Ingrown toenails are a common condition in which the corner or side of a toenail grows into the soft flesh. The result is pain, redness, swelling and, sometimes, an infection. Ingrown toenails usually affect your big toe.
Often you can take care of ingrown toenails on your own. If the pain is severe or spreading, your doctor can take steps to relieve your discomfort and help you avoid complications of ingrown toenails.
If you have diabetes or another condition that causes poor blood flow to your feet, you're at greater risk of complications of ingrown toenails.
Ingrown toenail symptoms include:
See your doctor if you:
Common ingrown toenail causes include:
Left untreated or undetected, an ingrown toenail can infect the underlying bone and lead to a serious bone infection.
Complications can be especially severe if you have diabetes, which can cause poor blood flow and damage nerves in your feet. So a minor foot injury — a cut, scrape, corn, callus or ingrown toenail — may not heal properly and become infected. A difficult-to-heal open sore (foot ulcer) may require surgery to prevent the decay and death of tissue (gangrene). Gangrene results from an interruption in blood flow to an area of your body.
Your family doctor or a foot doctor (podiatrist) can diagnose an ingrown toenail. Because appointments can be brief and you may have a lot of ground to cover, it can help to be well-prepared. Here are some tips to help you get ready.
What you can do
Prepare a list of questions to ask your doctor during your appointment. Put the most important questions first, in case time runs out. Some basic questions include:
What to expect from your doctor
Your doctor is likely to ask you questions such as:
If home remedies haven't helped your ingrown toenail, your doctor may recommend:
Your doctor may also recommend using topical or oral antibiotics, especially if the toe is infected or at risk of becoming infected.
You can treat most ingrown toenails at home. Here's how:
To help prevent an ingrown toenail:
Ingrown toenail. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00154. Accessed Nov. 12, 2013.
Foot care. American Diabetes Association. http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html. Accessed Nov. 12, 2013.
Tintinalli JE, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: The McGraw Hill Companies; 2011. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=40. Accessed Nov. 12, 2013.
Eekhof AH, et al. Interventions for ingrowing toenails. Cochrane Database of Systematic Reviews. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001541.pub3/abstract. Accessed Nov. 12, 2013.
Canale ST, et al. Campbell's Operative Orthopaedics. 12th ed. Philadelphia, Pa.: Mosby Elsevier; 2013. http://www.clinicalkey.com. Accessed Nov. 13, 2013.
Goldsmith LA, et al., eds. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York, N.Y.: The McGraw-Hill Companies; 2012. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=740. Accessed Nov. 14, 2013.
Living with Diabetes: Foot complications. American Diabetes Association. http://www.diabetes.org/living-with-diabetes/complications/foot-complications. Accessed Nov. 14, 2013.
Goldstein BG, et al. Paronychia and ingrown toenails. http://www.uptodate.com/home. Accessed Nov. 14, 2013.
Apr. 03, 2014
Earwax usually falls out on its own, so there's no need for extra help. Occasionally, it can completely block up your ear canal leading to hearing loss. It then may need to be removed.
Earwax also sometimes needs to be removed so that an impression of the ear canal can be made for a hearing aid mould. It can also be removed if the earwax is causing the hearing aid to whistle.
Eardrops, available from your pharmacy, can be used to soften and loosen the earwax, which may help it to work its way out naturally. Speak to your pharmacist about which eardrops are suitable for you.
Eardrops should only be used when they're at room temperature. Pour a few drops into the affected ear and lie on your side for a few minutes, with the affected ear facing upwards.
This will allow the eardrops to soak into the wax and soften it. Repeating this two or three times a day for between three and five days will cause the plug to soften. The wax should then gradually fall out of your ear bit by bit.
Eardrops should not be used if you have a perforated eardrum (a hole or tear in the eardrum).
Ear irrigation (or "syringing")
Ear irrigation may be recommended if your earwax blockage persists, even after using eardrops. It involves using a pressurised flow of water to remove the build-up of earwax.
A metal syringe is used to enable a controlled flow of water which is squirted into your ear canal to clean out the earwax. The water is a similar temperature to your body.
While irrigating your ear, the healthcare professional treating you may hold your ear at different angles to ensure the water reaches all of your ear canal.
They may also look inside your ear several times using an auroscope (an instrument that's used to examine the inside of the ear) to check whether the wax is coming out.
Ear irrigation is a painless procedure, but your ear may feel strange as the water is squirted around your ear canal. Tell the person who is treating you if you experience any:
These symptoms may be caused by an ear infection and will need further investigation.
If ear irrigation is unsuccessful at removing earwax from your ear, your GP may recommend:
When ear irrigation is not recommended
Ear irrigation isn't suitable for everyone. It shouldn't be used if you have:
Ear irrigation isn't recommended if you have a grommet. The grommet creates a passage in your middle ear, which allows water to enter during syringing.
Grommets come out naturally and the passage created by the grommet should eventually heal. Once the passage has healed, you can have ear irrigation.
You shouldn't have ear irrigation if the ear to be treated is your only hearing ear. This is because there's a small chance it could cause permanent hearing loss.
Young children who cannot tolerate it and some people with learning difficulties may also not be able to have ear irrigation.
Should ear drops or ear irrigation prove ineffective at removing your earwax, or if you're unsuitable for these treatments, there are some alternative options that you may want to consider. These are described below.
Microsuction and aural toileting can be performed at One Care Clinic Hougang. Please call for an appointment with Dr Jack Lee.
Ear syringing can be performed at all One Care Clinics.
(Adapted from NHS UK)
An Advance Medical Directive (AMD) is a legal document you sign in advance to inform your doctor that you do not want the use of any life-sustaining treatment to be used to prolong your life in the event you become terminally ill and unconscious and where death is imminent.
The AMD can be made by any person, aged 21 years and above, and is not mentally disordered. The AMD form is a legal document which must be completed and signed in the presence of two witnesses before it is returned to the Registrar of AMDs. The patient's doctor must be one of the two witnesses, while the other witness must be at least 21 years old. In addition, both witnesses must not have any vested interests in the patient's death.
AMD documentation is available at all One Care Clinics.
Source: Ministry of Health Singapore
Ear infections are common and easily managed by your local family physician. Fortunately, the majority of infections settle without ill effects whether the problem is in the outer, middle or inner ear, although sometimes longer term problems can arise.
The ear is divided into three parts: outer, middle and inner (see diagram). Infection in each part will give rise to certain patterns of symptoms and the type of symptoms which may occur with ear infections include:
The only sign of an ear infection in young children may simply be a fever and some tugging of the ear by the child.
Dependent on which features are predominant, it is possible to identify the infection as arising within one of the three parts of the ear.
Outer ear infections (otitis externa)
This is an infection of the skin of the ear canal and very common. It can be extremely painful so that sleep may be impossible. Usually, outer ear infections are caused by a bacterial infection though occasionally, it may be fungal related.
The skin can become so swollen that the ear canal closes, causing temporary deafness, and there can be a scanty discharge from the ear. It occurs commonly in people who suffer from skin problems such as eczema, psoriasis or dermatitis but also in people with narrow ear canals or who swim a great deal. It can affect both ears and often keeps recurring, especially if you are otherwise rundown or stressed. Not surprisingly, such symptoms usually mean that you will need to consult your doctor in order to receive effective treatment.
Treatment for outer ear infections is generally in the form of antibiotic ear drops which are instilled into the ear canal for at least a week. Sometimes antibiotics by mouth will also be necessary. In severe cases referral to an ear nose and throat specialist is both necessary and appropriate for cleaning of the ear canal and more intensive treatment.
Middle ear infections (otitis media)
Middle ear infections are also extremely common, particularly in children. The most common is acute otitis media which is characterised by a severe earache and high temperature, generally in a child, with associated hearing loss.
Like an abscess, once the eardrum bursts and the pus comes out of the ear the pain eases. Happily, the eardrum almost always heals once the infection settles and the hearing also returns to normal.
Longer term problems can occur when such infections are frequent, because there can be damage to the eardrum, or perhaps persistent deafness due to fluid remaining behind the eardrum (glue ear). In such cases referral to a specialist is appropriate.
A second but more serious form of middle ear infection is when it becomes chronic or long-lasting. Generally, chronic middle ear disease is associated with a smelly ear discharge and deafness, but rarely with pain.
Other significant symptoms such as tinnitus, weakness of the face or dizziness can occasionally occur. In these cases referral to an ear nose and throat surgeon is very important as the treatment usually involves surgery to remove the infection from the middle ear and mastoid bone. To ignore such disease can be potentially dangerous.
Mastoiditis is an acute infection of the mastoid bone which surrounds the ear. It is much less common than in previous decades, but certainly still occurs, especially in toddlers, and it needs urgent treatment with antibiotics once the child is admitted to hospital.
Inner ear infections
Infections of the inner ear are fortunately less common and are generally caused by viruses, although occasionally by secondary bacterial infection. They tend to cause problems with sudden hearing loss or dizziness.
The common cold virus is perhaps the most common cause of inner ear infections but many other viruses have also been associated with sudden deafness such as mumps, measles and herpes.
Your family practitioner should be able to manage most infections of the ears. Problems that do not settle with treatment may warrant a referral for specialist help.
Most ear infections will initially be treated with either antibiotic ear drops or antibiotics taken by mouth. When the infection is severe, admission to hospital may be necessary for antibiotics via a drip. In some complicated cases surgery may be the best form of treatment.
(Adapted from www.entuk.org)
Urinary Tract Infections are one of the most common infections, especially in women.
About 40% of women develop a urinary tract infection (UTI) at some point in their life. This condition is uncommon in boys and young men. Serious consequences can occur if a urinary tract infection affects the kidneys. Infections of the urinary tract are usually treated with antibiotics.
A Urinary tract infection (UTI) is an infection that affects any part of the urinary tract. The urinary system consists of the kidneys, ureters, bladder, and urethra. A Bladder infection, or cystitis, is the most common type of UTI. If the infection affects the kidney, it is called pyelonephritis which is a much more serious infection.
Women are especially prone to urinary tract infection. This is due to the shortness of the female urethra. In addition, women are at particular risk of recurrent UTIs after menopause because of decreased levels of oestrogen, which reduces the number of lactobacilli. Lactobacilli are 'friendly' bacteria that inhabit the vagina of fertile women and prevent other bacteria from invading the urethra. Also, after menopause, the mucous lining of the urinary tract 'thins out' and its ability to resist bacteria invasion is reduced. In Singapore, about 4% of young adult females are affected. The incidence rises with age to 7% at 50 years.
During the first six months of life, UTIs are more common in boys. This is because more males are born with structural abnormalities of the urinary tract. In older children and adults, UTIs are more common in females.
Urine is normally sterile. An infection occurs when micro-organisms (usually bacteria from the gut) attach itself to the urethra and begin to multiply. The infection may remain in the lower urinary tract (urethra and bladder) or it may move higher up to the kidneys as well. There are also micro-organisms causing this condition that are transmitted sexually.
Causes & risk factors
Cystitis is caused by bacteria which enter the urethra and bladder and cause inflammation. Over 90% of cases of cystitis are caused by E. coli, a bacterium normally found in the intestine.
Other risk factors for cystitis include:
If cystitis is not successfully treated, the infection may go up causing kidney damage. Bacteria may also enter into the bloodstream and this can cause a serious blood infection called septicaemia.
Screening & diagnosis
If a person has symptoms of UTI, the doctor usually requests for a urine sample analysis. The urine is examined for the presence of nitrites and white blood cells. However, a urine culture to identify the bacteria is needed to confirm the diagnosis. This also allows the doctor to identify the micro-organism involved.
Urinary tract infections in certain groups like young children and adult men warrant further work up and may require special methods of investigation.
Antibiotics may be used to control the infection. The drug of choice and length of treatment depends on the patient's history and the urine test that identify the offending bacteria. It is imperative that the patient finishes the entire course of prescribed antibiotics. For infection that spread to the kidneys , stronger antibiotics given intravenously may be indicated.
Surgery is generally not indicated in the presence of a urinary tract infection. Preventive measures may reduce symptoms and prevent recurrence of infection.
Follow-up measures may include urine cultures to ensure that bacteria are no longer present in the bladder. Appropriate hygiene and cleanliness of the genital area may help reduce the chances of introducing bacteria through the urethra.
Text adapted from Singapore Health Promotion Board
Causes of dizziness
There are a multitude of causes of dizziness which may have nothing to do with the balance organ in the inner ear. Fainting attacks, heart problems, thyroid problems and brain problems can all give rise to feelings of light-headedness, giddiness and general imbalance.
One form of dizziness is vertigo. Vertigo is the hallucination of movement usually described as either the environment moving in relation to the patient or the patient moving in relation to the environment as a spinning or rotatory sensation. Vertigo is specifically linked to problems with the inner ear. Of the people who suffer from vertigo due to inner ear problems, 99% will recover with time and without any treatment.
Balance and the ability to remain upright is dependent upon three systems:
All three of these systems give information to the brain about the position of the body in space. Generally people can keep their balance if two of the three systems are working, but they cannot cope with only one system working. This is why most people tend to become more unsteady as they get older, because they may have arthritis in their legs and their neck or poor eyesight
The balance organ (or labyrinth) is made up of three semicircular canals and the vestibule, which are all filled with liquid. The semicircular canals sense rotational movement and the vestibule senses acceleration and deceleration.
Inner ear disease and vertigo
Many different factors can affect the inner ear and cause vertigo. One way to distinguish them is by the duration of the dizziness.
Short-lived episodes of dizziness (few seconds to minutes)
An extremely common type of vertigo is benign paroxysmal positional vertigo (BPPV). This is typically a very sudden onset of dizziness, which settles rapidly after a few seconds or at most a couple of minutes.
It is often started off by the person suddenly looking upwards or sideways, and some people get it when they turn over in bed. In between attacks, the sufferer feels entirely normal. It is probably caused by a little piece of lining coming loose in the inner ear and floating into the balance receptor, causing a sudden increase in nerve stimulus to the brain.
Sometimes the attacks start following a whiplash injury or other head injury, but often there appears to be no reason that they should have started. The attacks usually disappear with time.
Medicines do not help, but a manoeuvre known as Epley's Manoeuvre can be extremely effective in some patients. This can be carried out a trained family practitioner, a ear nose and throat surgeon or physiotherapy department.
Medium length episodes of dizziness (half-hour to several hours)
These types of vertigo are rarer and are thought to be due to an increase in pressure of the fluid in the inner ear, although nobody really knows for sure.
Menière's disease or endolymphatic hydrops result in episodes of severe vertigo that can last up to several hours. The dizzy episodes are usually linked with vomiting, and the sufferer can often tell an episode is about to start because he or she notices a drop in their hearing, a feeling of fullness in the ear and some tinnitus. The hearing recovers once the vertigo has settled, but may gradually deteriorate with time. In between episodes, the patient feels completely normal. A hearing test is usually performed to determine the degree of hearing impairment.
Treatment of Menière's disease can involve medicines and, more rarely, surgery, but this will be organised by your local ear nose and throat department once the diagnosis of Menière's disease has been made.
Longer episodes of dizziness (days to weeks)
An infection of the inner ear (labyrinthitis) or an inflammation of the balance nerve (vestibular neuronitis) can give rise to severe rotatory dizziness for up to two to three weeks, with a slow return to normal balance which can take a further few weeks.
Again, the initial episode is often associated with vomiting and the patient can be bed-bound because the dizziness is so severe. This is best treated at first with a vestibular sedative such as Stemetil, but any treatment should be stopped quite quickly to allow the brain to compensate and recover from the dizziness. Recovery is much quicker in the long run if treatment with anti-dizziness medicines is not prolonged.
The majority of patients who experience episodes of vertigo will recover without any long-term ill effects and usually within a few weeks or month of the onset of the symptoms.
In the majority, specialist investigations do not help with the diagnosis but they can be helpful in certain circumstances. If they are thought necessary, investigations of vertigo can be carried out by a trained family physician, neurologist, general physician or ear nose and throat surgeon or a audiological physician.
Types of test that may be requested include: audiological (hearing) tests, tests of balance, blood tests (rarely), and radiological examinations such as an MRI scan or CT scan.
In general the treatment of vertigo is symptomatic, ie treatment is given to control the symptoms without regard to the specific cause of the vertigo. The body is very good at overcoming the imbalance experienced during inner ear disease, and so symptomatic treatment should be short because it can delay this natural compensation.
Rehabilitation (including Cawthorne Cooksey Exercises)
There are specifically targeted exercises to speed up the brain's natural compensation after inner ear disease. Recovery can be hastened by these exercises which can be organised by your local ear nose and throat or physiotherapy department.
The inner ear may be ‘suppressed' (or made sleepy) by the use of drugs such as Stemetil or Stugeron. These drugs reduce the overactivity of the balance organ and so reduce the dizziness and vomiting that can occur in inner ear problems.
However, they are not a long-term solution and should be used for as short a time as possible because they prolong the time taken for the body to readjust after the vertigo.
This is a longer term disease and there are two aims of treatment. One is to treat the acute episodes of dizziness with vestibular sedatives (see above), and the other is to try to reduce the frequency of the dizzy episodes.
Frequently advice will be given to restrict intake of salt, caffeine and alcohol, which can help some patients with Menière's disease. Increasing the bloodflow of the inner ear may help and so drugs like Betahistine (Serc) are often prescribed.
Some people with Menière's disease may benefit from surgery if the episodes of vertigo are frequent and disabling and not responding to medical treatment.
Surgery may be advised if medical treatment proves ineffective and the episodes of vertigo are disabling. The options range from those such as the simple insertion of a grommet through to operations which completely destroy the inner ear, or divide the nerves leading from the inner ear to the brain.
Unfortunately, many (although not all) effective surgical operations also destroy the hearing of that ear and so the vertigo is usually severe before a patient opts to undergo such treatment.
Because there are so many different causes of vertigo, there are several different operations and so it would take too much space to detail them all here, but your ear nose and throat consultant will go through them with you.
There are always new treatments being developed and there is very encouraging progress being made using drugs delivered directly into the ear which selectively destroy the inner ear balance mechanisms without affecting hearing.
Further work is still to be undertaken in this area and will no doubt result in improved techniques for the control of vertigo in patients who are long-term sufferers. Anyone suffering from persistent recurrence of vertigo should consult their doctor in order to find the cause and to arrange effective treatment.
(adapted from www.entuk.org)
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