Laryngeal cancer are the two most common forms of throat cancer.
Throat Polyps

The condition where there is an abnormal growth of the tissue which grows in the throat is known as throat polyps. Throat polyps may become cancerous and that is why a biopsy is performed. The symptoms include a feeling of having something at the back of the throat or can also be a feeling of sensation while swallowing.
Head and Neck Cancer

The cancers of head and neck usually starts in the squamous cells which lines the moist and mucosal surfaces in the head and neck. They are referred to as Squamous cell carcinomas of the head and neck. The cancers can also start in the salivary glands and that is a very uncommon situation. Salivary glands consist of a large number of cells which can become cancerous and ultimately leads to many types of salivary gland cancer

Procedure Details

This is an operation to remove part of the tongue and adjacent tissues. At the same time,reconstructive surgery is performed to restore normal appearance and speech. A tracheostomy may be performed to assist breathing postoperatively, and a skin graft may be needed to replace removed tissue. Carried out under general anesthesia, the procedure may take several hours. A lengthy hospital stay is usually necessary.Hemiglossectomy and subsequent reconstructive surgery are major procedures and as such entail risk. At present, this operation is the treatment of choice for some types of tongue cancer.Hemiglossectomy may be performed when a malignant growth is found in the tongue.Diagnosis depends on microscopic examination of cells obtained at biopsy (tissue sampling).Important decision on treatment are based on staging, a process to determine the extent of the primary growth in the tongue and whether it has metastasized (spread) to another part of the body.A graft may be needed to replace tissue removed during surgery. If skin cover only is needed, a thin layer of skin (split-skin graft) may be taken from the thigh and placed over the wound. When tissue loss is greater, a full-thickness graft of skin, underlying muscle, and blood vessels, may be taken from the chest, back or forehead and used to reconstruct the tongue and mouth.

Article by
Dr. Balabhai, Nanavati Hospital
Mumbai