Headache

Sinusitis-Management and Prevention -------------------------------------------------------- by Dr Sunil. Sinusitis is infl ammation of the mucous membranes lining one or more of the paranasal sinuses. The various presentations are as folllows: ● Acute sinusitis: infection lasting less than 30 days, with complete resolution of symptoms ● Subacute infection: lasts from 30 to 90 days, with complete resolution of symptoms ● Recurrent acute infection: episodes of acute infection lasting less than 30 days, with resolution of symptoms, which recur at intervals of at least 10 days apart ● Chronic sinusitis: infl ammation lasting more than 90 days, with persistent upper respiratory symptoms ● Acute bacterial sinusitis superimposed on chronic sinusitis: new symptoms that occur in patients with residual symptoms from prior infection(s). With treatment, the new symptoms resolve but the residual ones do not. PHYSICAL FINDINGS AND CLINICAL PRESENTATION ● Patients often give a history of a recent upper respiratory illness with some improvement, then a relapse. ● Mucopurulent secretions in the nasal passage ● Purulent nasal and postnasal discharge lasting more than 7 to 10 days ● Facial tightness, pressure, or pain ● Nasal obstruction ● Headache ● Decreased sense of smell ● Purulent pharyngeal secretions, brought up with cough, often worse at night ● Erythema, swelling, and tenderness over the infected sinus in a small proportion of patients ● Diagnosis cannot be excluded by the absence of such findings. ● These fi ndings are not common, and do not correlate with number of positive sinus aspirates. ● Intermittent low-grade fever in about one half of adults with acute bacterial sinusitis ● Toothache is a common complaint when the maxillary sinus is involved. ● Periorbital cellulitis and excessive tearing with ethmoid sinusitis ● Orbital extension of infection: chemosis, proptosis, impaired extraocular movements. Characteristics of acute sinusitis in children with upper respiratory tract infections: ● Persistence of symptoms ● Cough ● Bad breath ● Symptoms of chronic sinusitis (may or may not be present) ● Nasal or postnasal discharge ● Fever ● Facial pain or pressure ● Headache ● Nosocomial sinusitis is typically seen in patients with nasogastric tubes or nasotracheal intubation. CAUSE ● Each of the four paranasal sinuses is connected to the nasal cavity by narrow tubes (ostia), 1 to 3 mm in diameter; these drain directly into the nose through the turbinates. The sinuses are lined with a ciliated mucous membrane (mucoperiosteum). ● Acute viral infection ● Infection with the common cold or infl uenza ● Mucosal edema and sinus infl ammation ● Decreased drainage of thick secretions, obstruction of the sinus ostia ● Subsequent entrapment of bacteria a. Multiplication of bacteria b. Secondary bacterial infection  Other predisposing factors ● Tumors ● Polyps ● Foreign bodies ● Congenital choanal atresia ● Other entities that cause obstruction of sinus drainage ● Allergies ● Asthma ● Dental infections lead to maxillary sinusitis. ● Viruses recovered alone or in combination with bacteria (in 16% of cases): ● Rhinovirus ● Coronavirus ● Adenovirus ● Parainfluenza virus ● Respiratory syncytial virus ● The principal bacterial pathogens in sinusitis are Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. ● In the remainder of cases, fi ndings include Streptococcus pyogenes, Staphylococcus aureus, alpha-hemolytic streptococci, and mixed anaerobic infections (Peptostreptococcus, Fusobacterium, Bacteroides, Prevotella). Infection is polymicrobial in about one third of cases. ● Anaerobic infections seen more often in cases of chronic sinusitis and in cases associated with dental infection; anaerobes are unlikely pathogens in sinusitis in children. ● Fungal pathogens are isolated with increasing frequency in immunocompromised patients but remain uncommon pathogens in the paranasal sinuses. Fungal pathogens include Aspergillus, Pseudallescheria, Sporothrix, phaeohyphomycoses, Zygomycetes. ● Nosocomial infections occur in patients with nasogastric tubes, nasotracheal intubation, cystic fi brosis, or those who are immunocompromised. ● S. aureus ● Pseudomonas aeruginosa ● Klebsiella pneumoniae ● Enterobacter spp. ● Proteus mirabilis Organisms typically isolated in chronic sinusitis: ● S. aureus ● S. pneumoniae ● H. infl uenzae ● P. aeruginosa ● Anaerobes DIFFERENTIAL DIAGNOSIS ● Migraine headache ● Cluster headache ● Dental infection ● Trigeminal neuralgia WORKUP ● Water’s projection: sinus radiograph ● CT scan ● Much more sensitive than plain radiographs in detecting acute changes and disease in the sinuses ● Recommended for patients requiring surgical intervention, including sinus aspiration; it is a useful adjunct to guide therapy. ● Transillumination ● Used for diagnosis of frontal and maxillary sinusitis ● Place transilluminator in the mouth or against cheek to assess maxillary sinuses, and under the medial aspect of the supraorbital ridge to assess frontal sinuses. ● Absence of light transmission indicates that sinus is filled with fluid. ● Dullness (decreased light transmission) is less helpful in diagnosing infection. ● Endoscopy ● Used to visualize secretions coming from the ostia of infected sinuses ● Culture collection via endoscopy often contaminated by nasal flora; not nearly as good as sinus puncture ● Sinus puncture ● Gold standard for collecting sinus cultures ● Generally reserved for treatment failures, suspected intracranial extension, nosocomial sinusitis. TREATMENT Nonpharmacologic therapy ● Sinus drainage ● Nasal vasoconstrictors, such as phenylephrine nose drops, 0.25% or 0.5% ● Topical decongestants should not be used for more than a few days because of the risk of rebound congestion. ● Systemic decongestants ● Nasal or systemic corticosteroids, such as nasal beclomethasone, short-course oral prednisone ● Nasal irrigation, with hypertonic or normal saline (saline may act as a mild vasoconstrictor of nasal blood fl ow) ● Use of antihistamines has no proved benefi t, and the drying effect on the mucous membranes may cause crusting, which blocks the ostia, thus interfering with sinus drainage. ● Analgesics, antipyretics. Antimicrobial therapy ● Most cases of acute sinusitis have a viral cause and will resolve within 2 weeks without antibiotics. ● Current treatment recommendations favor symptomatic treatment for those with mild symptoms. ● Antibiotics should be reserved for those with moderate to severe symptoms who meet the criteria for diagnosis of bacterial sinusitis. ● Antibiotic therapy is usually empirical, targeting the common pathogens. ● First-line antibiotics include amoxicillin, TMP-SMZ. ● Second-line antibiotics include clarithromycin, azithromycin, amoxicillin-clavulanate, cefuroxime axetil, loracarbef, ciprofloxacin, levofloxacin. ● For patients with uncomplicated acute sinusitis, the less expensive first-line agents appear to be as effective as the costlier second-line agents. Surgery ● Surgical drainage indicated ● If intracranial or orbital complications suspected ● For many cases of frontal and sphenoid sinusitis ● For chronic sinusitis recalcitrant to medical therapy ● Surgical débridement imperative for treatment of fungal sinusitis Regards Dr Sunil

50 years female Pain and burning sensation on left side forehead, eye and nose since 6 days. Frontal head ache. What are these lesions ? Treatment ?

A 69 y/o female presented with a 5-day history of fever and left eyelid swelling. This was accompanied by partial gray-tan discoloration of the involved eyelid of over 3 days' duration. On examination, there was severe left eyelid swelling, which made the rest of the ocular examination difficult. The patient also had fever at 39.2°C. What are your comments?

Nasya Karma It is one of the panchakarmas mentioned in Ayurveda. It is a process by which drug is administered through the nostrils. If 'Nasyakarma' is done properly and regularly it will keep the person's eye, nose and ear unimpaired. It also prevents the early graying of hair and beard. Nasyakarma will prevent the falling of hair. It will ensure growth of hair and alleviate diseases like cervical spondilitis, headache, facial paralysis, hemiplegia, diseases of nose, frozen shoulder, hemi crania, coryza, sinusitis, mental disorders parkinsonism and skin complaints. Nasyakarma will enhance the activity of sense organs and prevent the diseases of head (urdhwanga). It will prevent the early aging process. Purvakarma (Pre-purification Measures) Prior to nasya karma, sneha and sweda should be done to the patients Face, Forehead, Head, Ears and Neck. This prior snehana (oleation) and swedana (sudation or sweating) will help to loosen the adhesive doshas, thereby facilitating the subsequent elimination. Pradhan karma (Main Procedure of Nasyakarma) After the Purvakarma the patient is asked to lie down in a bed with his hand and legs kept straight. His head is maintained at a lower position by keeping the pillow below the neck. This position will facilitate the direct passage of the drug. Placing the medicine above hot water gently warms it and then it is made to flow in to one nostril, while the other is kept closed the same process is carried out in the other nostril also. For the administration of the drug a pichu (Cotton swab) or nadi(tube) may be used (dropper can be used). The sole, shoulder, neck, ear and palm are gently massaged after the administration of the drug. He must pit out all the impurities and medicine that reach his mouth. The spitting is repeatedly carried out turning to both sides while the patient is lying. Swedakarma (sudation) should be repeated after the nasya treatment. The process of nasya can be repeated twice or thrice if necessary. This process should be repeated for 7 days. Mechanism of Nasyakarma The nasya dravya (medicine) acts by reaching 'Sringataka marma' (a main vital point situated on the surface of the brain corresponding to the nerve centres, which consisting of nerve cells and fibres responsible for the function of speech-Broca's Centre, vision, hearing, taste and smell). From where it spreads into various strotasas (vessels and nerves) and brings out vitiated doshas from the bread. Sringataka is a composite structure consisting of four siras (arteries) in connection with four sense organs-viz, nose, ear, eye and tongue. The composite structure formed by the union of these four arteries is called sringata. As per the ayurveda school of thought for the evolution of a disease the vitiated doshas should be brought to the site from its original seat. This movement will be made through the srotasa (channels) and if there is any disturbance in the integrity of the srotasas it will result in the development of disease. With regards to the Urdhwangarogas (diseases of head) there should be some disturbance in the normal functions of urdwanga srotasas (arteries, veins, nerves in the head). Sringadaka are the most important group of srotasas in the urdhwanga (head) and drugs acting through these srotasas are certain to bring about srotosuddhi (cleaning) in urdhwanga. Action of drugs used in Nasyakarma * By general blood circulation, after absorption through mucous membrane. * Direct pooling into venous sinuses of brain via, inferior ophthalmic veins. * Absorption directly into the cerebrospinal fluid. Many nerve endings which are arranged in the peripheral surface of mucous membrance, olfactory, trigeminal etc will be stimulated by Nasyadravy (the medicine used to give nasya) and impulses are transmitted to the central nervous system. This results in better circulation and nourishment of the organs and the diseases will subside. Most of the drugs described for nasya therapy have got katu (bitter), ushna (hot) and theekshna (sharpness ) properties. These drugs produce draveekaranam (liquifaction) and chhedanam(expulsion) of vitiated doshas. The kashaya rasa (astringent taste) drugs produce astringent effect while madhura rasa (sweat) drugs produce cooling and nourishing effect. In conclusion it may be stated that The nose is the doorway to the brain and it is also the doorway to consciousness. Prana or life energy enters the body through breath taken in through the nose. Nasal administration of medication helps to correct the disorders of prana affecting the higher cerebral, sensory and motor functions.the brief study of the mechanism of nasya can be summed up in a single statement made in the ayurvedic classics, "Nasahi Shirasodwaram" ie., nose is a pharmacological passage into the head. Types of Nasya There are six main types of nasya, as listed below. 1. Pradhamana (virechan) Nasya (cleansing nasya) uses dry powders (rather than oils) that are blown into the nose with a tube. Pradhamana nasya is mainly used for kapha types of diseases involving headaches, heaviness in the head, cold, nasal congestion, sticky eyes, hoarseness of voice due to sticky kapha, sinusitis, cervical lymph adenitis, tumors, worms, some skin diseases, epilepsy, drowsiness, Parkinsonism, inflammation of the nasal mucosa, attachment, greed and lust. Traditionally, powders such as brahmi are used. 2. Bruhana Nasya (nutrition nasya) uses ghee, oils, salt, shatavari ghee, ashwagandha ghee and medicated milk and is used mainly for vata disorders. It is said to benefit conditions resulting from vata imbalances such as vata-type headaches, migraine headache, dryness of voice, dry nose, nervousness, anxiety, fear, dizziness, emptiness, negativity, heaviness of eyelids, bursitis, stiffness in the neck, dry sinuses and loss of sense of smell. 3. Shaman Nasya (sedative nasya) is used according to which dosha is aggravated but mainly for pitta-type disorders such as thinning of hair, conjunctivitis and ringing in the ears. Generally certain herbal medicated decoctions, teas and medicated oils are used. 4. Navana Nasya (decoction nasya) is used in vata-pitta or kapha-pitta disorders and is made from decoctions and oils together. 5. Marshya Nasya (ghee or oil nasya) 6. Pratimarshya (daily oil nasya) is performed by dipping the clean little finger in the ghee or oil and inserting into each nostril, lubricating the nasal passage with gentle massage as described above. This helps to open deep tissues and can be done every day and at any time to release stress. Indications for Nasyakarma: Trigeminal Neuralgia Bel's Palsy To improves memory & eye sight Insomnia Elimination of excess Mucus Hyper pigmentation in the face Pre-mature graying of hair To brings clarity to voice Headaches of various origin Hemiplegia Loss of smell and taste Frozen Shoulder Migraine Stiffness of the neck Nasal Allergies Nasal Polyp Neurological dysfunctions Sinusitis To relive stress and emotional imbalances stiffness in the neck & shoulders dryness of the nose hoarseness of voice convulsions Contra-Indications for Nasya: Nasal medication should not be administered after a bath, food, sex, drinking alcohol, during pregnancy or menstruation. It should not be used below 7 years or over 80 years of age Substances Used in Nasya: brahmi, ginger, ghee, oils, decoctions, Piper longum, black pepper, curry pepper, rose, jasmine, henna etc. Dr. Hemant Adhikari

g cramps most commonly affect the calf muscle. • Leg cramps typically only last a few minutes, but the pain can last for 24 hours. • Older people and pregnant women are more prone to leg cramps than others. • Most often, leg cramps are no cause for concern and have no medical significance. • Dehydration , flat feet and alcoholism are potential factors involved in leg cramps. • If stretching does not help, some doctors advise taking quinine. • Supporting your toes when you sleep can help prevent cramps. • When diagnosing leg cramps, a doctor will rule out other more serious conditions first. • Some medications can increase the likelihood of cramps, including diuretics, salbutamol and statins. Fast facts on leg cramps Rate this article Public / Patient 353 total ratings Health Professionals 81 total ratings SPORTS MEDICINE / FITNESS REHABILITATION / PHYSICAL THERAPY PAIN / ANESTHETICS Recommended Related News Additional information Article last updated on Thu 10 December 2015. Visit our Sports Medicine / Fitness category page for the latest news on this subject, or sign up to our newsletter to receive the latest updates on Sports Medicine / Fitness. All references are available in the References tab. References Citations What is Charcot-Marie-Tooth Disease (CMT)? Charcot-Marie-Tooth disease is an inherited condition that affects the peripheral nervous system, causing the arms and legs to become weaker over time. READ MORE Low Bad Cholesterol Tied To Cancer Risk US researchers suggest there is an underlying mechanism that affects both cancer and low LDL (so-called 'bad') cholesterol, because they found low LDL cholesterol in people with no history... READ MORE Leg Pain Can Mean Heart Danger, Expert Says The story of how one man's back problems and leg pain ended up saving his life, as they ended up being signs of peripheral arterial disease. READ MORE Plantar flexion: Function, anatomy, and injuries Plantar flexion is a term that describes the motion of pointing the foot downwards. Learn about the muscles involved in this posture and possible injuries. READ MORE Exercise Improves Mobility And Fitness For Patients With Parkinson's Exercise, including resistance training, stretching, and treadmill use may boost muscle strength, gait speed, and overall fitness for patients with Parkinson's Disease (PD), suggests a new... READ MORE RELATED COVERAGE Comments (23) ADD A COMMENT Harsha NOVEMBER 16, 2011 1:45 AM i'm suffering from severe thigh cramps since 3 months. i'm a diabetic patient. pain killars are not working for me. please someone solve my problem. i very often get pains even if i climb steps or walk for a distance. Reply Keith C JULY 14, 2012 10:15 AM I am awakened perhaps three times during a nite of 5 - 6 Hours of trying to find a restful nite so I am not following asleep the next day at work. Anyone having these same symptoms? Help me please!!!! Reply View all Last updated Thu 10 Dec 2015 Overview | Causes of leg cramps | Tests and diagnosis | Treatment | Prevention Leg cramps , also known as night leg cramps , especially calf-muscle cramps, are fairly common. Some people experience cramps in the muscles of their feet, as well as their thigh muscles. In most cases these types of cramps occur while the individual is sleeping or resting. The following article will investigate the causes, diagnosis, prevention and treatments of leg cramps. What are leg cramps? Cramps are generally not a sign of an underlying condition. Leg cramps are sudden, painful involuntary contractions of a leg muscle. The cramp usually only lasts a few minutes, sometimes a few seconds. Rarely though, they can last up to 10 minutes. Sometimes the pain is so severe that the patient is woken up and has a tender muscle for up to 24 hours afterwards. In most cases the reason for leg cramps is never found, and they are considered harmless. Sometimes, however, they may be linked to an underlying disorder, such as diabetes or peripheral artery disease . As we get older we become more prone to experiencing leg cramps - about 1 in 3 people over the age of 60 years and half of people over 80 has regular leg cramps. Pregnant women tend to have night leg cramps more often than non-pregnant women. Approximately 40% of people who get leg cramps do so at least three times a week; in some cases they occur daily. Causes of leg cramps Unknown causes (idiopathic leg cramps) - in the majority of cases there is no underlying cause and we don't really know why it happens. On theory is that when a muscle tightens for a prolonged period, resulting in the muscle being shortened, it is stimulated to contract, causing it to go into a spasm (cramp) if it contracts further. This occurs more commonly while we are sleeping - our natural sleep position is with the knees slightly bent and the feet pointing downwards (shortening the calf muscle). The fact that stretching helps cure the problem makes the theory more compelling. Secondary causes - sometimes the leg cramps are caused by an underlying disease, situation or activity, including: Exercise - if a muscle is placed under severe stress or used for a long time a leg cramp may occur during the exertion or afterwards. Athletes and sportspeople commonly suffer from leg cramps, especially when having to work for longer than expected, as may happen in a soccer match that goes into extra time. If conditions are warm and the athlete has sweated profusely and lost a lot of sodium (salt), the risk of developing a muscle cramp is greater. Addison's disease Alcoholism or alcohol abuse Cirrhosis Dehydration Diarrhea Diuretics Electrolyte imbalance Flatfeet Gastric bypass surgery Hypothyroidism (underactive thyroid) Kidney failure, chronic Lead poisoning Sarcoidosis - a disease in which granulomatous (small growths or lumps) produces inflammation or swelling of the tissues in any part of the body. Muscle fatigue Motor neuron problems Oral contraceptives Parkinson's disease Peripheral artery disease (PAD) Pregnancy, especially in the later stages Some medications, including diuretics, salbutamol (used for treating asthma ), and statins (used to lower blood lipid levels) Type 2 diabetes Tests and diagnosis A GP (general practitioner, primary care physician) will ask the patient about symptoms, when they occur, as well as examining his/her legs and feet. Questions will be related to how severe the pain is, where the pain is located, how long it lasts, and whether the leg cramps affect their quality of life (sleep, moods, etc). The doctor will also ask about other possible symptoms, such as inflammation, numbness or pins and needles. The aim here is to either rule out or identify any possible underlying cause. Treatment If there is no underlying cause the leg cramps will probably get better without treatment. Stretching exercises - if the cramp is in the calf muscle: Straighten the leg and bend the ankle backwards, thus stretching the calf muscle. Walk on tiptoes for a few minutes. Stand about one meter from a wall with your feet flat on the ground. Lean forward against the wall with your arms outstretched, but don't lift your heels (keep your heels on the ground). Stay like that for about ten seconds and gently return to an upright position. Repeat about 5 to 10 times. Some people find that these stretching exercises not only help them get over a leg cramp episode, but also that help reduce how often they occur. Typically, a patient would do these exercises two or three times a day. Painkillers are normally too slow acting to be useful for leg cramps. Painkillers - although painkillers can be effective in reducing pain, they take time to work. By the time they start working the leg cramp is probably gone. Therefore, they are probably not very useful. If an individual had a severe leg cramp and the muscle is tender afterwards, an OTC (over-the-counter, non prescription required) painkiller may help. Quinine - some preliminary studies have found that a number of people benefit from taking quinine. There is no information yet about quinine's safety and long-term effectiveness. Some doctors may recommend quinine if the stretching has not helped, attacks are frequent, and/or the patient's quality of life is being undermined by the leg cramps. A course of treatment usually lasts from four to six weeks - the patient takes the medication just before going to bed. Pregnant women should not take quinine. Individuals who had a previous reaction to quinine, those with previous hemolytic anemia , optic neuritis, and/or glucose 6-phosphate dehydrogenase deficiency should not take quinine. As the quinine dosage is very low, side effects are rare. In rare cases the patient may develop a blood disorder. Some patients may develop cinchonism after long-term quinine therapy, which may cause vomiting, nausea, vision and/or hearing problems and dizziness. Patients with leg cramps on quinine therapy are usually monitored closely. Prevention Stretching exercises - these may help reduce the number of times leg cramps occur. Supporting your toes when lying down or asleep: Lying on your back - prop up your feet with a pillow/cushion. Lying on your front - let your feet hang over the end of the bed. Bedding - keep blankets and sheets loose. This helps prevent your feet and toes from pointing downwards during sleep. Stay hydrated - as dehydration may increase the risk of leg cramps, drinking plenty of fluids may help prevent them. Exercise - if you embark on an exercise program, make sure it is suitable for you and that your progress is gradual. If you want to prevent leg cramps from occurring, do not over-exert yourself, or train for prolonged periods. Footwear - people with flat feet and other structural problems may be more susceptible to leg cramps. Proper footwear may help.