The art and technology of photography can be overwhelming to the facial plastic surgeon. Photographic documentation of patients undergoing rhinoplasty is essential for patient consultation, perioperative planning, and postsurgical evaluation. Possession of a basic understanding of photographic principles, technique, equipment, as well as consideration regarding consistency of patient positioning is essential for producing the best photographic results. This article reviews the basic principles of photography and discusses their application to facial plastic surgery practice, and rhinoplasty in particular.
What are hiccups?
Hiccups occur when a spasm contracts the diaphragm, a large sheet of muscle that separates the chest cavity from the abdominal cavity. This spasm causes an intake of breath that is suddenly stopped by the closure of the vocal cords (glottis). This closure causes the characteristic “hiccup” sound.
What causes hiccups?
A very full stomach can cause bouts of hiccups that go away on their own. A full stomach can be caused by:
Eating too much food too quickly.
Drinking too much alcohol.
Swallowing too much air.
A sudden change in stomach temperature, such as drinking a hot beverage and then a cold beverage.
Emotional stress or excitement.
How long do hiccups last?
Hiccups usually stop within a few minutes to a few hours.
Hiccups that last longer than 48 hours are called persistent hiccups. Hiccups that last longer than a month are called intractable hiccups. While very rare, intractable hiccups can cause exhaustion, lack of sleep, and weight loss. Both persistent and intractable hiccups may be a sign of a more serious health problem and must be checked by a doctor.
There are many known causes of persistent or intractable hiccups, including:
Central nervous system problems, such as cancer, infections, stroke, or injury.
Problems with the chemical processes that take place in the body (metabolic problems), such as decreased kidney function or hyperventilation.
Irritation of the nerves in the head, neck, and chest (vagus or phrenic nerve).
Anesthesia or surgery.
Mental health problems.
How are hiccups treated?
Most bouts of hiccups go away on their own within a few minutes to a few hours and do not require any treatment.
Many home remedies are used to treat hiccups. Most of them involve increasing the level of carbon dioxide in the blood, which usually stops hiccups. Some of these remedies include:
Holding your breath and counting slowly to 10.
Breathing repeatedly into a paper bag for a limited period of time.
Quickly drinking a glass of cold water.
Eating a teaspoon of sugar or honey.
The treatment for persistent or intractable hiccups depends on the underlying cause of the hiccups and may range from medicine to acupuncture or hypnosis. Sometimes several treatments may be tried before persistent or intractable hiccups are controlled. If you have hiccups that last a few days or longer, your doctor may conduct tests to rule out a more serious problem.
Who is affected by hiccups?
Hiccups affect males more often than females. Hiccups occur in practically every human being, including babies and older adults.
Recently, pts. have become aware of the prevalance of H. pylori as a cause of ulcers and questioning why I don’t emperically tx. for it, rather than an initial trial of PPI’s. My response is that although H. pylori is present in >80% of ulcers, is has only been implicated as causative in ~20%. Plus, the potential risk of SE’s from triple therapy.
Blood test is easy. Unfortunately it detects antibodies, not infection. May remain positive for years even after eradication of infection. Detecting IgM vs. IgG is not always reliable.
Urea breath test and stool antigen test detect infection. As does biopsy for either rapid urease test or histology with special stains. Biopsy is most invasive, most expensive, and most accurate.
Keratosis obturans and external auditory canal cholesteatoma (EACC) have previously been considered to represent the same disease process. However, review of the literature and our cases reveal these to be two different clinical and pathological processes. Keratosis obturans presents as hearing loss and usually acute, severe pain secondary to the accumulation of large plugs of desquamated keratin in the ear canal. External auditory canal cholesteatoma presents as otorrhea with a chronic, dull pain secondary to an invasion of squamous tissue into a localized area of periosteitis in the canal wall. The treatment previously recommended for both of these conditions has been conservative debridement of the external canal and application of topical medication. While this remains the treatment of choice for keratosis obturans, surgery may be required to eradicate EACC.
Actinomycosis occurs rarely in humans but rather frequently in cattle as a disease called lumpy jaw. This name refers to the large abscesses that grow on the head and neck of the infected animal. It can also affect swine, horses, and dogs, and less often wild animals and sheep.
Signs and symptoms
The disease is characterised by the formation of painful abscesses in the mouth, lungs, or gastrointestinal tract. Actinomycosis abscesses grow larger as the disease progresses, often over months. In severe cases, they may penetrate the surrounding bone and muscle to the skin, where they break open and leak large amounts of pus, which often contains characteristic granules (sulphur granules). The purulent leakage via the sinus cavities contains “sulphur granules,” not actually sulphur-containing but resembling such particles. These granules contain progeny bacteria. Sometimes there is difficulty in making the correct diagnosis. In addition to microbiological examinations magnetic resonance imaging and immunological blood analyses may also be helpful.
Actinomycosis is primarily caused by any of several members of the bacterial genus Actinomyces. These bacteria are generally anaerobes. In animals, they normally live in the small spaces between the teeth and gums, causing infection only when they can multiply freely in anoxic environments. An affected human often has recently had dental work, poor oral hygiene, periodontal disease, radiation therapy, or trauma (broken jaw) causing local tissue damage to the oral mucosa, all of which predispose the person to developing actinomycosis. They are also normal commensals in the caecum; thus, abdominal actinomycosis can occur following removal of the appendix. The three most common sites of infection are decayed teeth, the lungs, and the intestines. It is important to note that actinomycosis does not occur in isolation from other bacteria. This infection depends on other bacteria (gram positive, gram negative, and cocci) to aid in invasion of tissue.
Actinomyces bacteria are generally sensitive to penicillin, which is frequently used to treat actinomycosis. In cases of penicillin allergy, doxycyclin is used. Sulfonamides such as sulfamethoxazole may be used as an alternative regimen at a total daily dosage of 2-4 grams. Response to therapy is slow and may take months.
There is a greater disease incidence in males between the ages of 20 and 60 years than in females. Before antibiotic treatments became available, the incidence in the Netherlands and Germany was 1 per 100,000 people/year. Incidence in the U.S. in the 1970s was 1 per 300,000 people/year, while in Germany in 1984, it was estimated to be 1 per 40,000 people/year. The use of intrauterine devices (IUDs) has increased incidence of genitourinary actinomycosis in females. Incidence of oral actinomycosis, which is harder to diagnose, has increased.
In 1877, pathologist Otto Bollinger described the presence of Actinomyces bovis in cattle, and shortly afterwards, James Israel discovered Actinomyces israelii in humans. In 1890, Eugen Bostroem isolated the causative organism from a culture of grain, grasses, and soil. After Bostroem’s discovery there was a general misconception that actinomycosis was a mycosis that affected individuals who chewed grass or straw. Violinist Joseph Joachim died of actinomycosis in 15 August 1907.
“One Doctor for One Nose”….
The Sinus and Allergy Center is focused exclusively on nasal, sinus, and allergy problems. We are board certified ear, nose, and throat surgeons. Dr. Todd had formal allergy training in his residency and obtained fellowship accreditation in allergy through the American Academy of Otolaryngic Allergy. He performs a very high and consistent volume sinus and nasal surgery.
Our unique combination of skills, training, and experience allows the Sinus and Allergy Center to be the final consult for all your allergy, nasal, and sinus problems.
The “over use” of Penicillin like antibiotics can eradicate the normal flora, leaving only the penicillinase producers. This can lead to what seem like fairly resistant cases that fail penicillin repeatedly. If they and family members are asymptomatic, there is no reason to treat. If the decision is to treat (ASO titers can help with that decision), then Cleocin or Ceftibutin can be considered. (Cleocin 20 mg/kg/day divided TID for 10 days). In reality antibiotics have no proven benefit for the treatment of any pharyngitis other than GABHS, Ghonorrhea, or Diptheria.
It is uncertain if the family dog can act as a reservoir or not. However, there have apparently been case reports, and treating the dog has been suggested by some.
Another consideration is to wash family toothbrushes in top drawer of dish washer on day 1, 5, and 10 of treatment.
Other adverse sequalae to strep infections include: Post Streptococcal Glomerular Nephritis (a type III reaction more common after Impetigo), PANDAS (acute childhood OCD), Scarlet Fever, and Toxic Shock Syndrome. It is not clear weather or not early treatment is preventive with this list of pathologies.
GABHS has a number of known problematic sequelae that are the primary reason we look for it. Although rare, ARF (Acute Rhematic Fever) or Rheumatic Heart Disease is our primary concern. It is a sterile Type II autoimmune attack on the heart valves, myocardium, and joints resulting from the protracted high anti strep circulating antibodies. It is my understanding that if you treat Strep within 9 days you avoid this possibility. Apparently you need to treat about 40,000 cases of strep throat to avoid one such case. With the incidence of a severe allergic reaction to PCN being 1/12,000 so clinical judgement is paramount. The most winning strategy is to just use the “rapid test” as the decision maker. Using this strategy, in the US, we could prevent 85 cases of rheumatic heart disease annually at the cost of $727,000 per case prevented. You are actually more likely to contract Lemeirre’s Syndrome from Fusobacterium with a GABHS infection than Rheumatic Heart Disease.
Most experts agree that a rapid strep test is diagnostic. Follow up cultures for negative studies may be appropriate in younger patients. Cultures are never indicated under the age of 3 as they have not had enough antigenic exposure to develope Rheumatic Heart Disease.