Some Important Eye Disorders


CONJUNCTIVITIS

Conjunctivitis, also called pink eye, is a common condition in which the conjunctiva, the clear membrane covering the white of the eye and lining the eyelids, becomes inflamed. The affected eye becomes red and sore and may look alarming, but the condition is rarely serious. One or both of the eyes may be affected, and in some cases it begins in one eye then spreads to the other.

What Are the Causes?

Conjunctivitis may be caused by a bacterial or viral infection, or it may result from an allergic reaction or irritation of the conjunctiva for example, by smoke, pollution, or ultraviolet light.
Bacterial conjunctivitis, which is common, may be caused by any of several types of bacteria. Viral conjunctivitis can occur in epidemics caused by one of the viruses responsible for the common cold. It may also be due to the herpes simplex virus that causes cold sores. Conjunctivitis due to a bacterial or viral infection can be spread by hand-by-eye contact and is usually highly contagious.

Newborn babies sometimes develop conjunctivitis. This can happen if an infection is transmitted to the baby's eyes from the mother's vagina during the birth. This form of conjunctivitis is usually caused by the microorganisms responsible for certain sexually transmitted diseases, including chlamydial cervicitis, gonorrhea, and genital herpes.


Allergic conjunctivitis is a common feature of hay fever and of allergy to dust, pollen, and other airborne substances. The condition may also be triggered by chemicals found in eye drops, cosmetics, or contact lens solutions. Allergic conjunctivitis often runs in families.

What Are the Symptoms?

The symptoms of conjunctivitis usually develop over a few hours and are often first experienced on waking. The symptoms generally include:

• Redness of the white of the eye.
• Gritty and uncomfortable sensation in the eye.
• Swelling and itching of the eyelids.
• Discharge that may be yellowish and thick or clear and watery.

The discharge may dry out during sleep and form crusts on the eyelashes and eyelid margins. As a result, the eyelids sometimes stick together on waking.

What Can I Do?

The symptoms of conjunctivitis can be relieved by bathing the eye with artificial tears. To avoid spreading infection, wash your hands after touching the eye and do not share towels or washcloths. Once the conjunctivitis has cleared up, vision is rarely affected.
If you are susceptible to allergic conjunctivitis, avoid exposure to triggering substances. Antiallergy eye drops can be used to ease the symptoms. If an eye becomes painful and red, you should consult your doctor to rule out the possibility of a more serious condition.

What Might the Doctor Do?

Your doctor probably makes a diagnosis from your symptoms. If infection is suspected, he or she may take a sample of the discharge to identify the cause.
Bacterial conjunctivitis is treated by applying antibiotic drops or ointment. In such cases, the symptoms usually clear up within 48 hours. However, the treatment should be continued for 2-10
days, even if the symptoms improve, to ensure the eradication of infection. Viral conjunctivitis that occurs because of a herpes infection may be treated with eyedrops containing an antiviral drug. Although other types of viral conjunctivitis cannot be treated, their symptoms usually clear up within 2-3 weeks. Your doctor may prescribe eye-drops or oral antiallergy drugs if you have allergic conjunctivitis.

Conjunctivitis cornealulcer

CORNEALULCER

Erosion in the cornea, the transparent outer part of the front of the eyes, is called a corneal ulcer. These ulcers can be very painful and, if they are left untreated, may cause scarring and lead to permanently impaired vision, blindness, or even loss of the eye. People who wear contact lenses are at increased risk of corneal ulcers.

What are the Causes?

Corneal ulcers may be caused by an eye injury, an infection, or a combination of both. A relatively small injury such as a corneal abrasion (left), can develop into a corneal ulcer if the damaged area becomes infected. A more severe injury, such as that caused by a caustic chemical, can produce an ulcer in the absence of infection. However, an ulcer that becomes infected may enlarge and penetrate more deeply into the cornea. Only rarely do infections cause corneal ulcers without prior injury. The most common of these infections are herpes zoster, known as shingles, and herpes simplex infections.

What are the Symptoms?

If you have a corneal ulcer, you may experience the following symptoms:

• Intense pain in the eye.
• Redness and discharge from the eye.
• Blurry vision.
• Increased sensitivity to light.



With an untreated infected ulcer, the infection may spread and permanently damage the vision in that eye and the eye itself. Consult your doctor immediately if you develop a painful, red eye along with blurry vision.

What Might Be Done?


Your doctor may place fluorescein eye-drops in the affected eye and examine it under blue light, using a slit lamp. He or she may also take a swab to identify the cause. If the dye reveals an ulcer, you may be given antibiotic or antiviral eye-drops to treat the infection. Even severe ulcers usually clear up within 1-2 weeks of treatment, but they can leave scars of treatment, but they can leave scars that permanently affect vision.


Conjunctivitis, Cornealulcer, trachoma

TRACHOMA


Trachoma is a serious, persistent eye infection that often causes permanent scarring of the cornea, the transparent front part of the eye. Although rare in developed countries, trachoma is one of the world's main causes of blindness. It affects about 400 million people, of whom about 6 million are blind.
Trachoma is due to the bacterium Chlamydia trachomatis, which is spread to the eyes by direct contact with contaminated hands or by flies. Trachoma is common in poor parts of the world, particularly in hot, dry countries that have poor sanitation and limited water supplies. Overcrowding encourages the spread of the trachoma infection.
To avoid becoming infected in a high-risk area, you should wash your hands and face regularly and avoid touching your eyes with dirty fingers.

What are the symptoms?

Initially, trachoma causes inflammation of the conjunctiva, the membrane that covers the white of the eye and lines the eyelids. Later symptoms include:

• Thick discharge from the affected eye that containspus.
• Redness of the white of the eye.
• Gritty sensation in the eye.

Over time, repeated episodes of trachoma can cause scarring on the inside eyelids. The scars may pull the eyelids inward and cause the eyelashes to rub against the delicate cornea. Left untreated, the condition can lead to blindness.

What is the treatment?

In the early stages, trachoma is treated with antibiotic eye drops or ointment. If the cornea has become scarred, sight may be restored by an operation called a corneal graft, in which a cornea from a donor is used to replace the scarred one.


Conjunctivitis, Cornealulcer, Trachoma, cataract

CATARACT

If you have a cataract, the normally transparent lens of the eye is cloudy as a result of changes in protein fibers in the lens. The clouding affects the transmission and focusing of light entering the eye, reducing clarity of vision.

If cataracts are present from birth, total loss of vision may result. However, cataracts do not usually affect children or young adults. Most people over age 75 have some cataract formation, but visual loss is often minimal as only the outer edges of the lens are affected.

Cataracts usually develop in both eyes, but generally one eye is more severely affected. A cataract in the central part of the lens or one that affects the whole lens can cause total loss of clarity and detail in vision. However, the affected eye will still be able to detect light and shade.

What are the causes?

All cataracts occur as a result of structural changes to protein fibers within the lens. These changes cause part or the entire lens

• Flashing lights in the cornea of the eye.
• Large numbers of dark spots in the field of vision.

If a large area of the retina has become detached, you may experience a cloudy ring or a black area across your field of vision. If you experience any of these symptoms, you should go to the emergency room of your local hospital or call your doctor immediately.

What might be done?

Retinal detachment is diagnosed by ophthalmoscopy, which is a technique used to examine the eye's internal structures. If only a small area of retina has detached, the tear may be sealed by laser treatment under local anesthesia. However, if a large area has detached, an operation under general anesthesia is necessary. If treated early, normal vision may be restored, but delayed treatment is less effective.


Conjunctivitis,Cornealulcer,Trachoma,Cataract,retinopathy

RETINOPATHY

Some long-standing diseases can damage small blood vessels throughout the body. If the blood vessels in the retina (the light-sensitive membrane at the back of the eye) are affected, the damage is known as retinopathy. Retinal damage varies according to the under lying disorder but can include leakage of blood from damaged vessels, loss of blood flow to some areas, and abnormal development of new blood vessels. Retinopathy may cause loss of vision.

One of the most common causes of retinopathy is diabetes mellitus. The condition can also occur as a result of high blood pressure, although vision is not usually affected in this case. Less frequently, retinopathy may be caused by AIDS, oxygen therapy in premature babies, or by sickle-cell anemia. Usually, only the underlying disease is treated. However, in diabetic retinopathy, laser surgery treatment of the retina itself can save vision.

EYE INJURIES

The eyelid-closing reflex and the bony socket around the eye help protect the eye from injury. However, eye injuries are still common, and in some cases blindness may result if the injuries are not treated promptly.

The most common injury to the eye is a scratch on the transparent cornea caused by a foreign body in the eye. Minor injuries of this type rarely damage vision permanently unless they develop an infection that remains untreated. However, penetrating injuries in which the eye is pierced by a tiny, fast-moving object, such as a metal chip from machinery, can lead to total loss of sight. Blunt injuries, such as those due to a blow from a fist or ball, may also endanger vision. Injuries can also occur by using caustic chemicals or by looking directly at the sun.

Most eye injuries can be prevented by the use of protective eyewear when working with dangerous machines or chemicals or when participating in athletic activities. Never look directly at the sun, even while wearing sunglasses.


What are the symptoms

what are the symptoms?

The symptoms of eye injuries differ according to the type and severity of damage, but symptoms may include:

• Pain and watering of the eye.
• Inability to open the eye.
• Bleeding under the front surface of the eye.
• Bruising and swelling of the skin around the eye.
• Reduced vision in the affected eye.
•
In the majority of minor eye injuries, first aid will often be helpful, but you should always seek medical attention for any eye injuries. If the injury was caused by a blow to the eye, involves a penetrating foreign body, or results in reduced vision, hold a clean, dry cloth over the injured eye and go to the nearest hospital emergency room.

What might be done?

Your doctor will probably assess the eye by ophthalmoscopy Potosi’s in adults can occur as a part of the aging process, or it may be a symptom of myasthenia gravis, which causes progressive muscle weakness. If ptosis starts suddenly, it may be due to a brain tumor or a defective blood vessel in the brain. If you develop ptosis, see your doctor to rule out a serious underlying disorder.


What is the Treatment?

Ptosis in babies can be corrected by surgically tightening the eyelid muscle. If the treatment is carried out early, the child's vision should develop normally.
In adults, surgery for ptosis should be carried out only after any possible significant underlying disorders have been ruled out. Surgery is very effective for ptosis caused by the aging process.

WATERY EYE

Watery eye usually results from irritation of the eye by a foreign body such as a particle of dirt. Older people often have watery eye as a result of entropion, in which the eyelashes rub against the eye, or ectropion, in which tears do not drain away normally. The watering usually stops when the irritant is removed or the underlying condition is corrected. Watery eye may also occur as a result of a blocked nasolacrimal system (which drains tears), possibly caused by an infection of the eye or sinus infection.

Babies may have watery eyes because the nasolacrimal system is underdeveloped. Gently massaging between the corner of the eyelid and the nose may help. The condition usually corrects itself by age 6 months. Persistent blockage, at any age, must be treated by a doctor, who may clear the blockage by inserting a fine probe into the tear duct.


xerophthalmia/Caries and Gingivitis

Xerophthalmia


Xerophthalmia, which occurs mainly in developing countries, means dryness of the eye. The condition is caused by a dietary deficiency of vitamin A.

Left untreated, xerophthalmia leads to chronic infection and the cornea (the transparent part of the front of the eye) may soften and perforate. Infection may then spread inside the eye and blindness may result. Artificial tears may relieve dryness, but the main treatment is large doses of vitamin A.

Caries

Medical term for tooth decay .Dental caries begin when bacteria in plaque eat away at the outer layer (enamel or cementum) of a tooth. Normally, these layers are strong enough to withstand invasion, but when the residue of built up food (plaque) remains on the teeth, it gives the bacteria a chance to work more steadily.

Tooth decay may start as a small spot on a tooth. Left untreated, it can destroy teeth, gums and even the bone around the teeth. The bacteria work their way into the tooth and into the pulp. The further the bacteria go, the more damage is done.

Early stage caries often go unnoticed. As the tooth deteriorates. it becomes increasingly sensitive to sweet, hot, or cold food. Removing the decayed area and filing the cavity is the usual form of treatment. For severe cases, removal of the tooth pulp (root canal treatment) or the tooth itself (dental extraction) is necessary.

People can prevent caries by reducing the amount of sugar and other refined carbohydrates in their diet. The next step is proper oral hygiene. The fluoride in toothpaste and fluoridated water strengthens enamel.

Gingivitis

Inflammation of the gums. Like the teeth, the gums (gingiva) are affected by plaque build up. Failure to brush and floss properly can result in an infection with bacteria that destroy the gums and the bones and teeth around them.

Most people pay insufficient attention to their gums and may be unaware of any trouble in this area until symptoms occur. In the early stages of gum disease (gingivitis), the gums bleed easily during tooth brushing. There may be pain and tenderness, the gums may be swollen, and there may be a discharge of pus, especially as the disease progresses.

Gingivitis can often be reversed simply through proper dental hygiene, including brushing regularly and flossing carefully. The use of either dental floss or interdentally stimulators is essential in keeping the gums healthy and strong. Failure to take care of the teeth and gums can result in a worsening of the inflammation, to the point that the damage is no longer reversible and more extreme measures must be taken.. The gums can recede to the point that even healthy teeth can loosen and fall out.



toothache-and-erosion-toothache

Toothache and Erosion Toothache

Pain in or around a tooth or teeth.

There are many causes for toothaches, but dicey all have one thing in common; they are the result of inflammation or injury to dental pulp. The most common cause of a toothache is simple tooth decay (caries) that irritates and can possibly affect the pulp of the teeth. As infection sets in, the pain increases.

The infection can progress to become an abscess. An abscess occurs when a pus-filled sac forms around the root. This can be painful and dangerous; the abscess infection can spread into the bloodstream. Interestingly, a burst abscess is often mistakenly thought to be a good sign, since it relieves the pain because there is no longer pressure.
Toothache always warrants the attention of a dentist. Sometimes the pain will go away for a while; this may be sign of a dead nerve, which needs to be addressed promptly if the tooth can be saved.

Erosion and Abrasion of Teeth

People who complain that their teeth are "wearing away" or becoming more sensitive to the cold aren't imagining things. But they may not realize that these symptoms are due to erosion and abrasion of the tooth surface that's almost entirely, if unintentionally, Self-inflicted.

Dental erosion is a chemical process that gradually eats away at your teeth's tough outer enamel coating. Abrasion also removes tooth enamel, but by physical instead of chemical means.
Neither should be confused with cavities, or caries, which result from a bacterial process that can bore through not only the enamel but also the inner dentin layer of the tooth. Eroded or abraded teeth can change shape and colour as the yellowish dentin begins to show through the thinned enamel. More significantly, teeth can become ultra-sensitive to cold.

Erosion

The major culprit in erosion is acidity: the crystalline calcium salts that make up most of toodi enamel start dissolving below a pH level of 5.5. In most people the main offenders are the mild acids contained in many beverages and citrus fruits.

Surprisingly, according to a study on extracted teeth in the General Dentistry, the worst enamel erosion is produced by non cola drinks, such as ginger ale, Mountain Dew, Sprite, and bottled iced tea.

In this study brewed black tea, brewed black coffee, and root beer produced minimal erosion; colas were more erosive than these beverages but less so than the non cola drinks. There was no difference between the sugar-free and regular versions of these products.

Other sources of oral acidity include gastro esophageal acid reflux (GERD) and acidic medications, such as chewable vitamin C and aspirin tablets.

Saliva is an important defense against tooth enamel erosion. It dilutes and helps neutralize acids and contains minerals to replace those lost to erosion. Therefore, people who experience low saliva levels, or dry mouth, whether from disease, radiation treatment, or medication, have a higher risk of developing the problem.


abrasion

Abrasion

It's ironic that the people most prone to abrasion are often the ones who are trying hardest to keep their teeth clean. Vigorous
brushing with hard bristle brushes and abrasive pastes not only can wear away the tooth enamel but also cause the gum line to recede, exposing and removing the outer covering of the root and exposing the underlying soft dentin.

Worse, tooth erosion and abrasion can act synergistically. For instance, if you consume an acidic drink and brush immediately afterward, you can actually accelerate the erosive process by brushing away the softened outer surface. If you wait a bit, to give your saliva time to rematerialize your teeth, you may not do as much damage. Save your set of 32


The following precautions will ensure that the minerals in' your tooth enamel last as long as you do:


Avoid acidic beverages when possible. If you prefer
the aerated kind, drink it promptly, rather than sipping.
Use a straw to help the acidic liquid bypass your teeth.

Instead of brushing after drinking a high-acid beverage,
Thoroughly rinse with water or use a fluoride rinse.

Use only a soft-bristled regular or electric toothbrush.
Brush with light pressure, using small, circular motions,
Rather than sawing away vigorously. Be especially gentle
when brushing along your gum line.

Don't have your teeth professionally cleaned more than
two or three times a year. The polishes used at some
dentists' offices can be extremely abrasive. So, too,
some whiteners.

If you suffer from dry mouth, stimulate your saliva flow
by sucking on sugar-free hard candy, chewing gum
Containing the sweetener xylitol, or snacking on fibrous
food such as carrots or celery.

If you grind your teeth at night, ask your dentist about
fitting a retainer like appliance that will protect your
teeth.


If erosion and abrasion have made your teeth sensitive to cold or other stimuli, switch to a desensitizing toothpaste. If your exposed roots have become extremely sensitive, ask your dentist about covering them up with a resin or composite.


conducting-hearing-loss

Conducting Hearing Loss and Its Management



Any disease process which interferes with the conduction of sound to reach cochlea causes conductive hearing loss. The lesion may lie in the external ear and tympanic membrane, middle ear or ossicles up to stapediovestibular joint.

The characteristics of conductive hearing loss are:

1. Negative Rinne test, i.e. BC>AC.

2. Weber lateral!sed to poorer ear.

3- Normal absolute bone conduction.

4. Low frequencies affected more.

5. Audiometry shows bone conduction better than airconduction with air-bone gap. Greater the air-bone gap,more is the conductive loss.

6. Loss is not more than 60 dB.

7. Speech discrimination is good.


Management

Management

Most cases of conductive hearing loss can be managed by medical or surgical means. Treatment of these conditions is discussed in respective sections. Briefly, it consists of:

1. Removal of canal obstructions, e.g. impacted wax, foreign body, osteoma or exostosis, keratotic mass, benign or malignant tumours, meatal atresia.


2. Removal of fluid. Myringotomy with or withoutgrommet insertion.

3. Removal of mass from middle ear. Tympanotomyand removal of small middle ear tumours orcholesteatoma behind intact drum.

4. Stapedectomy, as in otosclerotic fixation of stapesfootplate.

5. Tympanoplasty. Repairof perforation, ossicular chainor both.

6. Hearing aid. In cases, where surgery is not possible,refused or has failed.

Congenital causes of conductive hearing loss

• Meatal atresia
• Fixation of stapes footplate
• Fixation of malleus head
• Ossicular discontinuity
• Congenital cholesteatoma

Tympanoplasty

It is an operation to (i) eradicate disease in the middle ear and (ii) to reconstruct hearing mechanism. It may be combined with mastoidectomy if disease process so demands. Type of middle ear reconstruction depends on the damage present in the ear. The procedure may be limited only to repair of tympanic membrane (myringoplasty), or to reconstruction of ossicular chain (ossiculoplasty), or both (tympanoplasty). Recons-tructive surgery of the ear has been greatly facilitated by development of operating microscope, microsurgical instruments and biocompatible implant materials.


acquired-causes-of-conductive-hearing

Acquired causes of conductive hearing loss



External ear

Any obstruction in the ear canal, e.g. wax,
foreign body, furuncle, acute inflammatory
swelling, benign or malignant tumour or atresia of canal.


Middle ear


(a) Perforation of tympanic membrane, traumatic or infective

(b) Fluid in the middle ear, e.g. acute otitis media,serous ofitis media or haemotympanum

(c) Mass in middle ear, e.g. benign or malignanttumour

(d) Disruption of ossicles, e.g. trauma to ossicularchain, chronic suppurative otitis media,cholesteatoma

(e) Fixation of ossicles, e.g. otosclerosis,tympanosclerosis, adhesive otitis media

(f) Eustachian tube blockage, e.g. retractedtympanic membrane, serous otitis media.

Myringoplasty

It is repair of tympanic membrane. Graft materials of choice are temporalis fascia or the perichondrium taken from the patient.

Ossicular reconstruction

It is required when there is destruction or fixation of ossicular chain. Most common defect is necrosis of the long process of incus, the malleus and the stapes being normal.


acute-suppurative-otitis-media

Acute Suppurative Otitis Media


It is an acute inflammation of middle ear by pyogenic organisms. Here, middle ear implies middle ear cleft, i.e. eustachian tube, middle ear, attic, aditus, antrum and mastoid air cells.

Aetiology

It is more common especially in infants and children of lower socio economic group. Typically, the disease follows viral infection of upper respiratory tract but soon the pyogenic organisms invade the middle ear.

Routes of Infection

1. Via eustachian tube

. It is the most common route. Infectiontravels via the lumen of the tube or along subepithelial perituballymphatics. Eustachian tube in infants and young children is shorter,wider and more horizontal and thus may account for higher incidenceof infections in this age group. Breast or bottle feeding in a younginfant in horizontal position may force fluids through the tube intothe middle ear and hence the need to keep the infant propped upwith head a little higher. Swimming and diving can also force waterthrough the tube into the middle ear.

2. Via external ear. Traumatic perforations of tympanicmembrane due to any cause open a route to middle ear infection.

3. Blood-borne. This is an uncommon route.



Predisposing Factors

Anything that interferes with normal functioning of eustachian tube predisposes to middle ear infection. It could be:

1. Recurrent attacks of common cold, upper respiratorytract infections, and exanthematous fevers likemeasles, diphtheria, whooping cough.

2. Infections of tonsils and adenoids.

3. Chronic rhinitis and sinusitis.

4. Nasal allergy.

5. Tumours of nasopharynx, packing nose or nasopharynxfor epistaxis.
i
6. Cleft palate.

Bacteriology,

Most common organisms in infants and young children are Streptococcus pneumonia (30%), Hsaemophilus influenzae (20%) and Morexellacatarrhalis (12%). Other organisms include streptococcus pyogenes, staphylococcus aureus and sometimes pseudomas aeroginosa. In about 18-20%, no growth is seen. Many of the strains of H. influenzae and Morexella catarrhalis are b-lactamase producing.

Diseases run through the following stages

Pathology and clinical features


The diseases runs through the following stages:

1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or complication

1. Stage of tubal occlusion.

Oedema and hyperaemia of nasopharyngeal end of eustachian tube, blocks the tube, leading to absorption of air and negative intratympanic pressure. There is retraction of tympanic membrane with some degree of effusion in the middle ear but fluid may not be clinically appreciable.
Symptoms.
Deafness and earache are the two symptoms but they are not marked. There is generally no fever.


Signs.

Tympanic membrane is retracted with handle of malleus assuming a more horizontal position, prominence of lateral process of malleus and loss of light reflex. Tuning fork tests show conductive Deafness.

2. Stage of pre-suppuration.

If tubal occlusion is prolonged,
pyogenic organisms invade tympanic cavity causing hyperaemia of its lining. Inflammatory exudate appears in the middle ear. Tympanic membrane becomes congested.

Symptoms.

There is marked earache which may disturb sleep and is of throbbing nature. Deafness and tinnitus are also present, but complained only by adults. Usually, child runs high degree of fever and is restless.

Signs

. To begin with, there is congestion of pars tensa. Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane imparting it a cart-wheel appearance. Later, whole of tympanic membrane including pars flaccida becomes, uniformly red.Tuning fork tests will again show conductive type of hearing loss.

3. Stage of suppuration.

This is marked by formation of pusin the middle ear and to some extent in mastoid air cells. Tympanicmembrane starts bulging to the point of rupture.

Symptoms.

Earache becomes excruciating. Deafness increases. child may run fever of 102-103"F. This may be accompanied by vomiting and even convulsions.

Signs

. Tympanic membrane appears red and bulging with loss of landmarks. Handle of malleus may be engulfed by the swollen and protruding tympanic membrane and may not be discernible. A yellow spot may be seen on the tympanic membrane where rupture is imminent. In pre-antibiotic era, one could see a nipple-like protrusion of tympanic membrane with a yellow spot on its summit. Tenderness may be elicited over the mastoid antrum.

X-rays of mastoid will show clouding of air cells because of
exudate.

4. Stage of resolution.

The tympanic membrane ruptures withrelease of pus and subsidence of symptoms. Inflammatory processbegins to resolve. If proper treatment is started early or if the infectionwas mild, resolution may start even without rupture of tympanicmembrane.
Symptoms.

With evacuation of pus, earache is relieved, fever comes down and child feels better.
Signs.

External auditory canal may contain blood tinged discharge which later becomes mucopurulent. Usually, a small perforation is seen in antero-inferior quadrant of pars tensa.Hyperaemia of tympanic membrane begins to subside with return to normal colour and landmarks.

5. Stage of complication.

If virulence of organism is high orresistance of patient poor, resolution may not take place and diseasespreads beyond the confines of middle ear. It may lead to acutemastoiditis, subperiosteal abscess, facial paralysis, labyrinthitis,petrositis, extradural abscess, meningitis, brain abscess or lateralsinus thrombophlebitis.


Treatment

Treatment

1. Antibacterial therapy.

It is indicated in all cases with fever and severe earache. As the most common organisms are Strept. pneumoniae and H. influenzae, the drugs which are effective in acute otitis media are ampicillin (50 mg/kg/day in 4 divided doses), amoxicillin (40 mg/kg/day in 3 divided doses). Those allergic to these penicillins can be given cefaclor, co-trimoxazole or erythromycin. In cases where beta-Iactamase-producing H. influenzae or Moraxella catarrhalis are isolated, antibiotics like amoxicillin-clavulanate, augmentin, cefuroxime axetil orcefbdme may be used. Antibacterial therapy must be continued for a minimum of 10 days, till tympanic membrane regains normal appearance and hearing returns to normal. Early discontinuance of therapy with relief of earache and fever, or therapy given in inadequate doses may lead to secretory otitis media and residual hearling loss.


2. Decongenstant nasal drops.

Ephedrine nose drops (1%in adults and 0.5% in children) or oxymetazoline (Nasivion) orxylometazoline (Otrivin) should be used to relieve eustachian tubeoedema and promote ventilation of middle ear.

3. Oral nasal decongestants.

Psudoephedrine (Sudafed) 30mg twice daily or a combination of decongestant and antihistaminic(Triominic) may achieve drops which are difficult to administer inchildren.

4. Analgesics and antipyretics.

Paracetamol helps to relievepain and bring down temperature.

5. Ear toilet.

If there is discharge in the ear, it is dry-moppedwith sterile cotton buds and a wick moistened with antibiotic maybe inserted.

6. Dry local heat.
It helps to relieve pain.

7. Myringotomy

It is incising the drum to evacuate pus and isindicated when (a) drum is bulging and there is acute pain, (b) thereis an incomplete resolution despite antibiotics when drum remainsfull with persistent conductive deafness, (c) there is persistenteffusion beyond 12 weeks.

All cases of acute suppurative otitis media should be carefully followed till drum membrane returns to its normal appearance and conuctive deafness disappears.



Otalgia

Otalgia (Earache)

Pain in the ear can be due to problems occurring locally in the ear or referred to it from remote areas.
"
. Local Causes

1. External ear. Furuncle, impacted wax, otitis externa,
otomycosis, myringitis bullosa, herpes zoster, and malignant
i neoplasms.

2. Middle ear. Acute otitis media, eustachian tube obstruction,mastoiditis, extradural abscess, aero-otitis media, and carcinomamiddle ear.



B. Referred Causes

As ear receives nerve supply from Vth (auriculotemporal br.), IXth (tympanic br} and Xth (auricular br.) cranial nerves; and from C2 (lesser occipital) and C2 and C3 (greater auricular), pain may be referred from these remote areas.


1. Via Vth cranial nerve

(a) Dental. Caries tooth, apical abscess, impacted molar,malocclusion.
(b) Oral cavity. Benign or malignant ulcerative lesions oforal cavity or tongue.
(c) Temporomandibular joint disorders. Bruxism,osteoarthritis, recurrent dislocation, ill-fitting denture.
(d) Sphenopalatine neuralgia.



2. Via IXth cranial nerve


(a) Oropharynx. Acute tonsillitis, peritonsillar abscess,tonsillectomy. Benign or malignant ulcers of soft palate,tonsil and its pillars.
(b) Base of tongue. Tuberculosis or malignancy.
(c) Elongated styloid process.

3. Via Xth cranial nerve. Malignancy or ulcerative lesion of:vallecula, epiglottis, larynx or laryngopharynx, oesophagus.


4. Via C2 and C, spinal nerves. Cervical spondylosis, injuriesof cervical spine, caries spine.
C. Psychogenic
When no cause has been discovered, pain may be functional in origin but the patient should be kept under observation with periodic re-evaluation.
Otalgia is a symptom. It is essential to find its cause before specific treatment can be instituted.


Allergic Rhinitis

Allergic Rhinitis



It is an IgE-mediated immunologic response of nasal mucosa to air-borne allergens and is characterised by watery nasal discharge, nasal obstruction, sneezing and itching in the nose. This may also be associated with symptoms of itching in the eyes, palate and pharynx. Two clinical types have been recognised:

1. Seasonal. Symptoms appear in or around a particular seasonwhen the pollens of particular plant, to which the patient is sensitive,
Are present in the air.

1. Perennial. Symptoms are present throughout the year.Aetiology

Inhalant allergens are often the cause. Pollen from the trees and grasses, mold spores, house dust, debris from insects or house mite are common offenders. Food allergy is rarely an important cause.

Genetic predisposition plays an important part. Chances of children developing allergy are 20% and 47% respectively, if one or both parents suffer from allergic diathesis.

Pathogenesis

Inhaled allergens produce specific IgE antibody in the genetically predisposed individuals. This antibody becomes fixed to the blood basophils or tissue mast cells by its Fc end. On subsequent exposure, antigen combines with IgE antibody at its Fab end. This reaction produces degranulation of the mast cells with release of several chemical mediators, some of which already exist in preformed state while others are synthesised afresh. These mediators are responsible for symptomatology of allergic disease . Depending on the tissues involved, there may be vasodilation, mucosal oedema, infiltration with eosinophils, excessive secretion from nasal glands or smooth muscle contraction. A "priming affect" has also been described, i.e. mucosa earlier sensitised to an allergen will react to smaller doses of subsequnt specific allergen. It also gets "primed" to other non-specific antigens to which patient was not exposed. Clinically, allergic response occurs in 2 phases:


(a) Acute or early phase. It occurs immediately within 5-30minutes, after exposure to the specific allergen and consists ofsneezing, rhinorrhoea nasal blockage and/or bronchospasm. It isdue to release of vasoactive amines like histamine.


(b) Late or delayed phase. It occurs 2-8 hours after exposureto allergen without additional exposure. It is due to infiltration ofinflammatory cellseosinophils, neutrophils, basophil, monocytes andCD4 +T cells at the site of antigen deposition causing swelling,congestion, thick secretion. In the event of repeated or continuousexposure to allergen, acute phase symptomatology overlaps thelate phase.


Clinical Features

Clinical Features


There is no age or sex predilection. It may start in infants as young as 6 months or older people. Usually the onset is at 12-16 years of age.
The cardinal symptoms of seasonal nasal allergy include paroxysmal sneezing. 10-20 sneezes at a time, nasal obstruction, watery nasal discharge and itching in the nose. Itching may also involve eyes, palate or pharynx. Some may get bronchospasm. The duration and severity of symptoms may vary with the season.

Symptoms of perennial allergy are not so severe as that of the seasonal type. They include frequent colds, persistently stuffy nose, loss of sense of smell due to mucosal oedema, postnasal drip, chronic


cough and hearing impairment due to eustachian tube blockage or fluid in the middle ear.
Signs of allergy may be seen in the nose, eyes, ears, pharynx or larynx.
Nasal signs include transverse nasal crease a black line across the middle of dosrum of nose due to constant upward rubbing of nose simulating a salute (allergic salute), pale and oedematous nasal mucosa which may appear bluish. Turbinates are swollen. Thin, watery or mucoid discharge is usually present.

Ocular signs include oedema of lids, congestion and cobble­stone appearance of the conjunctiva dark circles under the eyes (allergic shiners).
Otologic signs include retracted tympanic membrane or serious otitis media as a result of eustachian tube blockage.

Pharyngeal signs include granular pharyngitis due to hyperplasia of submucosal lymphoid tissue. A child with perennial allergic rhinitis may show all the features of prolonged mouth breathing as seen in adenoid hyperplasia.
Laryngeal signs include hoarseness of voice and oedema of the vocal cords.

Diagnosis


A detailed history and physical examination is helpful, and also gives clues to the possible allergen. Other causes of nasal stuffiness should be excluded.

Investigations

1. Total and differential count. Peripheral eosinophiliamay be seen but is an inconsistent finding.

2. Nasal smear shows large number of eosinophils inallergic rhinitis. Nasal smear should be taken at thetime of clinically active disease or after nasal challengetest. Nasal eosinophilia is also seen in certain nonallergic rhinitis, e.g. NARES (nonallergic rhinitis with eosinophilia syndrome).

3. Skin tests help to identify specific allergen. They areprick, scratch a intradermal tests.

4. Radioallergosorbent test (RASTj is an invitro test andmeasures specific IgE antibody concentration in the
patient's serum.

5. Nasal provocation test. A crude method is to challengethe nasal mucosa with a small amount of allergen placedat the end of a toothpick and asking the patient to sniffinto each nostril and to observe if allergic symptomsare reproduced. More sophisticated techniques areavailable now.


Complications


Nasal allergy may cause:


1. Recurrent sinusitis because of obstruction to the sinusostia.


2. Nasal polypi.


3. Serous otitis media.


4. Orthodontic problems and other ill effects of prolongedmouth breathing especially in children.


5. Bronchial asthma. Patients of nasal allergy have fourtimes more risk of developing bronchial asthma.


Treatment

Treatment

Treatment can be divided into:

1. Avoidance of allergen

2. Treatment with drugs

3. Immunotherapy

1. Avoidance of allergen. This is most successful if the antigen involved is single. Removal of a pet from the house, encasing the pillow or mattress with plastic sheet, change of place of work or sometimes change of job may be required. A particular food article



to which the patient is found allergic can be eliminated from the diet.

2. Treatment with drugs.

(a) Antihistaminics. They control rhinorrhoea, sneezing andpruritis. All antihistaminics have the side effects of drowsiness;some more than the other. The dose and type of the antihistaminichas to be individualised. If one antihistaniinic is not effective, anothermay be tried from a different class.

(b) Sympathomimetic drugs (oral or topical). Alpha-adrenergic drugs constrict blood vessels and reduce nasal congestionand oedema. They also cause CNS stimulation and are often givenin combination with antihistaminics to counteract drowsiness.Pseudoephedrine and phenyl-propanolamine are often combinedwith antihistamanics for oral administration.
Topical use of sympathomimetic drugs cause nasal decongestion. Phenylephrine, oxymetazoline and xylometazoline are often used to relieve nasal obstruction, but are notorious to cause severe rebound congestion. Patient resorts to using more and more of them to relieve nasal obstruction. This vicious cycle leads to rhinitis medicamentosa.

(c) Corticosteroids. Oral corticosteroids are very effectivein controlling the symptoms of allergic rhinitis but their use shouldbe limited to acute episodes which have not been controlled byother measures. They have several systemic side effects.

Topical steroids such as beclomethasone dipropionate, budesomide, flunisolide acetate fluticasone and mometasone inhibit recruitment of inflammatory cells into the nasal mucosa and suppress late-phase allergic reaction, are used as aerosols and are very effective in the control of symptoms. They have also been used in rhinitis medicamentosa while withdrawing topical use of decongestant nasal drops. Topical steroids have fewer systemic side effects but their continuous use may cause mucosal atrophy and even septal perforation. It is wise to break their use for 1-2


weeks every 2-3 months. They may promote growth of fungus.

(d) Sodium chromoglycate. It stabilises the mast cells and prevents them from degranulation despite the formation of 19B-antigen complex. It is used as 2% solution for nasal drops or spray or as an aerosol powder. It is useful both in seasonal and perennial allergic rhinitis.

3. Immunotherapy.

Immunotherapy or hyposensitisation is used when drug treatment fails to control symptoms or produces intolerable side effects. Allergen is given in gradually increasing doses till the maintenance dose is reached. Immunotherapy suppresses the formation of 19B. It also raises the litre of specific IgG antibody. Immunotherapy has to be given for a year or so before significant improvement of symptoms can be noticed. It is discontinued if uninterrupted treatment for 3 years shows no clinical improvement.


Epistaxis

Epistaxis


Bleeding from inside the nose is called epistaxis. It is fairly common and is seen in all age groups children, adults and older people. It often presents as an emergency. Epistaxis is a sign and not a disease per se and an attempt should always be made lo find any local or constitutional cause.
Blood Supply of Nose
Nose is richly supplied by both the external and internal carotid systems, both on the septum and the lateral walls.

Nasal Septum Internal Carotid System

(a) Anterior ethmoidal artery. Branches of
(b) Posterior ethmoidal artery. \ ophthalmic artery
External Carotid System
(a) Sphenopalatine artery (branch of maxillary artery),gives nasopalatine and posterior nasal septal branches.
(b) Septal branch of greater palatine artery (Br. of maxillaryartery).
(c) Septal branch of superior labial artery (Br. of facialartery).
Lateral Wall

Internal Carotid System



(a) Anterior ethmoidal Branches of
(b) Posterior ethmoidal ophthalmic artery

External Carotid System

(a) Posterior lateral nasal branches -> From Sphenopalatine
artery
(b) Greater palatine artery -> From maxillary artery
(c) Nasal branch of anterior superior dental -> From infraorbitalbranch of maxillary artery
(d) Branches of facial artery to nasal vestibule

Little's Area


It is situated in the anterior inferior part of nasal septum, just above the vestibule. Four arteries—anterior ethmoidal, septal branch of superior labial, septal branch of Sphenopalatine and the greater palatine, anastomose form a vascular plexus called "Kiesselbach's plexus". This area is exposed to the drying effect of inspiratory current and to finger nail trauma, and is the usual site for epistaxis in children and young adults.

Retrocolumellar vein.

This vein runs vertically downwards just behind the columella, crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous bleeding in young people.


Causes of Epistaxis

Causes of Epistaxis

They may be divided into:

A. Local, in the nose or nasopharynx.
B. General.
C. Idiopathic.
A. Local Causes

Nose

1. Trauma. Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of face and base of skull, hard-blowing of nose, violent sneeze



2. Infections.

Acute: Viral rhinitis, nasal diphtheria, acute sinusitis. Chronic: All emst-forming diseases, e.g.atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal perforation, granulomatous lesion of the nose, e.g. rhinosporodiosis.

3. Foreign bodies.
Non-living: Any neglected foreign body, rhinolith. Living: Maggots leeches.

4. Neoplasms of nose and paranasal sinuses.Benign: Haemangioma, papilloma.Malignant: Carcinoma or sarcoma.

5. Atmospheric changes. High altitudes, suddendecompression (Caisson's disease).

6. Deviated nasal septum.
Nasopharynx

1. Adenoiditis

2. Juvenile angiofibroma

3. Malignant tumours

B. General Causes

1. Cardiovascular system. Hypertension, arteriosclerosis,mitral stenosis, pregnancy (hypertension and hormonal).

2. Disorders of blood and blood vessels. Aplasticanaemia, leukaemia, thrombocytopenic and vascularpurpura, haemophilia, Christmas disease, scurvy, vitaminK deficiency, hereditary haemorrhagic telangectasia.

3. Liver disease. Hepatic cirrhosis (deficiency of factor!!,VII,IX&X).

4. Kidney disease. Chronic nephritis.

5. Drugs. Excessive use of salicylates and otheranalgesics (as for joint pains or headaches),anticoagulant therapy (for heart disease).
Mediastinal compression. Tumours of mediastinum

(raised venous pressure in the nose).




7. Acute general infection. Influenza, measles,chickenpox, whooping cough, rheumatic fever,infectious mononucleosis, typhoid, pneumonia, malaria,dengue fever.

8. Vicarious menstruation (epistaxis occurring at the timeof menstruation).

C. Idiopathic

Many times the cause of epistaxis is not clear.



Sites of epistaxis

Sites of Epistaxis


1. Little's area. In 90% cases of epistaxis, bleeding occursfrom this site.

2. Above the level of middle turbinate, Bleeding fromabove the middle turbinate and corresponding area onthe septum is often from the anterior and posteriorethmoidal vessels (internal carotid system).

3. Below the level of middle turbinate. Here bleedingis from the branches of sphenopalatine artery. It maybe hidden, lying lateral to middle or inferior turbinateand may require infrastructure of these turbinates forlocalisation of the bleeding site and placement ofpacking to control it.

4. Posterior part of nasal cavity. Here blood flowsdirectly into the pharynx.

5. Diffuse. Both from septum and lateral nasal wall. Thisis often seen in general systemic disorders and blooddyscrasias.

6. Nasopharynx,

Classification of Epistaxis

Anterior Epistaxis
When blood flows out from the front of nose with the patient in sitting position.




Posterior Epistaxis

Mainly the blood flows back into the throat. Patient may swallow it and later have a "coffee coloured" vomitus. This may erroneously be diagnosed as haematemesis.
The differences between the two types of epistaxis are tabulated herewith.

Management

In any case of epistaxis, it is important to know:

1. Mode of onset.

2. Duration and frequency of bleeding.

3. Amount of blood loss.

4. Side of nose from where bleeding is occurring.

5. Whether bleeding is of anterior or posterior type.

6. Any known bleeding tendency in the patient or family.

7. History of known medical ailment (hypertension,leukaemias, mitral valve disease, cirrhosis, nephritis).

8. History of drug intake (analgesics, anticoagulant, etc.)First Aid

Most of the time, bleeding occurs from the Little's area and can be easily controlled by pinching the nose with thumb and index finger for about 5 minutes. This compresses the vessels of the Little's area. In Trotter's method patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from the mouth. Cold compresses should be applied to the nose to cause reflexi vasoconstriction.

Cauterisation

This is useful in anterior epistaxis when bleeding point has been located. The area is first anaesthetised and the bleeding point cauterised with a bead of silver nitrate or coagulated with electrocautery.


Nasal Packing

Anterior Nasal Packing


In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localise Ihe bleeding site, hi minor bleeds, from the accessible sites, cauterisation of the bleeding area can be done. If bleeding is profuse and/or the site of bleeding is difficult to localise, anterior packing should be done. For this, use a ribbon gauze soaked with liquid paraffin. About 1 metre gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the floor, and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof and from before backwards. Packing can also be done in vertical layers from back to the front. One or both cavities may need to be packed. Pack can be removed after 24 hours if bleeding has stopped. Sometimes, it has to be kept for 2 to 3 days; in that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.


Posterior Nasal Packing

It is required for patients bleeding posteriorly into the throat. A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rubber catheter is passed through the nose and its end brought out from the mouth. Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk thread, is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental roll. The third silk thread is cut short and allowed to hang in the oropharynx. It helps in easy removal of the pack later. Patients requiring postnasal pack should always be hospitalised. Instead of postnasal pack, a Policy's catheter can also be used. The bulb is inflated with saline and pulled forward so that choana is blocked and then an anterior nasal pack is kept in the usual manner. These days nasal balloons are also available. A nasal balloon has two bulbs, one for the postnasal space and the other for nasal cavity.


Endoscopic Cautery


Posterior bleeding point can sometimes be better located with an endoscope. It can be coagulated with suction cautery. Local anaesthesia with sedation may be required.
Elevation of Mucoperichondrial Flap and SMR Operation
In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.


Ligation Of Vessels

Ligation of Vessels


(a) External carotid. When bleeding is from the externalcarotid system and the conservative measures havefailed, ligation of external carotid artery above the originof superior thyroid artery should be done. It is avoidedthese days in favour of embolisation or ligation of moreperipheral branches.

(b) Maxillary artery. Ligation of this artery is done inuncontrollable posterior epistaxis. Approach is viaCaldwell- Luc operation. Posterior wall of maxillary•sinus is removed and the maxillary artery or its branchesare blocked by applying clips.
Endoscopic ligation of the maxillary artery can also be done through nose.

(c) Ethmoidal arteries. In anterosuperior bleeding abovethe middle turbinate, not controlled by packing, anteriorand posterior ethmoidal arteries which supply this area,can be ligated. The ''essels are exposed in the medialwall of the orbit by an external ethmoid incision.

General Measures in Epistaxis

1. Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.


2. Reassure the patient. Mild sedation should be given.

3. Keep check on pulse, blood preasure and respiration.

4. Maintain haemodynamics. Blood transfusion may berequired.

5. Antibiotics may be given to prevent sinusitis, if pack isto be kept beyond 24 hours.

6. Intermittent oxygen may be required in patients withbilateral packs because of increased pulmonaryresistance from nasopulmonary reflex.

7. Investigate and treat the patient for any underlying localor general cause.
Hereditary haemorrhagic telangectasia: It occurs on the anterior part of nasal septum and is the cause of recurrent bleeding. It can be treated by using Argon, KTP or Nd: YAG laser. The procedure may require to be repeated several times in a year as telangectasia recurs in the surrounding mucosa. Some cases require septodermoplasty where anterior part of septal mucosa is excised and replaced by a split skin graft.



chronic-sinusitis

Chronic Sinusitis

Chronic Sinusitis in General

Sinus infection lasting for months or years is called chronic sinusitis. Most important cause of chronic sinusitis is failure of acute infection to resolve.

Pathophysiology

Acute infection destroys normal ciliated epithelium impairing drainage from the sinus. Pooling and stagnation of secretions in the sinus invites infection. Persistence of infection causes mucosal changes, such as loss of cilia, oedema and polyp formation, thus continuing the vicious cycle.

Pathology

In chronic infections, process of destruction and attempts at healing proceed simultaneously. Sinus mucosa becomes thick and polypoidal (hypertrophic sinusitis) or undergoes atrophy (atrophic sinusitis). Surface epithelium may show desquamation, regeneration or metaplasia. Submucosa is infiltrated with lymphocytes and plasma cells and may show microabscesses, granulations, fibrosis or polyp formation.

Bacteriology


Mixed aerobic and anaerobic organisms are often present. Clinical Features
Clinical features are often vague and similar to those of acute sinusitis but of lesser severity. Purulent nasal discharge is the commonest complaint. Foul-smelling discharge suggests anaerobic infection. Local pain and headache are often not marked except in acute exacerbations. Some patients complain of nasal stuffiness and anosmia.

Diagnosis

1. X-ray of the involved sinus may show mucosalthickening or opacity.

2. X-rays after injection of contrast material may showsoft tissue changes in the sinus mucosa.

3. CT scan is particularly useful in ethmoid and sphenoidsinus infections and has replaced studies with contrastmaterials.
Treatment

It is essential to search for underlying aetiological factors which obstruct sinus drainage and ventilation. A work-up for nasal allergy may be required. Culture and sensitivity of sinus discharge helps in the proper selection of an antibiotic.
Initial treatment of chronic sinusitis is conservative, including antibiotics, decongestants, antihistaminics and sinus irrigations. More often, some form of surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases so as to provide wide drainage or to obliterate the sinus.

Recently, endoscopic sinus surgery is replacing radical operations on the sinuses and provides good drainage and ventilation. It also avoids external incisions.




Acute Tonsillitis

Acute Tonsillitis


Primarily, the tonsil consists of (a) surface epithelium which is continuous with the oropharyngeal lining; (b) crypts which are tubelike imaginations from the surface epithelium; and (c) the fymphoid tissue. Acute infections of tonsil may involve these components and are thus classified as:

I. Acute catarrhal or superficial tonsillitis. Here tonsillitis is a part of generalised pharyngitis and is mostly seen in viral infections.

4.
Acute folliciilar tonsillitis. Infection spreads into the crypts which become filled with purulent material, presenting at the openings of crypts as yellowish spots. Acute parenchymatous tonsillitis. Here tonsil substance is affected. Tonsil is uniformly enlarged and red. Acute membranous tonsillitis. It is a stage ahead of acute follicular tonsillitis when exudation from the crypts coalesces to form a membrane on the surface of tonsil.

Aetiology

Acute tonsillitis not only affects school-going children, but also adults. It is rare in infants and in persons who are above 50 years of age.
Haemolytic streptococcus is the most commonly infecting organism. Other causes of infection may be staphylococci


pneumococci or H. influenzae. These bacteria may primarily infect the tonsil or may be secondary to a viral infection.

Symptoms

The symptoms vary with severity of infection. The predominant symptoms are:

1. Sore throat.

2. Difficulty in swallowing. The child may refuse to eatanything due to local pain.

3. Fever. It may vary from 38 to 40°C and may be associatedwith chills and rigors. Sometimes, a child presents with anunexplained fever and it is only on examination that anacute tonsillitis is discovered.

4. Earache. It is either referred pain from the tonsil or theresult of acute otitis media which may occur as acomplication.

5. Constitutional symptoms. They are usually more markedthan seen in simple pharyngitis and may include headache,general body aches, malaise and constipation. There maybe abdominal pain due to mesenteric lymphadenitissimulating a clinical picture of acute appendicitis.

Signs

1. Often the breath is foetid and tongue is coasted.

2. There is hyperaemia of pillars, soft palate and uvula.

3. Tonsils are red and swollen with yellowish spots of purulentmaterial presenting at
the opening of crypts (acutefollicular tonsillitis) or there may be a whitish membraneon the medial surface of tonsil which can be easily wipedaway with a swab (acute membranous tonsillitis). Thetonsils may be enlarged and congested so much so thatthey almost meet in the midline along with some oedemaof the uvula and soft palate (acute parenchymatoustonsillitis).


4. The jugulodigastric lymph nodes are enlarged and tender. Treatment

1. Patient is put to bed and encouraged to take plenty of fluids.


2. Analgesics (Aspirin or paracetamol) are given accordingto the age of the patient to relieve local pain and bringdown the fever.

3. Antimicrobial therapy. Most of the infections are due tostreptococcus, and penicillin is the drug of choice. Patientsallergic to penicillin can be treated with' erythromycin.Antibiotics should be continued for 7-10 days.

Complications

1. Chronic tonsillitis with recurrent acute attacks. This isdue to incomplete resolution of acute infection. Chronicinfection may persist in lymphoid follicles of the tonsil inthe form of microabscesses.

2. Peritonsillar abscess.

3. Parapharyngeal abscess.

4. Cervical abscess due to suppuration of jugulodigastriclymph nodes.

5. Acute otitis media. Recurrent attacks of acute otitis mediamay coincide with recurrent tonsillitis.

6. Rheumatic fever. Often seen in association with tonsillitisdue to Group A beta-haemolytic streptococci.

7. Acute glomerulonephritis. Rare these days.Subacute bacterial endocarditis. Acute tonsillitis in apatient with valvular heart disease may be complicated byendocarditis. It is usually due to streptococcus viridans

What is Asthma?


Bronchial asthma, commonly called asthma, consists of repeated attacks of breathlessness and wheezing. When the patient is not in an attack, he feels normal. When an asthma patient comes in contact with an allergic substance, it behaves, as an antigen and reacts with the corresponding antibodies already present in his body. The histamine and other substances liberated during the allergic reactions cause the following changes in the bronchi:

1. Bronchial muscles are constricted to the content oflessening the diameter (calibre) of the bronchi.

2. Mucous membrane of the bronchi gets swollen, whichfurther restricts the lemen of the bronchi.

3. Secretions are poured out from the swollen mucouslining Into the constricted lumen of the bronchi.

When the bronchi are constricted and they are full of secretions, the patient has difficulty in breathing and his breath has a wheezing sound in it, which is more on breathing out because the bronchi gets narrower.

Asthma is a disease of the larger and medium-sized airways of the lungs and there is obstruction of outflow of air from the lungs. Since enough air does not reach the lungs for the exchange of gases, there is hurried breathing to compensate it.
Cough is a frequent symptom hi asthmatics. This occurs in order to throw out the excessive secretions produced in the lungs.


This is particularly so in those who have respiratory infection as well. Cough gets relieved by the same measures as breathlessness.

The airways of the asthmatics are over-reactive to pollens, air pollution, changes in temperature, physical excercise, etc., and they react strongly to those factors. Persons who are asthmatics find it extremely difficult to tolerate smoking or air-pollution. Smoke or strong fumes, smell of fresh paint, white-washing, house-dust, or dust from old files, or the opening of dusty almirahs or trunks cause symptoms in some patients.
Asthma patients are liable to some complications such as thoracic deformity in children, diminished growth, recurrent infection or pneumonia, chronic bronchitis and hyper-inflation of the lung tissues (emphysema).

Diagnosis of Asthma by Skin Test



If asthma is caused or, at least, suspected by some allergen, try to find out as to which of the allergens is the real causative factor and also what and when symptoms surfaced first; in which seasons symptoms aggravated. It is quite necessary to take a detailed history of the patient; taking into account the said points. One would be expected to undergo the following tests with the advise of a specialist.


Skin Tests

In order to detect presence of reagins (antibodies) which are present in the skin and blood, skin tests are called for. Union of antibody in the skin, with its corresponding antigen applied in the skin tests, causes the release either of histamine-like or histamine substance by the tissues and results in redness and a weal around the site.
Skin tests are performed with extracts of pollens, moulds, dusts, etc. While concluding or carrying out such tests, it must be ensured that extracts are processed in most appropriate method, are neither old, active or potent, have no pathogenic micro-organisms in them and have minimal amount of any antigen. The results will be more accurate and precise if the antigen extract retains more natural characteristics. When the extract is ready (after sterilization and stardization), skin tests are carried out either by:


• Scratch Test or " Intracutaneous test

Scratch Test


Skin of the arm or forehand is cleansed and a series of superficial abrasion/scratches of about 1A cm long are made either of the said parts. It should be ensured that scratches or abrasions are not made deep lest bleeding takes places. Now allergence extracts are applied over the sight (which has been scratched / abrased) and removed after 15-20 minutes from the skin, and reactions occuring at the test site are observed an interpreted on the basis of comparison with control tests. Control tests are made with diluents of the allergenic principle.

Intracutaneous Tests


About 0.02 ml of each of the sterile allergenic extracts is introduced into the skin by a syring but reactions, due to application of this technique, are often quite larger than the ones obtained from the scratch test and the results obtained may also vary. It is necessary to carry out such intracutaneous tests with much care and precision otherwise, in most cases, allergic reactions are most likely to surface though such tests are not painful and can be easily carried out with children who soon lose their apprehension. These skin tests are graded from 0-4 + depending upon the degree of redness and swelling produced. If there is a significant positive reaction, the same must correspond to and match with the clinical history of the patient recorded earlier.

Grading of Skin Tests


Grade, size of weal and size of redness can be determined from the following table
Grade Size of Weal Size of Redness
0 Same as control Same as control
1+ 2 times more
than control
10-20 mm


2+ 3 times more
than the control
3+ 4 times more than
the control
4+ 5 times more than
the control
20-30 mm More than 30mm
More than 40 mm



Normally negative reactions point out to absence of antibody against the tested allergen but other considerations (such as use of weak, inadequate or deteriorated extracts) can account for negative reactions/absence of antibody. Skin tests are carried out for following:

1. Grasses: Such as Sorghum, Cenchrus, Cynoden andPennisetum.

2. Trees: Morus, Putranjiva, Cassia Siamea, Eucalyptus,Kigelia, Melia, Prosopis, Salvadora and Ricinus.

3. Weeds: Ageraturm, Adhatoda, Asphodelons, Brassica,Argemone, Chenopodium Album, Xanthium, Parthenium,Dodonea, Artemesia, Amaranthus and Parthenium.

4. Fungi: Mucor, Phoma, Alternaria, Candida, AspergillusFumigatus, cladodosporium, Hehninthosporium.

5. Danders: Cat, Horse, Dog.

6. Dusts: Wheat dust, House dust, Paper dust, Cotton dust.

Kinds of Asthma


Asthma is of the following kinds:

Intrinsic Asthma

This type of asthma develops due to some pre-existing disease, like certain part infection or existing disease like bronchitis. Such type of patients do not benefit from or respond to anti-allergic treatment and, thus, not easy to manage and control due to non-response factor. This variety occurs mostly in advance age.

Extrinsic Asthma


Extrinsic asthma usually and commonly occurs in earlier part of one's life and generally responds to anti-allergic medication and treatment. The underlying cause can be attributed to exposure to allergic agents like certain fungi, house dust, pollens etc. The patient has an inherited tendency when he gets exposed to (he said allergens. Recurring bouts of rhinites (sneezing) and eczema could also be the pre-disposing and precipitatory cause to trigger an attack of asthma.

Exercise Induced Asthma

This type of asthma commonly occurs to those who take to physical exercise in the cold weather but, then all persons may be either partially or not, at all, affected or some may be having serious manifestations.
Problems relating to asthma can be easily managed in young adults, but extremely difficult to mange in case of the elderly and small children.

Potential Asthmatic Patients


Following situations and type of persons could be termed as potential customers to imbibe asthma.

• Those who generally suffer from some sort of throataffection and there is recurrence of symptoms relatingthereto.

• Those having a family history of asthma.

• Persons who often suffer from bouts of sneezing, especiallyat the change of season.

• Persons experiencing coughs at the change of season.

• Those living in polluted environments and whose housesare dark, damp, filthy, where standard of personal hygieneis appallingly poor and where sun rays cannot enter.

• Persons working in cloth mills, chemical factories, flourmills, paint and varnish factories, coal miners, labourerswho work in stone quarries.

• Persons who easily get breathless even after a light exerciseor due to change of season.

• Those who are sensitive to cold winds and develop breathingproblem.

• Persons whose nose often remains blocked and, thus, havedifficulty in breathing through nose.

There could be other situations/causes which may trigger an attack of asthma.
It is generally held that childhood eczema or development of sneezing in the grown up stage may manifest in the form of asthma. A child may inherit allergy but not a specific manifestation of allergy, that is allergy factor may be inherited but not the type/kind of allergy from which either parent suffers. Asthma has been observed to run from one generation to another.


Causes of allergy


• House Dust and Mites


• Plant pollens

• Fungi

• Insects/Insect bites

• Food Articles

• Animals

• Changing weather conditions

• Chemicals, Paints, Insecticides, Pesticides, Fertilizers(Indutrial Plooution)

• Smoke and fly-ash

• Heredity


Some other precipitatory factors may be sudden, coincidental or situation-based or some may be even specific to a person only in a given situation but disappear as soon as the agonizing situation becomes non-existent.

Causes of Ashttna

Asthma By House Dust Asthma By Plant Pollens Asthma By Fungi Asthma By Insects Asthma By Animals

Treating Asthma by Drugs



Asthma is treated firstly, to remove or lessen its symptoms and agony, and secondly, to remove its cause as far as possible. It is better and desirable that both aspects be undertaken side by side. Let us first take the drug treatment of asthma.
As we have already seen, a patient of asthma during an attack has narrowing of the airways and excessive production of lung secretions. The narrowed airways make respiration and exchange of gases in the lungs difficult, so that the patient has less of the oxygen and more of carbon dioxide in his blood.


The excessive secretions can within a short while lead to infection in the lungs, as the secretions are the nutrients of the different kind of bacteria and they grow very fast on it.
Furthermore, since a patient having an attack of asthma breathes very fast, he loses lot of water in the air which he throws out, and
so loses a lot of water from his body.

Treatment During an Attack


• If the attack is very severe and prolonged, leading todeficiency of oxygen in the blood, which can be clinicallyascertained by looking for bluish tinge on the body, tongueorconjunctivae, then administration of oxygen through noseis called for.

• The narrowing of the airways has to be removed andproduction of excessive secretion stopped.


• If there are signs of infection in the lungs, appropriateantibiotics are to be given.

• If the patient is dehydrated, intravenous 5 per cent glucose-saline is to be given.

Let us take up these items in more detail. Giving of Theophylline tablets, 2 tablets twice or thrice a day, depending upon the age, weight and severity of the condition, proves very helpful. Theophylline-Retard or sustained action tablets are also available.

The simplest and the well-tried drug combination for causing dilatation of the airways is giving a tablet which contains ephedrine, aminophylline and phenobarbitone. This combination is available under different proprietory names such as Tedral, Franal etc. This can be repeated two or three times a day. For children, syrups are available containing this combination.
For most patients having mild or moderate attack of asthma, this proves very helpful and even adequate in itself. Some patients do complain of palpitation after taking these tablets, and older patients having high blood pressure have to take it in lesser quantities. Ephedrine in it can cause constipation and if the patient has some enlargment of the prostate, it can cause some difficulty in passing urine. But generally speaking, such tablets prove very efficacious.

Drugs like salbutamol (which are B-2 stimulators) have come into use lately. They specifically dilate the bronchial airways without excessively stimulating the heart, so that they do not usually lead to palpitation. These drugs come in the form of tablets, injections or aerosol inhalers, hi combination with deriphy Hine, salbutamol tablets prove very useful,
In case there is a severe attack of asthma, deriphylline injection given intramuscularly or aminophylline with 5 per cent glucose intravenously, slowly in 5 to 10 minutes proves helpful. Aminophylline given through intravenous drip with 5 per cent glucose is very useful. An injection of adrenaline(l: 1000 solution) V£ ml, given very slowly subcutaneously, is also effective in many cases.


Most patients usually need only this medication and care. But, at times, the symptoms increase or when an infection supervenes, extra care is needed. If bacterial infection is present in the respiratory passages and unless properly and adequately treated, bronchodilator drugs either exert diminished action or have no action at all, so that the patient keeps getting breathless. So, as far as possible, the causative organism must be identified, its sensitiveness to a drug found, and then the proper drug administered.


But in the majority of the cases, this is not possible either because of the lack of facilities or the procedure takes more time than a patient can afford. In such a situation, ampicillin has been found to be helpful: one or two capsules of 250 mg thrice a day for a week proves adequate; the dose and length of administration depends, however, upon the severity of infection.
If the attack of asthma is such that it is not controlled by the bronchodilator tablets, injections as well as the antibiotics, then the patient can be put on corticosteroids. These can be given as tablets or intramuscularly or in very severe cases, intravenously.

Treatment in Status Asthmaticus



If the patient has been in status asthmaticus (i.e., continuous and severe attack of asthma for more than 24 hours), it is important to keep in mind that he may also be dehydrated because of excessive loss of water from the lungs; by excessive perspiration and by omitting to take fluids while in an attack. Hence his fluid loss has to be replaced adequately. This besides restoring the fluid balance of the body, lessens the thickness of the tenacious sputum so that it is coughed out easily. In such a case, intravenous fluids are administered early, usually 3 to 5 litres in the first twenty-four hour period, and thereafter 3 litres daily until hydration is achieved. Ruids usually consist of 5 per cent dextrose in water; every second or third such fluid should contain sodium chloride, particularly if prolonged intravenous therapy in necessary, or if the patient is perspiring freely and he vomits or has diarrhoea. As th patient becomes hydrated and starts eating well, the intravenous administration of fluids can be curtailed.

A cyanosed patient of asthma in status asthmaticus is in need of oxygen which must be given. This can be given either through a catheter in the nose or through a ventri-mask or through a positive pressure breathing apparatus along with a bronchodilator; the last mode of therapy has proved to be more effective.

The use of expectorants in the management of asthma is one of the most important yet often neglected aspects of treatment. One of the best expectorants is potassium iodide; when it is tolerated poorly, other substances such as glyceral guiacolate and ammonium chloride may be useful. Water vapour also may be helpful in thinning bronchial secretions.
Patients with severe asthma become profoundly exhausted, lose sleep, experience increasing anxiety, and therefore, are in need of a tranquilliser, but is should be kept to a minimum, because excess of it can interfere with respiration,

Deaths from asthma can occur in spite of the antibiotics and steroids, These occur not only in older people who die of the complications of long-standing asthma, but also in younger people aged between 5 and 35 years. Majority of these deaths occur outside the hospital. These are due to the fact that the patient and his relations could not realise the severity of the situation.
A proper understanding of the patient's fears and anxieties and the allaying of these fears through sympathetic conversation helps asthma patients very much. The majority of these patients are prone to suggestion. It has been seen, time and again, that when a prescription is given or a line of treatment is started with the emphatic suggestion to the patient that this will definitely give relief, it decidedly works and the patient fulfils the expectations. Not only that, I have observed, that with whatever symptoms the patient looks better, produces a corresponding response and the hope given that "You will imporve still further", works miracle. Such an approach is helpful,but care must be taken because over-optimistic hopes, once shattered, cause more harm than good.

Aerosol Inhalers

Aerosol are the solid or liquid particles of a substance suspended in air. They are very small, less than a micron (1/1000 mm) in size.
Aerosol inhalers were used initially with bronchodilator drugs like Isoprenaline. But because this drug caused many side-effects such as palpitation and dizziness and some deaths too due to too frequent use, this mode of treatment fell into some disrepute.
With the availability of aerosol inhalers with salbutamol and corticosteroids, this form of treatment has now become very popular.

The technique of using the inhaler is as follows:

• Shake the inhaler. Remove the cap from its mouth-piece.Insert the mouth-piece in the lips and purse the lips tightlyaround it.

• Take one or two breaths with the inhaler in the mouth.

• Exhale completely, and then as you start inhaling, press thenozzle-button of the inhaler. Aerosol would go in the airwaysalongwith the air inhaled,

• Now remove the inhaler from the mouth. Keep the lipsclosed, and hold the breath as long as possible, then openthe mouth.

• You can repeat the process and take one more does ofaerosol from the inhaler. The dose that comes out eachtime on pressing the inhaler is equal and is measured.

Cortisone


Cortisone, the miracle drug, has provided renewed hopes to the patient suffering from very severe forms of allergies including asthma. This is a very potent drug and ought to be used in acute life-threatening situations. In asthma cases, cortisone can help patients where nothing else helps, but then it ought to be used only when everything else has been tried and has failed.




It is difficult to say which manifestation of allergy are helped the most, but it is the asthma patients who make maximum use of them.

Among the asthma patients, corticosteroids have provided the maximum and most-needed relief to those having status asthmaticus. Intramuscular or intravenous asministration abolishes symptoms in those patients in whom adrenaline or aminophylline have not been of much use. After corticosteroid administration, some of the patients who previously did no respond to adrenaline or aminophylline start responding can be resorted to. Gradually the corticosteroids can be tapered off and the patient can be put on other routine bronchodilators.

Short term use of corticosteroids has proved very helpful to those asthma patients who do not do well with the usual bronchodilators or to those who do not get adequate relief from them.
With the dosage and time for which these drugs are usually prescribed, no serious side effects or complications are observed. Complaints of general weakness or epigastric distress or diminished appetite are certainly not more than are encountered when patients are given ephedrine and aminophylline.

Acute attacks not responding to other routine measures, show excellent improvement in seasonal asthma cases. On the other hand, perennial asthmatic cases who have developed irreversible structural changes in the lungs, do not respond very well.


Care in Administration:

The conditons generally forbid the use of cortisone are diabetes mellitus, pepticulcer, gastrointestinal bleeding, tuberculosis, psychosis, old age, chronic kidney disease, heart attack and significant hypertension. However, these contraindications are more relative than absolute. Long-term taking of corticosteroids may produce hairiness (hirsutism) over the face.
While corticosteroids are being taken, an acute infection in the body does not produce as much symptoms as it would do otherwise

Hence, if the symptoms of an infection are even minor, a doctor ought to be consulted.
Upon discontinuation of the corticosteroids, or on a too rapid decrease dosage, some patients complain of tiring easily, weakness, nervousness, irritability, gastro-intestinal disturbances and occasional dizziness.


Cortisone Inhaler:

In cases of intractable asthma where other medications have failed or have not provided adequater relief and cortisone tablets have to be taken, cortisone inhaler reduces the need for the tablets. Since the inhaled cortisone acts locally in the lungs, it hardly produces any side-effects. The inhaler is needed to be used 3 to 4 times a day and provides appreciable relief.
Inhalations of cortisone on heavy dosage and for long periods can be lead to growth of fungi in the throat, causing soreness and discomfort. If it happens, the inhalations have to be stopped.

Antihistamines in Asthma


Antihistamines are not effective in the case of asthma in adults. They have no effect on bronchospasm; in fact, the symptoms sometimes get aggravated because of the drying up of the secretions and the subsequent difficulty in passing phlegm. Allergic cough in children, however, is helped by giving antihistamines along with a bronchodilator in cough mixture.
Any drug taken should be in consultation with your doctor.

Inhalation Devices You Can Use


Powder Inhaler

Powder Inhalers are devices that deliver a measured dose of medicine in a powdered form. The transparent Rotahaler is one such device. It uses a capsule to deliver the medicine and is very easy to use.

Spray Inhaler

The Spray Inhaler is the most widely used inhalation device in the world. It delivers a measured dose of medicine through a pressurised spray. To get the full benefit from a spray inhaler, it is essential to use it in a proper way.

Spacer

The spacer is a holding chamber which can be attached to the Spray Inhaler. It makes the Spray Inhaler easier to use and adds to its effectiveness.

NebuHser

Nebulisers are used for giving higher doses of medication at times when breathing becomes very difficult. They are machines that transform the medicine into a fine mist, which can be breathed in by normal breathing, via a facemask or a mouthpiece. Nebulisers are usually used in hospitals and nursing homes, for the management of severe attacks.

Hiccough / Hiccup


Medically, the disease is also known as 'Singultus1. There is an abrupt involuntary lowering of the diaphragm and closure of sound-producing folds, at the upper end of the trachea, producing a characteristic sound when the breath is inspired (drawn in). Hiccups occurs repeatedly and almost in quick succession or the gap between two hiccups (paroxysmal period) is so short that the patient does not have any respite. In fact spasmodic contraction of the diaphragm (which is more often reflex) or mid-riff is the basic cause of hiccup which is a reflex from the kidney/liver/stomach etc- Since heart rests immediately over the diaphragm, so spasmodic contraction of it leads to repeated jerks on the heart; hence there is exhausation.
Hiccup is a serious disease due to dose affinity of heart and diaphragm, especially when the problem is associated with previous exhaustion and/or serious malady but the hiccup found in children and others is usually of hysterical nature (hysterical hiccup); hence is not that dangerous as spasmoitic hiccup(s).

General and traditional method, often practised is either to divert attention of the patient from episodes of hiccup or give water to be sipped only. I have seen certain cases improve instantaneously. About 5 years back I was staying with a business friend whose 18 year old girl had repeated paroxysms of exhausted; her eyes looking dangerously lachrymal and red. I suddenly entered her room and asked the young one to turn her back. When she turned her back, I blowed her back portion, within the shoulders, with a sudden jerking
blow and, surprisingly, she breathed a sigh of relief and had no



hiccups thereafter. It all implies that distraction of mind is necessary but may not always prove availing.

Homeopathic Treatment

Ginseng-Q: Should be used in all forms of hiccup (Give 5 drops with water)-may be repeated if attacks do not stop.
Cuprum Met / Cuprum Ars-6: If hiccup is accompanied with nausea, eructations, difficult breathing, or if drinking of water relieves hiccup.

Ignatia-6: When hiccup is caused after or followed by smoke, food or drink.

Carbo Veg-6: When caused by movement.

Lycopodium-30: When the tongue at one time is drawn in, and at another time extruded.

Cicuta-6: Hiccup with sound.

Cocculus-6: Hiccup and eructations, stabbing pain.

Nux Vom-3: If hiccup occurs, before meals are taken. Some people recommend water of green coconut or kernel inside the stone of palm fruit. Diet given should be in liquid and bland form.
Occasional paroxysms of hiccup, if short lived and abating quickly, should not cause any concern but prolonged attacks need to be treated, as some attacks are so quick and exhausting that the patient becomes nervous and cyanotic, breathing is also under strain, hence, in the later stage, there is no room for any complacent approach.

Croup

This is predominantly a children's disease when there is a stredor (deep, sharp sound) due to impeded breathing, constriction of chest and its capacity to expand and contract diminishes, face becomes pale, head tilts on one side and facial muscles benum. But all the above mentioned signs are not long-lasting. After a short while, there are convulsions and cramps in the whole body, and in grave


situations breathing stops (asphaxia) and finally the patient dies of suffocation.
Children between the age of 3 months and 2 years are generally the victims, attacks mostly coming at night. Children who are extremely weak and are brought up under unhygienic and unhealthy environs, fall prey to this horrible disease.

Treatment

It mostly consists of pure air, water and food. Food must be served with high nutritional values. Health building tonics like Ostomalt, Cod Liver oil with malt extract, Adexolrne drops etc may be given either along/with milk/or before or after milk, whenever the attack takes place; pat and sponge the child with hot or cold water, according to weather conditions. He may be given Ammonia to inhale 4-5 drops of. Tincture of Castor may be mixed with hot/ cold water. Homeopathic medicines like pot. Bromide (kali Bromide-30) or/and chlorum (chloral hydrate)-6 may be given with water; crude dose being 2-5gms of Pot Bromide and ¥2 -2gms of chloral hydrate. Before any medicine is given to child, it is advised that the child is never treated at home, rather he should be examined by a doctor so that there is no delay in proper treatment