15 December 2003

1. Reactive Airway Disease
2. Dealing with Ear Wax
3. Hair Loss
4. Viral Exanthem
5. Tongue Tie
6. Chronic Symptoms, No Relief
7. Hole at Top of Butt Crack
8. Musculoskeltal Injury
9. Disclaimer

• Read Questions & Answers in Another Column

Reactive Airway Disease

-(unsigned)

Dear Parent: Reactive airway disease is essentially asthma. The symptoms include wheezing, coughing, and recurrent bronchitis. The treatment is the same as for asthma. If the child has recurrent episodes of wheezing, then it is called asthma. For additional information, look for the articles I have written about asthma. If you have any more specific questions about your daughter, write back to me.

Sincerely,
Dr. Warren

-KR

Dear KR: As long as the ear drum is intact and there is no drainage from the ear, you can safely put mineral oil in your daughter's ears several times a week. Make sure you fill the ear canal and try to get her to keep her head to the side for a while or use a cotton wet with the oil to hold the drops in place. Alternate which ear you put oil in since she can't keep both ears facing up at the same time. This usually softens the wax so that it comes out easily, often by itself. Do NOT, under any circumstances, put a Q-tip or other swab into the ear canal. That will push wax in .

Sincerely,
Dr. Warren

Some problems that i have had in the past that might be a link would be:

• Anorexia Nervosa
• Bulimia Nervosa
• Severe Clinical Depression (stress)
• Using Anti-Depressants such as Paxil, Prozac, Ritilan (for A.D.D I don't have A.D.D. it was a mis diognosis)
• I am using the Depro Vera shot currently (for the past year)

-Jessica

Dear Jessica: A variety of stress related and emotional disorders can cause hair loss. This includes bulimia and anorexia nervosa. If you no longer have these problems, they shouldn't be playing a role in your current hair loss. Neither Prozac nor Paxil list hair loss as a side effect. Since you don't have ADHD, I presume you're not currently on Ritalin. Depo-Provera does list hair loss as a possible side effect..

Since there are several possible reasons you could be experiencing alopecia (hair loss), you and your doctor should consult a dermatologist to see what treatment options you have. This could include discontinuing the Depo-Provera, but you should not do that without discussing the risks, benefits and alternatives with your doctor.

Sincerely,
Dr. Warren

Gratefully yours,
-Sonja

Dear Sonja: The term "viral exanthem" simply means a rash caused by a virus infection. Many viruses cause rashes, for example, chicken pox, measles, and German measles. Those rashes are distinctive enough for an exact diagnosis to be made. Many virus rashes can't be told apart, so rather than making a specific diagnosis, the term "viral exanthem" is used. The other associated symptoms and the duration of the illness depends on what virus is causing it. Most virus infections and the exanthems associated with them are gone within a week.

The manner in which your daughter caught the illness depends on what virus is causing it. Respiratory virus are spread through secretions like mucus and saliva. Enteric viruses spread through contamination with germs from stool. Both major types of viruses spread readily from the hands of the sick person.

The illness must be considered contagious as long as your daughter has fever or rash.

Sincerely,
Dr. Warren

Love,
-Sonja

Dear Sonja: Roseola generally doesn't cause a severe rash. The typical story for roseola is high fever for 3 to 5 days in a child who does not appear ill followed by a rash. The rash of roseola does not appear until the fever breaks and the illness ends. The rash of roseola is generally faint and may disappear within a few hours. The roseola rash rarely lasts more than a day.

Most virus infections with rashes do not become contagious until there are signs of illness. You may inform parents of children who may have been exposed, but you have little useful information to tell them. Children are constantly exposed to infectious illnesses. It is really only useful for parents to know what the kids have been exposed to when the exposure has been to a serious illness and specific precautions should be taken, or when the illness follows a predictable course so that knowledge of the exposure will help the parents plan for the possibility of their child becoming ill.

Sincerely,
Dr. Warren

Thank You

-BG

Dear BG: The medical term for tongue tie is ankyloglossia. The surgery to correct it is called a frenotomy.

The information in Pfenninger: Procedures for Primary Care Physicians, 1st ed., Copyright © 1994 Mosby-Year Book, Inc. seemed so complete and relatively easy to understand that I thought the best thing would be to send you the chapter. Essentially, the issue of whether or not tongue tie can affect speech and whether or not it should be treatred remains controversial.

Here's the chapter:

Chapter 46 - Tongue-Tie Snipping (Frenotomy) for Ankyloglossia by Gary R. Newkirk

"Tongue-tie," or ankyloglossia, can be maxillary or mandibular. Maxillary ankyloglossia occurs when the tongue is ankylosed to the hard palate, the alveolar ridge, or the lower septal edge if cleft palate coexists. Mandibular ankyloglossia results from underdevelopment of the lingual frenulum, with the frenulum attaching in the midline near the tip of the tongue, along the floor of the mouth to the gingiva.

Infants and children differ substantially in the degree to which the frenulum attaches to the tongue. Most cases of tongue-tie are thought to resolve spontaneously by adulthood with little likelihood of feeding or speech-development problems. Usually, parents are the first to notice tongue-tie in their infant or child and bring this to the clinician's attention. The condition can easily be overlooked during the newborn examination, since infants typically retract their tongue when the mouth is opened, covering the short frenulum. Furthermore, newborn infants rarely stick their tongue out, which further obscures the limited tongue protrusion that accompanies this finding.

Since tongue-tie is a rare condition that lacks a precise definition, there have been no formal outcome studies comparing infants who have and who have not undergone frenotomy. However, problems with sucking, breastfeeding, chewing, swallowing, dentofacial growth and development, gingival hygiene, and speech have all been attributed to tongue-tie. Some researchers feel that the parents, not the child, have the problem. Others feel that simple frenotomy (referred to as snipping) remains a quick, easy, and safe procedure with benefits--even if only cosmetic--that in some instances outweigh the family anxiety generated by this condition.

The best method and timing for reducing partial ankyloglossia remains debatable as well. When ankyloglossia severely interferes with lingual function (e.g., "frozen tongue") few would argue the need for reduction; but in this case, Z-plasty is necessary, and the patient should be referred to a surgeon, since this procedure requires general anesthesia. Some clinicians feel if partial ankyloglossia contributes to poor infant sucking and other breastfeeding problems such as insufficient infant weight gain, or sore nipples or recurrent mastitis in the mother, frenotomy should be attempted. Simple frenotomy for infants and small children who have partial ankyloglossia can be performed readily in the outpatient setting.

INDICATIONS

• Clinical evidence of short lingual frenulum inhibiting tongue protrusion, feeding, swallowing, or speech

CONTRAINDICATIONS

• Lack of clinical evidence or suspicion that ankyloglossia is problematic to the infant or child
• Unstable medical conditions, such as bleeding disorders or diabetes mellitus
• Severe ankyloglossia, which requires frenectomy under general anesthesia (Usually this procedure involves Z-plasty or similar plastics reduction.)

PREPROCEDURE PATIENT EDUCATION

• Describe the risks, including possible medication reaction (if used), injury, infection, and bleeding.

TECHNIQUE

1. Parents may help position and hold small infants or children if willing. Note: Crying often improves exposure of the frenulum.
2. Identify the frenulum and the degree of surgical lysis necessary. A limited "snipping" of the lucent, membranous portions of the distal frenulum is usually all that is required.
3. Dip a cotton-tipped swab in Hurricaine syrup to provide excellent local anesthesia. (Many clinicians clip membranous distal frenulums without topical agents.)
4. Retract the tongue (a small spoon or wooden tongue blade with a slit fashioned in the end works well).
5. With the tip of the mosquito clamp, grab and crush the frenulum to a depth and at the position where the scissor snip is to be made.
6. Snip the crushed portion of the frenulum.
7. Use a dry cotton-tipped swab, or one soaked in 1% lidocaine with epinephrine, to control oozing.

POSTPROCEDURE PATIENT EDUCATION

• Ask the patient (or parent) to report significant bleeding or signs of infection.
• Instruct parent(s) to allow infants and children to resume normal feeding habits immediately.
• Ask the patient (or parent) to report any feeding difficulties, or significant swelling.
• Inform the patient to return for follow-up in 2 weeks, or sooner if complications arise.

COMPLICATIONS

• Bleeding
• Infection
• Injury to tongue or sublingual mucosa or tissue

Sincerely,
Dr. Warren

-ME

Dear ME: I suspect that if 20 doctors have the same opinion, their diagnosis must be correct; however, you haven't told me what kind of evaluation your husband has had. If he has had endoscopy by a gastroenterologist and the doctor saw an ulcer, then the diagnosis is unquestionably correct.

Ulcers do not cause fatigue, but chronic symptoms with depression and poor sleep can cause fatigue. I have to ask why your husband has seen so many doctors. I can understand seeking a second or even a third opinion, but if you go from doctor to doctor, no physician has the opportunity to manage your husbands symptoms long term and find the best treatment for him.

Sometimes chronic conditions can be treated but not cured. In that situation, the patient needs to have realistic expectations and learn to cope with his symptoms. This requires an ongoing relationship with a physician you trust who can explain what's going on, provide treatment options, order appropriate follow up tests and referrals to specialists as indicated, and provide emotional support. It may also require joining a support group and/or seeing a psychiatrist for medical management of mood.

You need to figure out which doctor is your husband's primary doctor and make an appointment for review of his case and then make sure your husband's doctor oversees and coordinates the evaluations and treatment of all the other physicians involved.

Sincerely,
Dr. Warren

-Concerned mommy,
Kelly

Dear Kelly: You may be describing a pilonidal sinus, however, the size of the hole is only the size of a pinhead and would hardly be described as a second anus. You must be born with a pilonidal sinus to have one. They are not serious, but if the tract gets obstructed, it could cause a pilonidal cyst which can cause pain or become infected requiring surgery.

Spina bifida is a congenital defect. Nothing leads to it. You have to be born with it. If a person has a spina bifida occulta (an opening in the vertebra with no opening to the outside) it does not show up as a hole. It can only be found by x-ray.

Sincerely,
Dr. Warren

-JG

Dear JG: Muscle pain with restriction of movement in an athlete should be evaluated by an orthopedist. Without proper treatment, it is likely your daughter will injure herself further, interfering with her success as an athlete and possibly resulting in permanent disability.

Sincerely,
Dr. Warren

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