Treatment:
Drainage of abscess, excision of sinus and removal of the nest of hairs – this can be done with small incisions for faster healing.

He promptly explained to me that Jack Dancer means cancer!

Anyway, I did a further search on the web and found this useful link:

http://www.australianhistory.org/australian-slang-etoz.php

Cases I have seen include:
1. Removing a box thorn embedded deep in the tissues
2. Metallic foreign body – located by the use of a magnet; not always possible to remove it – especially if it is deeply located; sometimes one has to use an image intensifier in theatre, this is often an injury from work-related cause(eg miner in Broken Hill, apprentice on first day at work with mechanic; worker in factory)
3. Deeply penetrating large splinter – part of it was initially removed at a major trauma centre, patient was referred to me weeks later as persisting pain and granuloma. On exploration, 4cm remnant of penetrating splinter found and removed
(It is not always possible to remove every single fragment especially if friable object)
4. Spines of fish – this can be very hard to find, sometimes can be radioopaque
5. Broken glass – again also can be hard to find, I would say it is sometimes harder than looking for a needle in a haystack! But is it often satisfactory to be able to find the broken fragment.
6. Splinters, rose thorns etc

Sometimes by the time I am referred, a small abscess has formed around the foreign body – then it is easier to incise over the abscess, drain the abscess and remove the foreign body.

Reminder for residents:
Check tetanus status
Consider oral antibiotics treatment
Xray can be helpful to the surgeon ?radioopaque – some glasses are

What is it?
There is a dimple or pit in the skin in front of the ear. From here a tract heads under the skin. This tract may or may not branch out. Frequently, the tract ends up being infected leading to redness of the overlying skin and a purulent discharge.

Why does it occur?
During foetal development, different parts of the head(called branchial arches) join together. Failure of this may lead to congenital problems such as cleft lip or cleft palate. In a similar fashion, the preauricular tract is due to different parts of the head not fusing together completely during foetal development. Occassionally, there may be other associated anomalies for example in the kidneys.

Treatment

When acutely infected, antibiotics is required. Sometimes if there is an abscess, this requires drainage. If possible, this should be drained by enlarging the pit opening and the tract washed out with Betadiene.

Surgery is the definitive treatment if there has been previous infections. This involves excising the whole tract and is best done in an operating theatre. Often the tract needs to be identified by injecting it with a blue dye. There is significant risk of recurrence with surgery(rates published are as high as 15-40%) – usually this occurs when the tract has branched and the the other tract has not been excised. Sometimes more radical surgery is required to excise out all the tissue in front of the ear to prevent recurrence and this would required a general anaesthesia.

Risks of surgery
Scar
Wound problems – infection, discharge, ooze, redness
Pain
Bleeding, bruising
Nerve damage – the facial nerve lies close
Recurrence

Examples:
Warts in foot – often because of the long duration, the roots of the warts are digging deep into the sole causing pain on walking
Warts in fingers and palms
Warts on the nostril, around the face

Treatment options

1. Cryotherapy – liquid nitrogen. I often find it useful to consider this option first before considering surgery. For cryotherapy to be effective, the roots of the warts need to be frozen off as well. This requires a more prolonged application of the liquid nitrogen and often several repeat freeze-thaw cycles. The benefit is that it avoids surgery and leaves less scar. Risks with cryotherapy – discomfort and pain on application, blood blister(this can form after but the benefit is that the wart will usually fall off with time). Cryotherapy also needs to be repeated several times for it to work especially in chronic warts with deep roots. Once the warts resolves, the area may be darker or lighter than the surrounding skin.
2. Surgery – excision with scalpel or diathermy. This is more painful and requires either a local anaesthesia or general anaesthesia. Risks – the smoke from the diathermy may contain carcinogens(and be potentially infectious); surgery will cause bleeding and leave a scar.

Symptoms caused by the hernia
1. Lump – usually this contains fat(either omental fat from the peritoneal cavity or extraperitoneal fat). Rarely, this can contain bowel (the danger here is of the bowel becoming stuck leading to either bowel obstruction or strangulation of the blood supply causing the bowel to die/necrose)
2. Pain or discomfort – this is often associated with the lump
3. If the hernia has developed a complication such as bowel obstruction – then one can get a severe cramping abdominal pain, nausea and vomiting, abdominal distension. If the bowel within it has perforated, the one can get a fever and become septic. (These are both surgical emergencies and one should be take to the hospital urgently for resuscitation and surgery)

Treatment of the hernia around the belly button area (On the ventral abdominal wall)

Surgical options include:
1. Direct repair without mesh – this involves using suturing the defect with nondissolvable sutures eg 1 Nylon. This alone has a higher risk of recurrence. In the past, a Mayo repair is used – this involves overlapping two layers of tissue and suturing the defect together under tension. Again this has a higher risk of recurrence.
2. Mesh hernioplasty – there are many variations to these. My preference is to use a sublay Ventralex mesh. This mesh is a dual surface mesh with PTFE(smooth) on one side(the side facing the bowel) and polypropelene on the outside. This is placed in a sublay position – that is under the hole of the hernia defect within the peritoneal cavity. The PTFE surface is in contact with the bowel – because this is smooth there is much reduced risk of developing adhesions of the bowel(adhesions can cause small bowel obstruction). The outside surface is the usual polypropelene mesh – the most commonly used mesh. This mesh allows fibrous tissue to grow it. This mesh is secured by suturing its two polypropelene straps to the edges of the hernia defects without any tension. The overlying skin is then closed in layers with dissolvable sutures.

Postoperative Care
1. This surgery is usually carried out as a day case.
2. It is important to take regular analgesics as soon as one wakes up from the surgery before feeling any pain(ie before the local anaesthesia wears off)
3. Leave the plastic waterproof dressing on for 1-2 weeks(there is also often a piece of gauze rolled into a ball under that – this is to push the belly button back in and avoid fluid filling the space of the hernia) . Leave the tape dressings on for a further 1-2 weeks.
4. Surgical review is at 2 weeks and 2 months.

When to return to driving ?
This varies from person to person – the answer is : only when one is comfortable especially to apply the brakes! Please discuss this with your doctor

When to return to work?
Because this mesh is placed in a sublay position(ie the mesh to patch the hole from the hernia is placed on the inside of the hernia defect), there is no strict restrictions to be completely off work.

Generally, I find that most of my private patients particularly those who are self-employed return to work within days. For example, the next day for office work. I have had one patient, a fruiterer, return to his work within 3 days – lifting dozens of boxes of fruits.

It really depends on how comfortable ones feel from the cut on the skin and the stitches holding the mesh! I try my best in the surgery to minimize the pain by:
1. Using as little tension as possible in suturing
2. Minimizing tissue damage and dissection
3. Keeping the skin scar short and vertical (this can make the operation technically more challenging; but I can operate with both hands and have a surgical assistant to retract)
4. Ensuring a good local anaesthetic block from right before I make the skin incision(preemptive analgesia).

I do not encourage prolonged time off work. I often have Workcover patients tell me that their colleagues have had 6 weeks off from a hernia repair! I would really encourage my patients to get back to light duties within the week and slowly increase their hours. Of course one has too be sensible in the type of work one returns too – I certainly do not recommend getting into and driving a 16 tonne truck until one is fully comfortable. I would also not recommend lifting 200kg boilers(in fact, there must surely be a Worksafe rule on the limit one can lift – more so as not to develop hernias elsewhere!)

What if I have lots of sick leave?
Again that is not a reason for not returning to light duties sooner especially with the sublay mesh technique!

Risks of surgery
Risks of anaesthesia
Scar
Pain – rarely complex regional pain syndrome(those at highest risks are Workcover patients who have delay in returning to work)
Bleeding, bruising
Recurrence – especially from a sutured repair
Adhesions – rarely bowel obstruction(rare with the sublay dual surface mesh)
Risk from the mesh – the PTFE and polypropelene material are generally inert. Of course with any foreign material placed within the body, new discoveries may be made in future of potential new side-effects.
Future laparoscopic surgery may be more difficult – especially if port has to be place around the belly button area! There might also be increased risks of bleeding and of damaging other organs.

This reason for this is the increased risk of bleeding. Studies have shown patients on aspirin have an increased risk of bleeding( X1.5 times). For patients on both aspirin AND clopidogrel, the increased risks of bleeding is 50%. On the other hand(this point is often quoted by the cardiologists), there is no increase in the severity of bleeding complications(except for brain and prostate surgery) and no increase in the risks of dying from surgery(except for brain surgery)

On the other hand, stopping aspirin or clopidogrel during the time of surgery would increase the riks of getting a heart attack and even dying threefold. The risks here would be greater for someone with a coronary stent in. There are basically 2 types – the bare stents and the drug-eluting stents. Even with being on aspirin and clopidogrel, there is always a risk of occlusion of the stents. Cardiologists vary in the advice on the duration one needs to take the aspirin and clopidogrel.

It is best if you are on aspirin or clopidogrel, that you discuss this with your general practitioner first. Your family doctor is the one who is fully aware of what advice the cardiologist has given. If there is any doubt, discuss this further with your cardiologist.

An easy way to remember is to consider an apple as having 3 grams of fibre. Hence one needs 10 apple-equivalent of fibre to reach the target of 30grams of fibre a day.

Other simple easy ways to remember the figures:
2 Weetbix = 3 grams

Hence one needs about 10 grams of fibre with each main meal of the day to reach that target.

Often patients tell me that they already eat a lot of fibre. Here is an example of a typical diet that is relatively health but may not have all the 30G of fibre:
1. Breakfast – cereals inc bran
2. Morning tea – a piece of fruit
3. Lunch – Sandwich with leafy vegetables in it and a piece of fruit
4. Dinner – generous servings of vegetables/salad and another fruit
This might mean only about 20-22Grams of fibre for the day – still 8 grams short of the target!

If dietary intake is not adequate, then one can easily top up the balance with fibre in the powdered form that one can mix with drinks. Eg psyllium husks such as Metamucil or Fybogel(you can mix the latter with one’s cooking)

Advantages
Less painful that haemorrhoidectomy(excision of haemorrhoids)
Does not require general anaesthesia
Can be applied at the end of a colonoscopy procedure

Limitations
Haemorrhoids that are too large may not be successfully banded – this may require surgery.

Risks
Discomfort/feeling of going to the toilet – this is when the rubber bands pulls on the lining of the rectum
Bleeding – when the haemorrhoids fall off over the next 2 weeks
Pain – this can happen if the haemorrhoids is banded too low down(ie below the dentage line), this can also happen if one tries to band a prolapsing haemorrhoid. However the pain is certainly less than for a haemorrhoidectomy
Infection – uncommon

Other alternative options of treating haemorrhoids
1. Injection with phenol in almond oil – this has risks of extravasation and pelvic sepsis(During my training, I can recall a case in England who came in via ED with severe pelvic pain after the phenol was injected outside the lining of the rectum. She had just had her haemorrhoids injected the day before by a very capable consultant)
2. Haemorrhoidectomy – this involves excising the haemorrhoid +- associated anal skin tag. If only one is to be excised, this can be done under local anaesthesia in the rooms. If more than one needs to be excised, best to be done in an operating theatre under anaesthesia(either general anaesthesia or spinal anaesthesia)

This is a rare condition affecting the  arteries in the head. Usually affecting people over 50. Twice as common in females than males. Commoner in Caucasians. And associated with polymyalgia rheumatica(PMR)

What is the condition?

This condition is due to the inflammation of the artery in particular the temporal artery in the head. We do not know what causes the inflammation.

What are the symptoms?

Headache – especially if it is worse on the temple or occiput; usually described by patients as different from their previous headaches

Symptoms of polymyalgia rheumatica (PMR) – aches and stiffenss of shoulders and hips

General constitutional symptoms – fever, tiredness, loss of weight

Local symptoms on the temporal artery – tender scalp(eg painful on combing hair), thickened palpable temporal artery

Jaw claudication – pain on chewing

Visual disturbances – eg visual loss, double vision

What other conditions can mimic this?

Other types of vasculiltis

Infection

Malignancy

Cervical spondylosis

Investigations

1. Blood test – ESR/CRP (elevated)

2. The gold standard is temporal artery biopsy – this can be performed under local anaesthesia in theatre. A cut is made over the palpable temporal artery and at segment of the artery is cut out after tying up the ends. The artery specimen is sent to the pathology lab for testing. (Histology findings: Multinucleate giant cells)

Treatment

Steroids – high does for 2 to 4 weeks(typically 40-60mg/day) And then tapered off. Higher doses may be needed if there are visual symptoms.

Author’s note: In my practice, the rheumatologist refers the patients with suspected giant cell arteritis to me to perform the temporal artery biopsy.

Disclaimer:

This article does not constitute medical advice

You should see a qualified medical practitioner for a formal opinion.