MAYO CLINIC HEALTH LETTER Tools for Healthier Lives VOLUME 28 NUMBER 10 OCTOBER 2010
Inside this issue HEALTH TIPS . . . . . . . . . . . . . 3 First-aid kits. NEWS AND OUR VIEWS . . . . 4 New treatment option for Dupuytren’s contracture. Personal music listening devices and hearing loss. DIABETES AND BLOOD GLUCOSE . . . . . . . . . . . . . . 4 Advances in measuring devices. SCROTAL LUMPS AND SWELLING . . . . . . . . . . 6 In older men, usually not cancer. PAIN ‘RED FLAGS’ . . . . . . . . 7 Recognizing the signs. SECOND OPINION . . . . . . . . 8
Coming in November ROTATOR CUFF INJURY Quieting a painful shoulder. IRON DEFICIENCY Causes determine treatment. FISH ON YOUR DISH The heart of the matter JET LAG Reducing its effects.
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Dysphagia The trouble with swallowing Pop some food in your mouth, chew and swallow — you’ve done it countless times. Lately, though, when you swallow, things don’t always travel downward as smoothly as in the past. You’ve noticed that what you’re swallowing increasingly seems to get hung up about halfway down to your stomach. If you stop eating for a minute, it passes. The medical term for difficulty swallowing is dysphagia. Occasional difficulty swallowing isn’t necessarily a cause for concern. For instance, it may just be a problem of eating too fast or not taking time to chew food properly. But, if it’s persistent, dysphagia may be connected to a serious medical condition that requires treatment.
to your stomach (esophagus). At the same time, this reflex prevents what’s being swallowed from entering your windpipe (trachea). At the top and bottom of the esophagus are circular bands of muscles (sphincters). These act like gatekeepers, opening and then closing as they allow food to enter the esophagus and finally pass through into your stomach. Muscles in the wall of your esophagus contract in sequence, helping to push food toward your stomach. Dysphagia occurs when something goes wrong at any stage of the swallowing process from the mouth on down, and it can develop at any age. Any condition that weakens or
The art of swallowing
When all is working right, the process of swallowing involves about 50 pairs of muscles and nerves all working in concert to move what’s in your mouth to your stomach. As you chew, your tongue moves food and liquids around and saliva is added. When you’re ready to swallow, your tongue triggers the swallow reflex by pushing everything to the back of your throat (pharynx) and into the top of the tube connected
Esophageal narrowing (stricture) can result in food getting caught in the esophagus.
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damages the muscles and nerves involved in swallowing may cause dysphagia. Signs and symptoms may include pain while swallowing, difficulty starting to swallow, the sensation of food being stuck in your throat or chest, drooling, regurgitating food, and coughing or gagging while swallowing.
Where’s the hang up?
The two most common forms of dysphagia are: Oropharyngeal dysphagia — This type of dysphagia is due to problems related to nerves and muscles that can weaken the mouth and throat muscles. As a result, you may experience difficulty chewing foods, starting the swallowing process, and moving food and liquid from your mouth into your throat and esophagus. In the midst of trying to swallow, you may choke, gag or cough. Liquids or food particles may come back up through your nose, or you may feel like the food or liquid is entering your trachea. Causes of oropharyngeal dysphagia include: ■ Sudden neurological or mus cle damage — Weakened throat muscles may be caused by neurological damage, such as stroke or spinal cord injury, or by damage to muscles caused by inflammation. ■ Progressive neurological dis orders — The difficulty with swallowing may be due to neurological disorders, such as Parkinson’s disease, multiple sclerosis and amyotrophic lateral sclerosis (ALS). ■ Certain cancers — Treatment for cancers of the mouth and throat, including surgery, radiation or chemotherapy, often affect swallowing. ■ Zenker’s diverticulum — This is a small pouch that forms at the back of the throat, usually just above the esophagus. It may trap food, resulting in regurgitation of food or gurgling after eating.
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Esophageal dysphagia — This type of dysphagia occurs after you begin swallowing. Typically, you have the sensation of food or liquid sticking or getting hung up in the base of your throat or chest before it makes it to your stomach. Pain with swallowing may suggest irritation or inflammation caused by certain infections. Among causes for esophageal dysphagia are: ■ Gastroesophageal reflux dis ease (GERD) causing esophagitis — Esophageal tissue is damaged from stomach acid backing up (refluxing) into the esophagus. This can lead to spasm or scarring and narrowing in the lower esophagus, which makes swallowing difficult. ■ Esophageal narrowing (stric ture) — This may be due to scar tissue that’s often related to GERD, cancerous or noncancerous esophageal tumors, or radiation therapy. This can result in large chunks of food getting caught in the esophagus. ■ Nonrelaxing esophageal sphinc ter (achalasia) — With this, food has trouble entering your stomach due to failure of the lower esophageal muscle (sphincter) to relax properly. Often, muscles in the esophageal wall also are weak. The result may be regurgitation of food not yet mixed with stomach contents. ■ Esophageal ring — A narrowing in the lower esophagus may cause intermittent difficulty swallowing solid foods and large pills. ■ Eosinophilic esophagitis — This condition causes difficulty swallowing solid foods because of an overpopulation of cells called eosinophils in the esophagus. Often, no cause is identified.
the muscle strength and coordination needed to push food into your stomach — rarely produce symptoms. However, any persistent trouble swallowing needs to be evaluated by a doctor. Left unchecked, swallowing difficulties may put you at risk of not getting enough food and fluids to be adequately nourished. If food or liquid enters your airway (aspiration) due to swallowing trouble, you also may be at risk of respiratory problems — such as pneumonia — or upper respiratory infections. It’s important to keep your mouth clean by regularly brushing your teeth to minimize the growth of bacteria that may be aspirated. To diagnose the cause of dysphagia, your doctor may use one or more of the following tests to get an up-close look at what happens when you swallow:
Getting to the cause
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Although dysphagia is frequently encountered among older adults, dysphagia isn’t considered a normal part of aging. Normal changes with aging — such as a loss in some of
October 2010
MAYO CLINIC HEALTH LETTER Managing Editor Aleta Capelle
Medical Editor Robert Sheeler, M.D.
Associate Editors Carol Gunderson Joey Keillor
Associate Medical Editor Amindra Arora, M.D.
Medical Illustration Michael King Customer Service Manager Ann Allen
Editorial Research Deirdre Herman Proofreading Miranda Attlesey Donna Hanson Administrative Assistant Deborah Adler
EDITORIAL BOARD Shreyasee Amin, M.D., Rheumatology; Amindra Arora, M.D., Gastroenterology and Hepatology; Brent Bauer, M.D., Internal Medicine; Julie Bjoraker, M.D., Internal Medicine; Lisa Buss Preszler, Pharm.D., Pharmacy; Bart Clarke, M.D., Endocrinology and Me tabolism; William Cliby, M.D., Gynecologic Surgery; Diane Dahm, M.D., Orthopedics; Mark Davis, M.D., Dermatology; Timothy Hobday, M.D., Oncology; Lois Krahn, M.D., Psychiatry; Amy Krambeck, M.D., Urology; Suzanne Norby, M.D., Nephrology; Robert Sheeler, M.D., Family Medicine; Phillip Sheridan, D.D.S., Periodontics; Peter Southorn, M.D., Anes thesiology; Ronald Swee, M.D., Radiology; Farris Timimi, M.D., Cardiology; Aleta Capelle, Health Information. Ex officio: Carol Gunderson, Joey Keillor.
Managing swallowing challenges after stroke Rehabilitation in the aftermath of a stroke can be multifaceted, depending on what areas of the body have been affected. It’s not uncommon for stroke rehabilitation to include therapy directed at swallowing difficulties. Typically, a speech-language pathologist is involved in evaluating your ability to swallow and determining whether it’s safe for you to eat by mouth. Depending on your situation, some food consistencies — such as thicker liquids and pureed foods — may be more easily swallowed than others. After it has been determined which consistencies are easiest and safest for you to swallow, a dietitian can help you plan meals to meet your nutritional and hydration needs. Making adjustments in your posture or repositioning your body while eating also may be helpful. Individualized techniques — such as sitting up straight, tucking your chin and turning your head — may make it easier to swallow. In addition, targeted exercises to strengthen the swallowing muscles may be taught by your therapist. ■ Barium swallow X-ray — For this test, you drink a barium solution, which coats your esophagus and makes it show up better on Xrays. Changes in the shape of your esophagus and muscular activity can be viewed. The radiologist may have you swallow a pill made of barium in order to look for subtle blockages in your esophagus. ■ Videofluoroscopic swallow ing study (VFSS) — During this X-ray study, a radiologist and a speech-language pathologist evaluate your swallowing as you swallow a variety of liquids and foods. ■ Endoscopy — A thin, flexible, lighted scope (endoscope) is passed down your throat in order to view your esophagus. Most people choose to be sedated during this procedure. ■ Fiber optic endoscopic eval uation of swallowing (FEES) — In order to see what’s going on when you swallow, your doctor may place a small lighted tube (flexible laryngoscope) in your nose so your throat and airway can be observed as you drink liquids and eat food. ■ Manometry (muh-NOM-uhtree) — With this, a small tube is inserted into your esophagus and
connected to a pressure recorder. Then, as you swallow, it measures the muscle contractions of your throat and esophagus.
Tailoring treatment
The cause of dysphagia determines the treatment plan. Oropharyngeal dysphagia may mean a referral to a throat specialist or neurologist for additional testing. A speech-language pathologist may work with you on exercises to better coordinate the muscles you use when you swallow. You may learn techniques for better food placement in your mouth or ways to position your body and head to better assist in swallowing. Treatments for a narrowed esophagus or achalasia may involve tissue stretching (dilation) using an endoscope and an attached special balloon. In the case of a tumor or diverticulum in the pharynx or esophagus, surgery may be performed to clear the esophageal path. If the problem is related to GERD, it may be treated with prescription oral medications to help reduce stomach acid, possibly for an extended period of time. ❒ October 2010
Health tips First aid kits Be prepared for illness or injury at home with a first aid kit that includes items to treat: ■ Cuts and burns — Have an antiseptic solution such as Hibiclens or Betadine to clean wounds and a cream or ointment such as Vaseline to prevent infection. Include bandages of various sizes, gauze and adhesive tape. ■ Aches, pain and fever — Include acetaminophen (Tylenol, others) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, Naprosyn, others). ■ Eye injuries — A sterile eyewash and rinse cup can help get something out of your eye. ■ Insect bites and stings — An instant cold pack can help reduce pain and swelling. Hydrocortisone cream can relieve itching. An oral antihistamine may help swelling and itching. ■ Common conditions — Keep on hand anti-diarrheals such as loperamide (Imodium), antacids such as short-acting Tums or Maalox or longer acting famotidine (Pepcid) or ranitidine (Zantac). Aspirin can be a lifesaver if you experience chest pain and are seeking emergency care because you suspect you might be having a heart attack. Also include a sharp scissors, cotton swabs, cotton balls, tissues, hand sanitizer, antiseptic towelettes, tweezers and disposable surgical gloves. ❒ www.HealthLetter.MayoClinic.com
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News and our views New treatment option for Dupuytren’s contracture The Food and Drug Administration recently approved the first drug — an injectable enzyme — for treatment of the cord-thickening hand disease Dupuytren’s contracture. The progressive disease thickens the connective tissue under the palm’s skin. Knots of tissue and tendon thickening in the palm can pull one or more fingers into a bent position. Over time, Dupuytren’s contracture can dramatically impair hand function. The new drug — collagenase clostridium histolyticum (Xiaflex) — softens and weakens the cord that holds a bent finger in place. It may be injected up to three different times at four-week intervals. The day after injecting a thickened cord, your doctor will manipulate your hand in an attempt to break or release the cord and straighten your finger. A local anesthesic may be required during the injection and when the hand is manipulated the next day. Treatment choices for Dupuytren’s contracture before release of the new injection included either surgically removing the thickened cords or puncturing and “breaking” the cords using a needle inserted through the skin to perform a needling technique. Although surgery generally allows for more complete release of the joint, there’s a more complex recovery period. Another advantage of surgery and also the needling technique is that all affected areas can be treated at once. The drug is used on one area at a time. With the injection, there’s typically some pain and swelling for several days. However, the chance Dupuytren’s contracture will recur is probably somewhat lower than when needling is done. Mayo Clinic orthopedists note that treatment of Dupuytren’s contracture depends on the severity of your symptoms and your overall health. For now, use of the injectable enzyme may be appropriate if surgery has been ruled out and if the needle procedure isn’t possible due to the size and location of the diseased area. ❒
Personal music listening devices and hearing loss It seems as if your grandson is always listening to music on his iPod or MP3 player. Won’t this wreck his hearing? Not necessarily. According to an article in the May 2010 issue of Hearing Review, volume and duration of listening time are the two factors that affect hearing safety when assessing the risks associated with using personal music devices such as these. At maximum volume, iPods or MP3 players are capable of causing permanent hearing damage over time. The volume-duration recommendations in the article suggest these devices may be used for: ■ About 90 minutes at 80 percent of volume ■ Unlimited amounts at less than 60 percent of volume Be aware of pitfalls, including turning the volume up because there’s a lot of background noise or adjusting the volume upward over time because you have become accustomed to that volume. ❒
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October 2010
Diabetes and blood glucose Advances in measuring devices For many with diabetes, the task of pricking a finger in order to measure blood sugar (glucose) levels may be a tolerable annoyance at best — and for some it may even be a source of anxiety and fear. Isn’t there a better way? So far, the answer is yes and no. Advances in the finger-stick method have made this process much easier and less painful than in the past. In addition, several fairly reliable home glucose monitoring devices and approaches have been developed that may allow you to avoid some — but not all — finger sticks. With a little know-how and the use of an appropriate device, most people find that monitoring their blood glucose doesn’t need to be all that painful or difficult, and with practice, it can become just another routine.
Why test?
Monitoring the levels of glucose in your bloodstream is a cornerstone of keeping your diabetes under control. Testing your blood glucose is the only reliable way to know whether your blood sugar levels are drifting outside of the desirable range, or even to dangerously high or low levels. Monitoring blood glucose levels provides critical information about how exercise, food, medications, stress and many other factors affect your blood glucose. If you have type 1 diabetes, your doctor will likely recommend testing your blood glucose at least three or four times a day. If you have type 2 diabetes and take insulin, your doctor will likely rec-
Devices
How they work
Considerations
Alternative site monitors
These allow you to take blood samples from areas likely to be less sensitive than your finger, such as your arm, abdomen or thigh.
Because blood flow to alternate test sites isn’t as robust as in the fingertips, these aren’t as accurate as fingertip samples when blood sugar level is rising quickly after eating or falling quickly in response to insulin or exercise.
Continuous glucose testing devices
These use a sensor placed under your skin to measure blood sugar level. The devices transmit readings to a small recording device worn on your body. An alarm sounds if your blood sugar level becomes too low or too high.
These are expensive and may require the sensor to be replaced every few days. You still must confirm blood sugar level readings several times a day with a traditional monitor for calibration of the glucose sensor, dosing for insulin or treating low blood sugar.
New tools
ommend testing at least daily, and probably more often. If you have type 2 diabetes and don’t take insulin, the amount of testing your doctor recommends may vary.
Advanced devices, old way
The most commonly used blood glucose testing devices involve three main components, including: ■ A lancet and lancing device — A lancet is a small needle that pricks the skin on your finger so that you can draw a drop of blood. Lancets are very fine and are coated with silicone, which helps to reduce the discomfort of a finger stick. A lancing device holds the lancet. Spring-loaded lancing devices are generally less painful than are other types. Lancing devices can be set to different prick depths, so you can minimize the depth the lancet needs to go into your skin. ■ A blood glucose meter or monitor — This is a small, computerized device that measures and displays your blood glucose level. Some meters are easier to use than are others. There are meters that are large with test strips that are easier to handle and meters that are compact and easier to carry. If you have impaired vision, you can buy a meter with a large screen or a “talking” meter that announces the results. Some meters display a single result that you must enter into a
A blood glucose meter measures and displays your blood glucose level.
logbook for long-term tracking. Some meters can save test results for you, and some offer the ability to download your blood glucose readings to a computer and email the test results to your doctor. ■ Test strips — One end of these chemically treated strips is inserted into your blood glucose meter. On the other end, you put blood from your finger stick. The test strip feeds information about the chemical composition of your blood into the meter, allowing it to produce a blood glucose value. Test strips are used once and thrown away, often making the ongoing cost of buying test strips the most expensive part of blood glucose testing. Be sure the strips you buy are compatible with your monitor. October 2010
No new home blood glucose measuring device will allow you to totally avoid using a finger stick. However, the devices listed in the table above may provide some additional glucose testing options. Many new technologies for testing blood glucose at home are in development — although none is on the market in the United States. One such device is an infrared light monitor that uses a beam of light to penetrate the skin and measure your blood sugar level. Even if this device or another device were to be approved for use in the U.S., it probably wouldn’t totally replace the need for finger-stick testing.
For best results
Whichever blood glucose monitoring device you use, work with your doctor or diabetes educator to make sure you understand how to properly use and maintain the device. Have him or her watch you perform a test on yourself to look for potential problems. Periodically verify that your glucose monitor and test strips are working properly by using a liquid control solution instead of blood. Bring your home glucose monitor with you to doctor appointments so that you can compare the results of your home meter against the results of a laboratory test. ❒ www.HealthLetter.MayoClinic.com
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Scrotal lumps and swelling
With pain in the picture
In older men, usually not cancer Lately, you’ve noticed a lump within the pouch of skin (scrotum) that holds your testicles. It doesn’t hurt, but concern about cancer prompted you to make a doctor appointment right away. Seeking care for a lump or swelling within your scrotum or near your testicles is a good call. But for older men, it’s not necessarily cancer. It’s uncommon for men over 40 to develop testicular cancer — and even more rare in men over 65. However, numerous other problems can cause scrotal lumps (masses). A lump or swelling may not be painful or cause harm — or need to be treated — but a diagnosis is still important. Pain in the scrotum area with or without a scrotal mass can be serious.
A mass, but no pain
Diagnosing the cause of a scrotal mass often can be done based on the signs and symptoms it’s causing and the location and feel of the mass. Additional visualization is usually done with ultrasound imaging, and by viewing the mass while shining a bright light through the scrotum (transillumination). Urine or blood tests may be done to test for a bacterial or viral infection. Causes of relatively painless lumps may include: ■ Varicocele — This is an enlargement of the veins that carry oxygen-depleted blood away from scrotal tissues. Most varicoceles occur on the left side of the scrotum. Less commonly, they occur on both sides. They may not cause symptoms and often don’t require treatment. When a varicocele causes symptoms, they’re usually felt as a dull
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ache in the scrotum that’s more noticeable when standing and goes away when lying down. Treatment of problem varicoceles typically involves sealing off the enlarged veins with a minimally invasive surgical procedure. ■ Hydrocele — This occurs when fluid accumulates within the tissue layers that surround the testicle (tunica vaginalis). Typically, hydroceles begin small and fill slowly over time. They’re usually harmless with painless swelling their only sign. However, they can become quite large and tense, leading to discomfort and making it difficult for your doctor to examine your scrotum for other problems. Treatment of a problematic hydrocele involves surgical removal of the tunica vaginalis. Draining the hydrocele won’t work, as it will quickly refill. ■ Spermatocele — This is a fluidfilled bulge (cyst) that occurs on an area of tissue (epididymis) at the top of the testicle that stores and transports sperm. Surgical removal of the cyst isn’t necessary unless it becomes bothersome. ■ Testicular cancer — Although rare, testicular cancer can occur in older men, usually as a painless lump on the testicle that may be accompanied by a dull ache or sense of heaviness of the scrotum. October 2010
A painful scrotum typically signals the need for emergency care, as certain causes of pain can begin causing permanent tissue damage within hours of the start of pain. A painful scrotum may indicate: ■ Inflammation of the epididy mis (epididymitis) — This is typically caused by a bacterial infection. In older men, the infection often stems from a urinary tract infection, a recent urologic procedure or the obstruction of normal urine flow, which can occur if you have an enlarged prostate gland. Depending on the cause, an antibiotic usually clears the infection. ■ Testicle inflammation (orchitis) — The virus that causes mumps is often the cause of this painful inflammation and swelling of the testicles. If the cause is viral, treatment centers on pain management as the infection runs its course. ■ Inguinal hernia — A portion of the small intestine can push through an opening or weak spot in the tissue separating the abdomen and groin, and enter the scrotum. This can cause a swollen or enlarged scrotum. You may experience varying levels of pain, ranging from discomfort or sharp pain while straining or exercising to sudden and severe pain that worsens rapidly. Inguinal hernias that cause symptoms usually can be repaired surgically. ■ Testicular torsion — Although extremely rare in older adults, this occurs when the spermatic cord — which consists of blood vessels that serve the testicles and the tube (vas deferens) that transports sperm — becomes twisted, cutting off blood supply. Testicle tissue begins to die within about six hours if blood flow isn’t restored. Surgery is often necessary to properly untwist the cord. The pain of testicular torsion may be less severe in older adults, but urgent treatment is still warranted. ❒
Pain ‘red flags’ Recognizing the signs You’ve dealt with low back pain for years. Generally, doing your prescribed exercises results in less pain. But now, even though you’ve followed your exercise plan, your back has become progressively more painful in the last few weeks. You’ve been sleeping in a recliner to try to get relief, and you’re having some numbness in one of your legs. Is it time to call your doctor? Medical “red flags” related to changes in pain — or certain signs and symptoms that occur along with pain — may signal a serious underlying condition or a need for prompt medical attention. Being alert to these red flags and seeking timely medical care may help you avoid a more serious problem.
Acute vs. chronic pain
There are two major categories of pain: ■ Acute pain — This type generally accompanies illness, injury or surgery. It’s triggered by tissue damage and actually protects you from further injury because you automatically pull away from the source of your pain. Typically with acute pain, you know exactly where it hurts. A toothache from a cavity and pain from a surgical incision are examples of acute pain. Generally, the pain fades away with time and treatment of the underlying cause. ■ Chronic pain — Pain that lasts six months or longer is generally considered chronic. Chronic pain may be due to a chronic condition, such as the painful joint inflammation associated with arthritis, or the tingling pain of peripheral neuropathy, a nerve-related condition that most often affects
Know when it’s an emergency Some pain signals the need for immediate medical attention. Seek emergency medical care if you experience: Sudden or severe pain Pain or pressure in your chest or upper abdominal area A sudden severe head ache or a change in vision Difficulty breathing or shortness of breath Fainting, sudden dizzi ness or weakness Severe or persistent vomiting or diarrhea Coughing or vomiting blood Uncontrolled bleeding Difficulty speaking Confusion or changes in mental status the hands and feet. It may stem from nerve damage due to an accident, infection, surgery or tumor. For some with chronic pain, the cause isn’t well understood. There may be no evidence of disease or damage to tissues. This type of pain may remain after the original injury shows every indication of being healed.
A change in character
Whether pain is acute or chronic, a change in its character — for instance, your pain escalates from mild to severe, or new symptoms develop, such as tingling or numbness — is a noteworthy development. Generally, pain that changes significantly in nature warrants re-evaluation by a doctor. Consider the common complaint of back pain, which many people encounter at some point in their lives. Lingering back pain may stem from a variety of causes, including October 2010
muscle strain and spasm, poor body mechanics, physical deconditioning, spinal changes such as a herniated disk, and degenerative diseases such as osteoarthritis. Occasionally, though, the possibility of a more serious — and sometimes even lifethreatening — medical condition is behind a change in signs and symptoms associated with back pain. In the case of low back pain, among the red flags signaling a need for further evaluation are: ■ Fever, chills or night sweats ■ Unexplained weight loss ■ Pain that isn’t relieved with rest ■ Pain that awakens you at night ■ Pain that persists despite movement or changing positions ■ Pain, numbness or weakness in one or both legs ■ Inability to empty your bladder ■ Bowel or bladder incontinence Signs and symptoms such as these may indicate the presence of undiagnosed: ■ Infection ■ Vertebral compression fracture — often from osteoporosis ■ Spinal cord or nerve root compression ■ Kidney stone ■ Abdominal aortic aneurysm ■ Cancer of the spine ■ Tumors that start in another location and spread to the spine, particularly prostate, breast and lung cancers
Timely intervention
Whether or not you live with chronic pain, your body constantly informs you of its needs. Some messages are more urgent than others. Take note of changes related to pain. Even if chronic pain is part of your day-to-day experience, don’t assume that a noticeable change for the worse is to be expected. Instead, make a point to talk with your doctor about it. ❒ www.HealthLetter.MayoClinic.com
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Second opinion Questions and our answers Q: My doctor drained a sebaceous
cyst that was on my neck. Now, my doctor is suggesting that I also consider having it surgically removed. Why?
A: A sebaceous or epidermoid cyst is a bump that develops just below the skin surface, most commonly on the face, neck or trunk. Cysts can be as small as a pea or as large as a golf ball. Unless they become infected, they’re usually not painful or bothersome. If a cyst becomes infected, it increases in size, becomes tender and some pus may drain from it. Your doctor can make an incision in the cyst and drain it, which will temporarily relieve these signs and symptoms. Your doctor may also prescribe an oral antibiotic. However, if the cyst wall remains in place, the cyst typically returns. Permanent removal of an epidermoid cyst typically requires a surgical procedure. This is usually done through an incision. Stitches are often needed. The size of the incision and subsequent scar will depend on the size of the cyst. Unfortunately, there’s no known way to prevent epidermoid cysts. However, you can reduce your risk of infection and scarring by resisting the urge to pop or drain a cyst on your own. ❒ Q: Recently, my lower eyelid did
this brief, twitchy thing. It felt like very quick, tiny quiverings under Copyright
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the skin. By the time I got to a mirror to see if it was noticeable, it had stopped. What causes this?
A: Tiny, involuntary eyelid twitches that are short-lived are common and usually considered harmless. Sometimes, intermittent twitching recurs over a few days and may be associated with fatigue, lack of sleep, stress and physical exertion. Excessive caffeine consumption also may be a factor. Occasionally, harmless intermittent eyelid twitching persists off and on over several weeks or even a few months. Very rarely, a twitching eyelid is a symptom of muscle or nerve disease — such as benign essential blepharospasm, in which involuntary spasms result in eye closure. Eyelid twitching associated with muscle or nerve disease almost always occurs along with other signs and symptoms associated with the underlying cause. If the twitching forces your eyelid to close or spreads to other parts of your face, make an appointment with your doctor. ❒ Q: I’ve had some stool leakage problems that have resulted in a lot of stained undergarments and very annoying bouts of anal itching. However, anti-diarrheal medications don’t do anything to stop it. Is there anything else I can try? A: Talk to your doctor. Stool leakage can be a sign of incontinence — but it can also be a sign of constipation. If you have a history of
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constipation including frequent bowel movements that feel incomplete, you may be at risk of fecal impaction. Fecal impaction is when a hard mass of stool is lodged in the rectum and can’t be pushed out naturally. Impacted stool may partially block the rectum, allowing looser stool to leak around the edges and soil your undergarments. This may appear to be incontinence, and if wrongly diagnosed as incontinence only, and treated with antidiarrheal medications, these may worsen the situation. Removing fecal impaction often involves softening the impaction with a laxative taken by mouth or by enema. Once softened, the stool may pass or your doctor may be able to break up the impaction with a gloved, lubricated finger. Develop a plan with your doctor to address the constipation issues that may have caused fecal impaction to develop. ❒ Have a question or comment? We appreciate every letter sent to Second Opinion but cannot publish an answer to each question or respond to requests for consultation on individual medical conditions. Editorial comments can be directed to: Managing Editor, Mayo Clinic Health Letter, 200 First St. SW, Rochester, MN 55905, or send email to
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October 2010
