Thursday, September 23, 2010

5.(2-5) Bumps Under Skin, Face, Nose & Throat, Colds & Coughs

Physician's Notebooks 5  - - See Homepage

      This 5 December 2018 update contains Chapters 2 to 5 in scroll down order of lumps under skin; allergy & hypersensitivity; face, head & neck with carotid artery pulse; and nose, mouth, lips, tongue & throat symptoms and diseases including the common cold and aging voice.

2. Things that Go Bump in the Night under Your Skin 
Lymph Node 
Sebaceous Cyst 
Tumor in Neck 
Baker's Cyst or Ganglion 
Femoral hernia 
My first girlfriend called me Bumpy because of a bump she felt under my skin when we played feelies on her parlor couch at night in dark. As her bumps were more symmetrical than my bump, I called her SweetieYou may guess what I was handling, but you would not guess that she was feeling my lipoma (fatty tumor). Everyone has one or more. They do not need worry unless unsightly. Interested lovers can discover one another's tumors. Later, I regretted not becoming someone’s lover because it might have saved her life. Dorrie was the elegant woman that educated, cultured men like I, born nearly 85 years ago, desired. Physically beautiful, intelligent, and talented as actress and operatic singer, she was my opium. But like a collector who comes upon a beautiful butterfly poised on a blossom, I desired her so awe-fully that I was scared to make a move for fear of frightening her away. Came a day we had lunch privately in a hotel room. At age 40 she was deserting a successful acting career to study opera-singing in Italy. A goodbye lunch it proved. I had no suspicion I would never see her again. Despite opportunity, I found myself unable to make my move. Ironic! From a letter she wrote while dying of breast cancer, I discovered she wanted me to. Had I done so, I might have discovered the bump in her right breast she only first felt a year later when it was beyond cure. 
Lymph node is another potential bump under skin. It feels a little like lipoma but is located where lipoma is not (elbow crease, armpit, side of neck, behind ear, in the crease beside groin). In adult, a new lymph-node enlargement ought to be evaluated with the idea it might be malignant or first sign of HIV/AIDS. The most dangerous node to feel is deep behind left collarbone (‘sentinel node’ from stomach cancer) or on front abdominal wall in a woman (from ovary cancer). Biopsy should be done on unexplained, persistent lymph-node enlargement in an adult, preceded by medical workup to rule out infection or inflammation. Enlarged node is common in child, usually around head and neck because immature immune system tends to be hyper-responsive to infection. Lymph node felt in armpit suggests breast cancer in a woman but more often is due to infected sweat gland from shaving underarm hair. 
Sebaceous Cyst is another felt skin bump. It is from skin oil gland and being part of skin is not movable separately as is lymph node or lipoma. Everybody has such cysts and eventually one gets infected with swelling, and becomes sore and red, usually on upper back and either bursts or gets cut open. Skin abscess occurs from drug addict injecting self with dirty needle, or from infected hemorrhoid by anus or from insect bite. It needs to be opened so pus can drain.  
Tumor in Neck; Bump on mid front of neck low down in bony notch is usually small thyroid tumor, which needs to be seen by endocrine specialist; a bump under the jaw is swollen salivary gland. 
Baker's Cyst or Ganglion is a bump felt behind the knee and if noted after trauma to leg, should be waited on. Ultrasound should confirm diagnosis and then needle drainage by experienced doctor may cure it. A ganglion as a complaint is a cyst on back-of-hand. The old treatment was dropping a heavy book on it but today better an experienced physician drain it with needle .
Diagnostic Pearl:  Pea-size bump, like a lymph node, appears just under thigh crease at its midpoint. It gives strange soreness worse after walking. Femoral hernia is possibility by location and you should get surgical check-up because, if a hernia, it will strangulate if not operated on. The appearance suddenly overnight is due to motion or exercise that pushed a piece of intestine or attachment along the potential hernia tunnel.
3. Allergy & Hypersensitivity
Allergy means reacting to a usually harmless, previously contacted substance in the immediate environment – breathed air, ingested food or drink, oral and injected medication or skin contact – by specific symptom or sign and not dose related.
Hypersensitivity is very like allergy; it is reaction to even tiny dose of a substance (eg, nickel dermatitis to trace of the metal in jewelry). In contrast to allergy though, hypersensitivity does not need previous contact - it irritates immediately and continuously as long as the irritant contacts you. Skin-contact eczema rash (red, tiny blister, itch) in area of contact is hypersensitivity due to irritating substance. Worst example of hypersensitivity is contact dermatitis poison ivy.
   The source of the allergy and the target tissue determines the type of allergic reaction. From air, the symptom may be itchy, stuffed nostrils, reddened, irritated eyes; blocked, easily infected sinuses; inflamed throat, ear tube, and windpipe; with strangulation feeling or chronic cough. Bronchial tube allergy gives asthma.
Air allergy & hypersensitivity: have same symptom  - cough and asthma wheeze - the symptom slops over into chronic irritation from air pollutant. To prevent, keep breathed air clean and filtered. Do not smoke anything or get in presence of a smoker! Get in the habit of breathing by nose and keeping mouth shut. Purpose of nose is to filter irritants out of breathed-in air to protect respiratory tract. All other factors being equal and if you have the choice, live in a high-rise; the air will be better higher up. It is always worst in basement. At home, use hypoallergenic furnishing. Also as preventive do not have furry or feathery pet, and no curtain or drape; similarly for seat cover and pillow, and no flowering plant. 
Food and Drink Allergy: a few persons have egg and milk allergy and they know it quickly and avoid dairy. Most food allergy comes from raw or poorly cooked food because cooking food well destroys the allergy-causing protein. Avoid raw meat (seafood a big cause of food allergy). Veg and fruit only rarely cause allergy because low protein. 
Medicinal allergy can seem like food allergy but food allergy will not cause trouble in blood as medicinal allergy does (eg, anemia from inhibition of red blood cell production in bone marrow or loss of resistance to infection from depression of White Blood Cell count). Try to limit medication course to less than several days. Developing a first allergic reaction is related to number of days the medicine is taken; particularly with antibiotic. Rash from medication is sometime confusing, especially in virus infection treated with antibiotic. But, you never go wrong by stopping the medication and seeing your doctor. Drug rash rarely needs treatment, clearing in 10 days once drug is stopped. Need for treatment is obvious (blistering, unbearable itch).
Read label on medicines!
Serious allergic or hypersensitivity reaction is hard to miss: You swell up around face and mouth, have difficulty breathing, and do not need book l’arnin’ to know an emergency has happened. 
If you seek continuing medical care for major allergy or air hypersensitivity start with a University-HMO and if no satisfaction go to a World-Beater institution (Rochester Minnesota, Mayo Clinic level) for a major consultation.
4. Face and Neck   
The following in descending column are the topics in order as they appear.
Inspect Your Face 
Swollen Lymph Nodes 
Neck Front
Carotid Artery Pulses
Symmetry of Mouth and and Lips; Bell's  or Facial Palsy
The Numb Chin Sign
Inspect Your Face  Sit in front of a mirror in a good light and look directly at your face. First, focus on the relation of each ear to the sides of your face. Normally you should see the lower rim of your ears down to the point where the lower earlobe meets the outline of the side of your face. The parotid salivary gland is on each side, at the level of each lower earlobe and extending to the angle of jaw. The normal parotid gland causes no elevation of surface skin. But when swollen, as in mumps or tumor, the surface just in front of the lower earlobe becomes so elevated that on looking straight in a mirror you cannot see your lower earlobe because it’s blocked by the swelling. Then you know the swelling is the parotid gland. In mumps, left and right parotid glands may swell together or in sequence and you feel discomfort especially when eating or drinking sour. Also you get a fever. The bilateral (both sides) swelling of mumps is symmetrical and not hard or bumpy but may be slightly tender. With a parotid tumor, the swelling is one-sided, irregular shape, and hard and bumpy without pain or tenderness, and no fever. Infections of teeth and gum swell one side of the face over the area.
Swollen Lymph Nodes in Neck: Swelling lymph node(s) on the side of neck may be mistakenly diagnosed as mumps, but front-face mirror observation will show the swelling to be below the earlobe. Side of neck swellings, especially on both sides, are part of general body lymph node swellings (also armpit, groin and elbow crease) typical of early stage AIDS or else of lymphoma. In neck, one-sided or asymmetric both-side swelling is often seen in child due to frequent tonsillitis. In adult, lymphoma should be suspected.
Neck Front: Now lift up your chin and look at front of neck. Normally, its appearance should be symmetric with no irregular line, bump or swelling. Feel your “Adam’s apple,” which is like a hard cartilage shield over the windpipe. In some, it is prominent – in center front of neck. Feel its outline, running your forefinger over it. Note at its top, a V-shape like a cartoon apple and accounting for the famous name. Run your finger from the V directly down and you should feel small, indent area a little below the Adam's apple. Here is point that resuscitating technician may insert a wide-bore needle to relieve upper airway obstruction in a collapsed person who is not passing air through airway, a lifesaver with foreign body blocking upper windpipe.
Carotid Artery pulses are important because closest to heart. To feel them, place palm of hand on front throat part of neck with thumb and forefinger as if holding up lower jaws. Your Adam’s apple should be nestled right in the web between thumb and forefinger. Now adjust tip of thumb and tip of forefinger so each gently presses into the soft tissue to right and left. You should feel pulsation of carotid on each side separately. Count number of pulses per minute and note regularity of beat, and strength and symmetry of strength.
Symmetry of Mouth and and Lips; Bell's, or Facial Palsy: Note appearance of your mouth and lips in mirror with mouth closed. Then smile with and without show of teeth. Note your mouth appears normally symmetric at rest and, when smiling, the edges pull away equally to right and left. Asymmetry of mouth expression at rest or smiling may be sign of damage to the facial nerve at any point between its origin in the brain's cerebral cortex and its lower control center in brain or along course of left or right peripheral facial nerve as result of tumor, stroke, virus infection or surgical damage or trauma at birth. Sudden development of facial asymmetry in young and middle age adult is usually Bell’s palsy from virus infection of facial nerve. In older person, gradual development of asymmetry often goes unnoticed and may be sign of brain tumor or narrowing and obstruction of artery in brain area of facial muscle control. Sudden asymmetry in older person that is brief is one of many forms of Transient (brief, quick recovery) Ischemic Attack (TIA) warning of impending stroke on opposite side of brain from the muscle weakness source of the asymmetry. Both sides of face weakness or palsies suggest multiple sclerosis or Gullain-Barre Syndrome
The Numb Chin Sign is numbness of the chin (and lower lip) as a first sign of a previously unsuspected cancer of the breast, prostate or a multiple myeloma due to metastatic cancer infiltration of the mental nerve (the sensory nerve branch of cranial nerve V, to the chin).
5. Nose, Mouth, Lip, Tongue & Throat
The following descending column has the topics of chapter as they appear in text. 
Nasal Pain Spot 
Ulcer & Fissure on Lip and in Mouth
Blister of Lower Lip from inadvertent Burn
The Common Cold and Other Upper Respiratory Infection (URI)
my own recent two severe URI's
Sore Throat, Tonsils & Larynx
The larynx 
The Uvula, in allergic reaction
Dry Cough and Moist Cough
Avoiding Upper Respiratory Infection 
Voice Change

Nosebleed comes mostly from small area just inside each nostril on side of septum (central divider of nose). Pressing thumb firmly against side of nose from where bleed is coming (or, if not sure, closing off both nostrils by pinching between thumb and forefinger) will stop it. But just before applying pressure, go to WC and give a good nose blow. Then with ice water, rinse out mouth and clean off nose. From hereon, swallow all blood. (Your feces may show black for a day) After 15 minutes, relax the pressure gradually. Best position for stopping nosebleed is reclining. Even after a bleed stops, if you pick, poke or push nose it may restart. For a sneeze or cough, reapply nose pressure and open mouth wide before expelling air in sneeze. With repeated re-bleeding, go to emergency room. Most bleeds are slight, a few are bad, and a rare one, horrid. Victim gets into trouble due to panic, impatience or not knowing what to do. Tips: first, many do not realize the superficial location of the bleeding point and how it can be stopped by finger pressure; second, with nostrils closed one must depend on mouth breathing and thus should not talk; third, do not relax pressure too soon; and fourth, keep calm and do not get excited, because it raises blood pressure which may restart the bleeding. Twice I have noted nosebleed from eating sharp sauces like curry or mustard. It has been otherwise unprovoked and bright red, meaning capillary or small arterial. Probably due to vasodilating hypertension effect. If you are someone who is prone to bad nosebleeds best avoid these food condiments.
Nasal Pain Spot due to inflamed, infected point just inside nostril after a cold: Pain may be relieved quickly by application of fluocinolone acetonide 0.025% (Synalar) or 0.12% betamethasone corticosteroid ointment by cotton tip or your pinkie. Follow with antibacterial ointment (Some corticosteroid ointments are combined with antibiotic, eg, in Japan Rinderon VG). If skin over it appears reddened use a good oral antibiotic like Amoxicillin at chemoprophylactic single dose (3.5 gram). 
Ulcer & Fissure on Lip and in Mouth and on Tongue  At corner of mouth fissure it is often due to trauma (shaving, etc). Rarely may be due to B vitamin deficiency, in alcoholic. Fever blister on lips or in mouth or on tongue harbors herpes simplex virus, so, please, no kissing. Blister on lower lip is burn from chemical in pill or late-night table-reading lamp heat-touch. (See below) Use antibiotic ointment (Gentamicin best) before each eating. Painful ulcer of inner cheek opposite teeth and tongue is from toothbrush; healing helped by mouthwash of 1:1 hydrogen peroxide and water or Listerine antiseptic. 
Blister of Lower Lip from inadvertent Burn  The thin-skin lower lip can suffer burn at lower-than-usual burn-temperature. Thus, one may get lip burned and never have felt initial burn pain. This happens on lower lip to a nighttime reader who uses clip-on table lamp and, as he gets sleepy, tends to rest chin on lamp and his lower lip touches overly warm lamp guard for a second, and he does not note feeling of being burned but within 24 hours sees blister at midpoint of lower lip. Especially seen with opioid user due to raised pain threshold and somnolence. The blister bursts, scabs and after 10 days is healed. Gentamicin ointment before each eating speeds healing. 
The Common Cold and Other Upper Respiratory Infection  Seasonal in the U.S. between 1 Oct. and 31 March. Research suggests its main transmission is being near to another cold virus infection and getting virus on hands and then putting a hand to nose, eye or mouth. Preventive is to not get too close to others with colds, to repeatedly clean hands with antiseptic alcohol; and if you catch cold, to not subject others to contact your virus. Wearing a nose-face mask is good, but difficult for social life. And keep in mind if you travel from or to a far place or meet such a traveler, the risk of catching cold is high, from a virus you are not immune to. The common cold is a name for variously caused and types of upper respiratory virus infection. Very strictly speaking the common cold is a type caused by a specific virus and localized to nose and throat but commonly any URI that does not go lower into the lungs than the bronchial tree and that at least involves throat and nose qualifies as a cold.
The following is a description of my own recent two severe URI's. At that time the cold symptoms started with nose sensitivity and easy sneezing and quickly a drippy nose. At start there was a feeling of fever about the head although the body temperature did not go above 100 F (37.6 C). In a day, symptoms worsened to include a seized-up sore throat that hurt like daggers going in with every swallowing while congestion in nostrils and runny nose continued. My body also ached a bit. After 3 days, I lost voice. (Some cold sufferers will have hypersensitive larynx and throat and experience episodes of acute croup-like strangling brought on by eating or holding pills in mouth or just talking too much) No medicine relieved the cold well. Aspirin two adult dose (325 mg) pills worked partially after 15 minutes and lasted 1 or 2 hours. Warm to hot fluids or beverages were soothing. For loss of voice try honey several times a day and for the cough try a good suppressant like dextromethorpan when you very much do not wish to cough. Also avoid being close to powders or animal fur. If you develop yellow or colored discharge from nose, eyes or in sputum it means bacterial infection and 5 days ciprofloxacin (or similar floxacin antibiotic) 500 mg once a day should cure.
  The next cold started 13 March 2016 with a slight irritation cough I located in my left upper chest. By Monday and Tuesday it had spread to my throat and nose giving the exquisite dagger-like pain on swallowing typical of the epiglottitis (in the floor of the entrance to the throat) that accompanies most bad colds. And my cough had become moist and low-pitched and localized to left chest. Thursday, Friday and early Saturday symptoms were the worst and I even contemplated checking myself into a hospital. On Sunday it seemed slightly improved but the rest of the week it settled into a very irritating, tiring cough with almost every breath, worst on lying on back and somewhat relieved by lying on right side. (This is quite atypical for most common colds) By the Thursday of the 2nd week, it was so bad I consulted my doctor ready to be admitted to hospital. But the chest x-rays did not show pneumonia or other consolidation in lung; just an acute mild emphysema typical with continuing cough and my blood test showed no sign of body affect (no high white blood cell count, no elevated CRP) and the EKG was unchanged from my usual, ruling out pulmonary embolus. I was started on Levofloxacin 500 mg tab once a day and by, Saturday, 26 March I was just starting to notice improvement. Honey was very soothing for the pain. Note I had no fevers or muscle aches typical of the usual flu type viruses. (That year I did not get a flu shot) Also note that this recent cold in contrast to the first appeared to originate in the left upper main bronchus of the lung's left upper lobe so, strictly speaking, it was a bronchitis that blossomed into a cold. Had it gone the other way, down into my lung it might have ended up a pneumonia. It was the worst URI I've ever experienced and, at age 83 then, very, very worrisome at its worst. From this experience I draw a conclusion that old persons (over 65) or those with other chronic illnesses should get a yearly flu shot, seek good medical care and blood test earlier in the course of the illness than I did.
Sore Throat, Tonsils & Larynx:  The tonsils are lymph-gland tissue that form a ring behind the nostril inner openings, the back of mouth, and the upper throat. Lingual tonsils surround back of tongue; palatine tonsils can be seen back of throat alongside and are what most persons mean by tonsils. The pharyngeal tonsils are popularly known as adenoids and located out of sight high in rear of nasal canal. Enlarged adenoids block nose-breathing and cause a child to have the open-mouth adenoid look and the adenoid voice. Hearing may also be impaired because of blocked middle ear tube entrance to pharynx. Enlarged palatine tonsils are common and easily seen in many throat infections. The tonsil ring normally is quiescent and not enlarged before age 2; then,enlarging, sometimes much, between ages 3 and 12; and gradually becoming smaller. In adult, the palatine tonsils should not be obvious on deep throat inspection. If, looking in a throat, you see enlarged, reddened pharyngeal tonsils especially when they are covered with white spots, it is ‘exudative tonsillitis’, frequently due to Epstein-Barr virus (EBV) of infectious mononucleosis. (Mono; aka "the Kissing Disease" ); the symptoms of infectious mono are severe sore throat, fever, body ache & lethargy and rash appearing with or after the fever; it can only be differentiated from bad cold or flu by the rash, and a blood test makes the diagnosis. The spots may be also due to beta-hemolytic streptococcus infection. Infectious mono is diagnosed by a Mono spot test that most doctors can do. It is important to quickly diagnose the tonsillitis in child and adolescent because the streptococcus type can cause serious kidney, heart and other complication, and is cured quickly by penicillin-type antibiotic, while Mono is not cured by antibiotic and treatment by Amoxicillin may cause cosmetically unpleasant red rash.When tonsillectomy is advised, get an HMO university-based oral/throat second opinion and go slow. Usually not needed. 
The larynx  is the voice box and located where the throat connects into the trachea. It is often affected more or less by sore throat. When it is more affected you get hoarse or lose voice and get typical strangling cough paroxysms brought on by food particles from eating or pill particles from medicines. Other than locating the anatomy, laryngitis does not suggest a specific diagnosis - it can be from virus, bacteria or allergy/hypersensitivity.
The Uvula, in allergic reaction, may swell markedly making one feel as if a piece of meat got stuck in throat. Well-lit examination of throat, using mirror, will show swollen hanging-from-rear-of-palate piece of flesh exactly in the mid line from upper arch of throat. If it is part of acute swelling of lip and face, get to emergency since breathing may become obstructed. 
Dry Cough and Moist Cough follows a cold or a flu, or sometimes comes out of the blue, and can last months. (One of mine lasted 2 months) It may cause unnecessary medical visit, chest x-ray and antibiotic expense, worsen or cause a hernia, crack a rib or two with much pain after or, in worst case, rarely break a blood vessel in brain. It may give an itchy sensation in back of throat that forces need to cough. Worse in company, when exercising or after eating, or taking medicine in mouth, or when lying down, it is relieved temporarily by cough suppressant like Dextromethorphan (DXM pill best, and hold in back of mouth to numb the area). Gargle with warm water after eating; avoid smoke and smoker, outdoor exercise, cold air or powders and do not chew pills or keep pills in mouth.
        Particularly coughs that come on when lying down or in certain positions suggest a location for the source in the upper bronchial tubes on one side or the other. You may discover that the cough is very bad when you lie flat on your back but is completely relieved when you lie on one side or the other. That's useful to get to sleep and also suggests it needs a chest x-ray. Another observation is that medications that cause a dry mouth (anti-cholinergic, depression or anti-histamine medicines) will relieve the cough which means it's due to excessive secretion in the bronchial tube.
Moist cough shows sputum and tends to be low-pitched accompanied by localized chest soreness. It needs quick M.D. consultation and chest x-ray.
Avoiding Upper Respiratory Infection (URI)  Mouth-entry infection; first principle is keep mouth shut. Upper Respiratory Infection is usually an Oct. to March infection but avoid crowd of coughers and sneezers. Avoid kids, avoid unnecessary hugs and kissing and use good antiseptic throat wash/gargle. If you are an international traveler or come in contact with one, be aware of high risk of a traveler picking up or transferring a cold virus to someone who has low immunity due to being overseas. So the traveler can catch or give a cold in or out of season and more precautions are in order. Follow general principles of avoiding upper respiratory infection: Wash Hands! Wash Hands! Wash Hands! Do not touch others and keep a decent distance. 
Voice Change A changing, hoarse voice not due to infection may be start of larynx tumor. A curiosity is the aging voice, usually starting after age 85 which is vibrato, low pitch, and tending toward whispery inaudibility. The aging voice is due to shrinkage of tissue. I do not know how to prevent it. Singers seem to get it more often. The American comedienne, Joan Rivers recently died getting medical test for her aging voice.
 END OF SECTION. To read on next, now, click 5.(6-7) Headache & Migraine and Fever

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