How do people raise kids in the West and in the East.


When I talked to Alice her son James was not home. I inquired about him and I came to know that as he is 19 now he was uncomfortable living with his mother so he has gone to another city in USA for work and lives there. She also added that he now has a girl friend and is happy. After talking to many other parents and reading I realized that after turning 18, it is some sort of a sin to live with parents in the West (America, Europe, Canada etc).

Aslam is now 32 and lives with his parents in Lahore, Pakistan. He is married with two kids. His wife has differences with in-laws but she doesn’t want to live alone either. Millions of boys are living like this in Asia. I don’t include girls as they get married and live with their respective in-laws.

I remember a young girl about 25, in USA who writes a blog regularly and who in her introduction says that her widowed mother has re-married, her sisters and brothers are all married and since she has a chronic illness and lives with her family, she is the only one not getting laid. Apparently getting laid is a big problem in the West. Not that in Asia and the East in general young don’t want sex but its contained within the norms of family, faith and society.

By writing these lines its not intended to prove which group of parents is doing good and which region has lousy parenthood practices.  Both West and East has good and bad points when it comes to rearing the young ones.

In most of the Asian, African and middle Eastern countries poverty plays an important role in child rearing customs. With poverty I mean not having a house or residential place of ones own, no means of transportation, not enough food and abject illiteracy. The corruption in third world countries led to some families of ruling elite get their kids (and grand kids) quality education and top jobs in the West or in countries of their origin. It is common to hear that in Asia, Africa and middle East somebody has ruled for more than 25 or 35 years while it is unheard of in the developed world where democracy has strong roots and people at the helm of affairs are held responsible and punished if an irregularity is seen. The result is that in most countries of the East there is no long term planning in educational fields and the children are not given education which in turn makes the future generations also poor. Their parents are too busy making two ends meet and they prefer to have two working hands instead of a college degree after a long unproductive time. Having educated parents like in the West plays an important role in rearing the young ones. The parents of the developed world are (almost) all educated and read a lot when a child is born in the family. They know the do’s and don’t s of the parenthood. They know when to seek help when needed. When a child falls ill, they take him to the doctor. In poor countries or so called developing nations the average parents are not educated. They trust in centuries old practice of taking care of kids. There is hardly any role of emotional well being of a child. Instead the father or the father figure in the family is supposed to be the strict-at-all-times while the mother is the giver of everything from food to well being of the child.

In most of the poor countries religion and ritualistic practices are all the stuff parents are equipped with. When a young ones falls ill, there is no health care facility near them. So they are forced to depend on the local hakim (a quack who has been trained in the field of medicine through ages of accumulated knowledge) or a 10th grade so-called doctor who only knows the names of Aspirin and a few antibiotics. Steroids are given in every minor illness even. Its a miracle that children in these countries survive. Please note that the infant and maternal mortality rates are highest in these countries.

In Asian and other countries parents provide a very strong financial and emotional hard shell to their young ones. No matter what age they reach, they know they have parents at home and family around them which will always take their side. When Aslam was 18 he took admission in a university for his masters class. After post graduation he got a decent job and then they married him. Not for a single day he thought he can live without them. Nor his parents ever wish that their son live separately. Here is a very prominent difference between the two child rearing customs. We can argue that in developed countries children are given freedom but we should not forget that children in the West later develop depression frequently and suicide rate is much higher than in the poor countries.

Not only the children live with their parents for their lifetime but they in turn take care of them when they grow old and its not considered an unpleasant duty. They do it with all their heart. Perhaps that is the reason that there are hardly any old people homes or nursing homes in these cultures.







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Ten (10) characteristics of empty men and women.

We are all empty at times. Being empty is not derogatory at all and does not mean you are not useful. Useful to yourself and to others. Emptiness simply means scarce use of or no upper story. Of course these men and women have an (almost) fully developed brain inside their heads which is measured in grams like everyone of us have this mass of protoplasm. But is brain just another measurement like temperature and weight which can be gauged by means of tools? After all brain is much more than a few grams of tissue and we need to fill it with our experiences. It however depends greatly what are those experiences and how deep is our yearning for learning. Education does play an important part in its growth. Empty people fill it with very shallow and superficial stuff and then claim they have a ‘know it all’ brain. That is where things get askew.


1. Empty people are mostly concerned about themselves only. They start the conversation with “I or me” and end it at the same note. During talking they hardly ever think about the content. They ride on impulses and therefore whatever they talk about is mostly gibberish and lacks in solid content.


2. They have very selective memories. Their past is full of insignificant (not for them) and random learning processes. For example if in grade 6 their colleague told them that she has seen pigeons pooping on a window sill, they will repeat it after doing graduation at any random point and leave the listener bewildered about its reference. Element of suddenness is the hall mark of their talk.

3. They are mostly concerned about their shoes and clothes. Hours or even days are short when it comes to their choice and description of these items. They firmly believe if something goes wrong with these things, life will stop but for others. They will continue to flourish however. In this choice of clothes and shoes they give all the importance to the newness of the fashion market. They, somehow, must grab every new fashion regardless of the fact that they can afford it or not.

4. They don’t know how to speak softly. Always loud, they firmly believe that the pitch of their voice is a big argument in itself. In a sedate environment it is quite often that the only voice (loud) you hear is their yelling or shouting. They believe that if they talk in a soft tone, others will not be impressed by them.

being empty

5. They believe in argument but they don’t believe in reason. Quickly and without thinking they will convert any segment of daily talk into an argument of their choice and then start yelling. The proverb, think before you speak, is not in their vocabulary.

6. They believe they are the king or queen of the universe and rest of the population was created to obey them. If they happen to be a worker, they spend their lives lamenting that why someone else is the boss. In a work environment they live to see that their activities (all of them including the visits to the wash room) are all conveyed to their boss who should always think that in the work area there is no body else capable of swift raises and promotions.

7. They talk incessantly.  But when it comes to content, well, that is another matter. They are capable of talking only about people (or their shoes and clothes). They are not capable of talking about events or ideas.

8. They are always full of complaints. A faith keeps them alive that the world has been very cruel to them and that they deserve a better life, in home or office. The result is that they believe they are the only perfect humans on earth.

9. They make fun of other people in their absence. They will ridicule the other person for his/her appearance, color, habits, the way they converse, clothes he/she wears, even nails. Its inevitable that they find flaws and above mentioned and other areas of daily life. They will appear real cool in front of these people and act very polite but as soon as they meet another person, they start telling him how inferior is the person they just met.

10. Empty men and women are ingrates. They will never acknowledge if someone has been kind to them or did a favor. When talking about something in this area, they will always downplay the guy who helped them. Their main premise is that they are the perfect human beings and nobody ever helped them nor they would need help at any time in future.

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Profile of a poor family in Pakistan

(Names and places are real like poverty. In one US$ you get approximately 100 rupees).
Tufail and Razia got married some 30 years ago. At that time they lived in Kasur. They both belonged to poor families and when I asked about it they were not hesitant in telling me that they didn’t have any fancy dreams about a happy life. It was a sin to think of a comfortable life. That is how poor Pakistanis live in villages (mostly) and in big cities.

kasur foods

Like their village dwellers they were also not educated (there are usually no schools in villages and if there are some, they charge large amounts of money which the villagers can’t afford then there are schools in public sector which don’t charge much but they don’t teach either) the  only education they got was from the molvi (prayer leader) of the nearby mosque who taught them how to read Arabic alphabets and some verses of Quran. Within one year they had a son. Tufail’s father was a laborer (called kammi in Pakistan which means a worker of low existence). These kammis are not paid a salary but are given wheat and other edibles as approved by the big landlords who employ these people to keep them entertained and work in their household. The zamindar or big landlord is like a god to these people and they spend their lives according to whatever they think is ‘good’ for them. Worse case scenario of slavery in 21st century.

After Shoki was born, Tufail was taken seriously ill. His father spent all his belongings and got him admitted in the ‘big’ hospital in the city (the district head quarter hospital with basic health facilities but no medicines or even decent lab tests as a rule). He had ‘sugar’  (Diabetes mellitus) and the entire village ‘knew’ there is no cure for it. Razia had a sister in law who was working as household maid in nearby Lahore (provincial capital of Punjab). Razia was pregnant again and in next three years they had two more kids. Both daughters.

Tufail himself was not a craftsman or skilled laborer and too weak to work as a farm hand. There was nothing to eat and the joint family system couldn’t support them. Razia’s sister in law told her to come to Lahore and she did that. They landed in a upper middle class neighborhood and Razia was hired as a maid for Rs. 500.00 per month. Insulin for her husband took 400.00 per month and three kids were growing up fast. She was given a one room ‘quarter’ in the house where she worked. For electricity and gas Rs. 100.00 were deducted by her employers. Her three kids were now placed in nearby houses as servants. They were from 5 to 7 years old and could only help the ‘begum sahib’ (landlady) to the extent that her babies were kept busy. Physical beating was a rule whenever a toy or a kitchen utensil was broken by these kids and they also started to help in washing and laundry. Total monthly income of the family was now 900.00 rupees. For an estimated price of essential commodities this table can help you visualize how much this 900.00 is:

Flour (the staple food which is used to make bread three times a day): Rupees 300.00 per 10 kg (20 pounds, the family needs 40 kg or 80 pounds of flour per month).

Rice: 100.00 Rs / Kg (2 pounds). Monthly use: 10 kg or 20 pounds (Rs. 1000).

Eggs: Rs. 10 each (they don’t eat eggs. Breakfast is leftover bread and tea.

Milk: 2 pounds (1 kg ) daily @ Rs. 50.00 per kg.

Meat: Poultry: 200.00 / kg or 2 pounds

Beef: 250.00 / kg or 2 pounds (result: They don’t eat meat).

Edible oil: 150.00 Rs. / 2 pounds.

Utility bills are not included as for 100.00 Rs. the ‘quarter’ owners don’t want anything more from the family.

When they get sick, they have to buy the medicine which is very costly. Medical attention can be had for Rs. 20.00 from a government hospital but they have to commute and spend an entire day and that costs money. So they prefer to stay ill or go to the nearby pharmacy which sells all the drugs and prescribes for their illness by someone who has passed grade 10 education. They cannot think of having vacations and can’t afford TV or schools. The eldest son was sent to a handicraft center where he earns Rs. 600.00 per month. He got married 3 years ago and now has 2 sons. The younger daughters were married off similarly when they reached 14 or 15. After getting married the girls found husbands who didn’t make more than a few thousand rupees and thus they are also working as maids in various houses to make the ends meet. There is another, youngest boy who goes to a government school where there is nominal fee of Rs. 50.00 per month but he has to buy all the books and stationary from his own pocket which is again a burden on family income. There is no social security to help them (and there are thousands of such rural families working in the posh houses of big cities). Their boys who remain uneducated, tend to either fall to drugs or crime or more recently resort to violence in the form of terrorist groups. But before becoming big they constitute small mafias which extract protection money from the local vendors and carry illegal weapons with them. Police have no mercy for these lesser people. Whenever there is a theft or burglary, their men are always the first suspects and beaten mercilessly in the process as there is no body to talk to the local police station in-charge who operates on ‘power and sifarish’ (approach & reference of a powerful man).

This story continues like this in millions of households across Pakistan and it does not have an end as the misery keeps on growing while the people in power corridors are themselves busy in making money and buying palaces in England and Dubai. Law has lost its place from this land and it has become a painful gulf between the very rich and very poor. Lack of a literate middle class which is vanishing rapidly is even more painful to observe.

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PAKISTAN – as of October 2017.

Three months have passed since the historic supreme court judgment on 28th July 2017 which declared that the prime minister of Pakistan, Nawaz Sharif is not honest and credible since he be removed from his office. There was no public out cry as everybody knew that Sharifs have done nothing but amass huge wealth in their 30 year rule over the country. They constructed some roads in their majority province, Punjab but nothing was done in the domains of education, health care or even clean drinking water. The younger Sharif, Shahbaz Sharif who is the chief minister of the largest province, Punjab madly persuaded his mega schemes for transport but in the same province patients died of unavailability of medicines. In the largest cardio-vascular hospital in the city of Lahore, patients with Coronary artery disease were given two years time for a bypass operation while he spent billions of rupees on local train project. His utterly failed schemes which were supposed to revolutionize the economy were Yellow cab scheme, Danish schools, and Cheap roti scheme. Billions were spent on these projects and they yielded nothing for the poor. PMLN cronies got all the benefits and they were clamped officially.


The camp of the ruling party (PMLN) is now busy to malign judiciary and military because they firmly believe that these two institutions are behind the supreme court decision. Fortunately for Pakistan the public does not believe in the thesis of PMLN. They are fully aware of the corruption scandals of Sharifs which were first came to international lime light by the Panama papers.

The second and third place political parties, PTI (Pakistan tehrik e insaf) and PPP (Pakistan peoples party) are trying their best to fill the vacuum. The one province which has been the source of power for Sharifs has a cultural set up in which people don’t choose leaders but gods. In a recently concluded by elections in NA 120 the PMLN candidate won because they generously distributed money, cell phones and jobs. What we are observing is the sad demise of integrity and merit from Pakistan. When the public is ready to be sold for a few thousand bucks, there is no room for quality or honesty. It looks as if the people have accepted that the political leadership is allowed to earn billions and that they are above the law.


On 19th October 2017, the NAB (National accountability bureau) judge, Bashir Ahmad formally indicted Maryam Nawaz Sharif (who incidentally is the de facto prime minister of the country and the daughter of Nawaz Sharif), her husband, Captain retired Safdar and Nawaz Sharif. There was no public out cry seen outside the NAB court in Islamabad and the proceedings progressed peacefully.  All of them have pleaded not guilty and now the nation will wait for the court proceedings while Sharifs will try their best to malign the institutions because they love to claim that there is some conspiracy going on against them. They, however, fail to tell the people of Pakistan that what magic wand they had which made them billionaires after coming to power 30 years ago.


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Freshly Pressed Ideas: (Not a manual for being freshly pressed).

1. Photography: Use the lens to capture the following.

A bicycle or its parts. Any other machine / machinery parts are also FP worthy. So take heed and give importance to the old parts lying in and around your dwelling. A favorite is a very old (read ancient) automobile. The likes of a T model and Volkswagen photographed at oblique angles with rust showing as decor are strongly recommended. Fungus growth is to be considered an added advantage, provided your shots highlight it.

A passage/ street/ residential block/ sea or riverside etc. and what grows out there like ground nuts and sweet potatoes (which are not seen on the ground hence the whole charm of photographing them).

A flower or its parts. Flower containers are somehow not popular.

A bridge or its parts (like what is it like under the bridge). Little bit of water can be included to increase the marks (if there are such in deciding a FP blog).

Try to capture the abstract like Wind, Breeze, Sounds etc.

Decorations on festive occasions.

2. Prose (remember poetry as such finds it very difficult to find place in the freshly pressed elite club).

Preparing a meal.

Thinking of preparing a meal.

Talk about a movie you don’t want to watch.

Talk about a set of movies you don’t want to watch.

Latest fight between husband and wife (read girlfriend / boyfriend if you don’t like the nomenclature).

How you avoided a fight with your girlfriend / boyfriend.

Teething problems of your dog.

Travel & / or visit to an exotic place (exotic means outside America). This account will encourage the Americans to have sympathy for those ‘poor’ people / their system of living & they would feel great. You get freshly pressed.

Wear an old dress and talk about it (want be sure of getting freshly pressed: get a corresponding photograph also).

Numbered account of your recent visit to your in-laws who gave you a very cold shoulder.

Lists: Like a list of activities which you never plan to do or a list of things which you actually did but the neighbors called the police.

Sketches are popular. You can be FP if you can draw like a 2nd grader. Cruder the sketches, more FP’able they become. Like you can sketch your cat’s maternity leave and see it getting popular in no time (or till the kittens become grand parents – who knows).

1. FP = Freshly Pressed.

2. … This list is not complete and cannot be completed. New ideas will keep on coming. So keep on waiting for them and add yours, please. Till then good luck with the dreams of getting freshly pressed.

3. No matter what your FP’ed blog contain, rest assured that there will be hundred of keen followers and like-ers who will shower you with even keen (read absurd) comments as it provides them with the only chance of getting noticed.

A step behind being freshly pressed. Image

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How the time flies. How it stops when it’s a holiday.

I do not make ‘to do’ lists. They scare me as I know I would not be able to place tick marks on at least 90% of the listed items. Remaining 10% to me are never so important and therefore can be comfortably left alone. Without much (a)do.

I had a wonderful holiday time when ammi (Urdu for mom) was alive. She was my angel and she was a god when it came to taking care of me. On a holiday she would even ask the maids to stop talking loudly as I used to sleep till late. With late it means till it was lunch time or just before that. The normal utensil friction in the kitchen, the running tap water, the phish phish of insect killer spray, the grrrlp grrrlp of whirling washing machine – everything would come to a standstill because ammi would not allow any of this. She truly and magnanimously and selflessly loved me.

It was very early morning when all the tubes and lines attached to her stopped working all of a sudden and the monitors at her bedside showed a deep, silent, aggrieved, straight and lifeless line. My mornings and life had changed for ever. That also was very early in the morning, around 5 am and it was a Sunday.

Now I get up around 6 and head straight to kitchen to make a cup of tea. Somehow I believe it is rejuvenating and has the capacity to soothe my aching body and soul. Good thing about a holiday is there is no hurry to get to work. So I make that one cup and let the remaining water in the kettle so that to make another one and another one if my hunger or thirst for tea wasn’t quenched. My tiny study is usually clean as the maid gives some last-minute cleaning touches before leaving at night. The unwritten agreement is that on a Sunday I ‘ll not wake her up before 10 am. But by that time most of my ‘work’ is already finished.

Thankfully being fussy about eating is not a problem for me anymore. Frankly eating too much and being super choosy about what is for lunch/ diner is out of life (and believe me it makes life much easier). One realizes how much time and energy is spent daily basis on the selection of food items and mode of cooking /baking in an attempt to make sure that everyone leaves the dining table happy. Resorting to simple, basic foods is a blessing I have now. Though I shudder at how rudely choosy I was in this arena. For the past few years newspapers also have lost their ‘newness’ and charm, if you may call it. Rape, crime, war, terror, war on terror, killing of innocent people and calling it collateral damage, large ads of movies and gossip about movie stars is the stuff newspapers are made of. Sprinkle politics here and there and see your holiday morning destroyed and shredded.

Subtract breakfast and newspaper and you will suddenly realize how rich you are having so much of time. Problem with lot of time is humans want to spend it and on a holiday I am at a loss. I switch on the computer and avoid seeing the clock on the wall facing me. Then I get up and try to find a nail and hammer to place the clock behind me. One or two hours later I succeed in the first project of the morning and am ready for the 3rd cup of tea. And I am thinking of the remaining (almost) 20 hours of the holiday with clock now fixed at my back wall and nothing to do in sight. Should I be using to-do chits then? I wonder. There is silence to deal with when you don’t have anything else to do and it deepens into the crevices of soul.

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On getting up in the morning with a severe headache.

Severe headache getting up in the morning

Around 6 a.m. it is dark outside. The morning is crisp and clean with the breeze full of winter’s coolness. It is customary to give compliments to the morning otherwise there is nothing crisp about it as far as I am concerned. My son was up much before me as he has a term exam or whatever they call it in the university. The moment I tried to lift my head from the pillow I gave out a cry. “Idhar aao” (come here in Urdu). Hamza ran to me and held my head in his hands. He is now used to this exercise. When ever I have this headache, and it is always severe, he is the only one who consoles and cajoles me and tries to soothe me. Soothing helps sometimes. But the machinery inside the head continues to churn out pain in the form of … no, in every conceivable form. From large boulders of shattering pain to subtle needles of piercing agony. And there is no noise in the room. All this noise comes from within my head which by now is making me retch and vomit. “ulti kar lo” (please throw out) says Hamza while rubbing my nape and shoulders. He knows my headache get better if I vomit. But today morning it was different. There was an element of vertigo along with this excruciating pain and I was sick to the pit of my stomach. “Nahi ati tau kya karun” (if it doesn’t happen, what can I do), I shouted back. He kept quiet knowing too well that my temper takes a very deep plunge with the headache.

In the meantime Tahira comes downstairs. She is the maid who lives upstairs. Immediately she goes to the kitchen to make tea, following her morning ritual. That made me more furious. “STOP IT. STOP THIS NOISE. YOU WILL KILL ME”. I was trying to shout with authority but knew that my voice is trembling and she would be giggling behind the closed doors of kitchen. Even she is aware of my weaknesses during such pain and that is surely not a very pleasant thought for one who is suffering.

Tea came. My agony doubled. I wanted to take a few sips in the hope (and oh how I hoped this pain to get better) that it will soothe me but the clanking of utensils made it worse. Even when sugar was being mixed in the tea cup I almost shouted, ‘please leave it as such, I can live without this much sugar for one day’, it angered people around me (read my wife who does not need any valid situation to be angry), and it made me suffer more as I understood that none of them is trying to understand my agony. On top of that and on top of my head it seemed that many thousand animals with sharp claws are running in a stampede, literally crushing each and every nerve fiber in my brain and head. It was just like in the Disney movie, The lion king and hyenas are a perfect simile to the horde of animals making me suffer. As a doctor I learned that brain tissue is insensitive to pain. So this terrible pain (which has slowly taken the shape of added throbbing now) must be due to blood vessels and other tissues above the brain. Who wants to think of etiology when your head is being crushed at a hammering pace?

It gets worse with the help around

Finally, I took a sip of tea and glared at everyone in the room. My eyes must be very red and scary as the maid pointed out, ‘Bhai jan (elder brother) you must sleep a little, lack of sleep does this to you’. You know, when one is in pain, any advice is like a flesh or brain substance tearing weapon and I was struck with it with full force. ‘If I chose to sleep, who will go to work’ was my very (un)friendly mumbling back which I of course wished to sound like a real threat like command. There was silence inside the room but the headache was getting worst. My head was splitting and my temples throbbed as if there is some rattling steel furnace running at full speed inside my scalp.

Pounding headache with no relief in sight

After two or three sips of tea I objected to the degree of temperature and was told in a whisper that I don’t usually like lukewarm or cold tea. The poor gal who uttered those careful words never thought they will ignite me. At this point I was almost trembling with anger (more with pain but I would use anger to make me less guilty). ‘So I am not entitled to a less hot tea when I am dying with torture!’ was my calculated response. Though all calculations cease to exist in one’s mind when one of these headaches sound the war trumpet, knowing too well that they will win. Humans always lose this battle.

Two Aspirins and one Valium later I was slightly drowsy and Hamza hurriedly took advantage of the situation and started to press my shoulders and back. In a dreamy state I could feel the pain leaving me through my pores and I inhaled deeply. I am sure everyone saw it and took it as a sign to switch off all the lights and tip toe out of the room. Twenty five minutes later I suddenly got up with the residual pain like a stretching elastic band around my head but I could get up and go to office.

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2. How do I know the Dengue fever has become dangerous? Dengue in Lahore: Serious symptoms.

Dengue fever can become very serious if the element of hemorrhage sets in. If the following symptoms are observed, take immediate steps.


1. Abdominal pain

2. Persistent vomitting

3. Weakness, increasing sleepiness

4. Cold sweats

5. Shortness of breath

6. Dark color urine

7. Lot of drinking fluids but very low urinary output.

If you or any body near you is found to have these symptoms, NEVER wait and IMMEDIATELY take the patient to the nearest emergency hospital. Any time spent at home will be wasted and can be fatal.

For more information a helpline by the government of Punjab has been set up. You can try this number: 0800-99000 (toll free).

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What do I do if I have swelling in the neck: Mumps, Lymph nodes, Goiter, Thyroid enlargement.

A person with neck swelling has enlargement of the soft tissues that covers the neck. A neck swelling can also occur as accumulation of fluid, lymph, or inflammatory, or tumor cells in an area under the skin of the neck. Clinically speaking swellings in the region of neck are of great importance as they not only help in diagnosing some serious underlying disease but are also easy to treat if they are benign. Most of the times a simple surgical procedure is all we need.

Neck swelling may be caused by an injury, inflammation, infection, or a benign / malignant tumor. In mild cases of neck swelling, treatment may not be required. If the neck swelling is bothersome, over-the-counter medications such as anti-inflammatory drugs or pain medications or cold compresses may help reduce discomfort and swelling. In more serious cases, a visit to a medical professional may be necessary to determine the cause of neck swelling and appropriate treatment. Seek medical attention if your symptoms of neck swelling, or those of someone you are with, are accompanied by sudden swelling of the face, lips, or tongue, or breathing problems such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, or choking. These symptoms may be signs of a severe allergic reaction.

Anatomy of the neck

Benign skin conditions can cause small areas of the neck to appear swollen. Swelling of the lymph nodes in the neck is a common symptom of many different types of viral and bacterial infections as well as many benign and malignant disorders. Lymph nodes are small organs distributed in the body which collect fluid. They get swollen if inflammatory fluid deposits in them. They are also swollen if cancer cells from an organ reach them in case they are said to have metastasized. In the neck they are present in distinct groups and are almost always show as medium to small size swelling mostly on the sides of the neck and / or under the jaw. Have a look at this illustration, it shows different groups of nodes in and around the neck.

you can see different sets of these lymph nodes like sub-mandibular, and occipital. So their enlargement is either benign or malignant. These nodes are also swollen in cases of TUBERCULOSIS (TB). TB is a treatable disease which affects millions of people all over the world. A biopsy result of the neck swelling, from a pathology laboratory is all you need.

If the swelling is on one or both sides of

Lymph nodes in the neck

the neck just below the ear lobe, it may be MUMPS. In that case immediately consult your doctor. Mumps is a viral infection and can have serious side effects long after the swellings have disappeared. This viral attack  can lead to swelling and pain in the salivary glands (Parotid glands), along with fever, loss of appetite, and fatigue. It mostly occurs in children but can affect us in later life. Remember there is a vaccine against Mumps which protects us from this viral infection.

MUMPS: A viral illness which causes swelling of Parotid glands.

There are some skin causes of neck swelling:

Neck swelling may be caused by a variety of skin conditions including:

  • Acne
  •  Boils
  • Cyst (a benign collection of fluid)
  • Lipoma (collection of fatty tissue under the skin; a benign condition)
  • Skin infections

Other causes of neck swelling

Neck swelling can also be caused by a variety of other conditions including:

  • General infection leading to swollen lymph nodes in the neck region
  • Goiter (an enlarged thyroid gland)
  • Mumps (viral infection of the salivary glands in the neck)
  • Recent neck injury or trauma
  • Recent neck surgery

Other causes of lymph node swelling in the neck are the blood cancers like Leukemia, Lymphoma and Hodgkin disease.

In some cases, neck swelling may be a symptom of a serious or life-threatening condition that should be immediately evaluated in an emergency setting. These include:

  • Anaphylaxis (severe allergic reaction)
  • Angioedema (a severe swelling beneath the skin that can cause breathing difficulty)
  • Cancer of the throat, thyroid gland or other structures in the neck


A goiter is an enlarged thyroid gland. Some people with a goiter (but not all) have an under-active or overactive thyroid.  A goiter can mean that all the thyroid gland is swollen or enlarged, or one or more swellings or lumps develop in a part or parts of the thyroid.
The thyroid gland is in the lower part of the front of the neck. It lies just in front of the trachea (windpipe). It has a right and left lobe which are connected together by a narrower band of thyroid tissue. (It is roughly the shape of a butterfly.) You cannot usually see or feel a normal thyroid gland. If the thyroid enlarges it causes a swelling in the neck which you can see – a goiter. There are various causes of goiter and treatment depends on the cause. As such the thyroid swellings can also be classified as benign or malignant. The benign swellings do not cause spread of the disease and are mostly fluid collection in some part of the gland. Hemorrhage in the gland is another example where a neck swelling is observed. Thyroid swellings are prominent and are always situated in front of the neck (see illustration). They may be mobile (moving with swallowing) or fixed. If the swelling is benign   and is mobile, there are chances that it is not dangerous at all and a simple surgical procedure will correct it.

In case of more than one swelling (lumps) in front of the neck which are due to thyroid enlargement, they are called as Multinodular goiter while a single swelling (lump) is termed as simple nodular goiter.


Always remember that a thyroid swelling does not mean there is an element of dysfunction also (please see previous blogs about hypothyroidism and hyperthyroidism).

Simple diffuse goiter

They may be there due to IODINE DEFICIENCY in which case they are termed as IODINE DEFICIENCY GOITER. In most of the cases they are diffuse (no nodularity is seen). When there is no nodule palpable in the neck and there is diffuse swelling, it is SIMPLE GOITER. It can also occur at puberty in young girls and is called PUBERTY GOITER.

Diffuse/Simple goiter:

This means that the entire thyroid gland is larger than normal. The thyroid feels smooth but large. There are a number of causes. For example:

  • Grave’s disease – an auto-immune disease which causes the thyroid to swell and make too much thyroxine.
  • Thyroiditis (inflammation of the thyroid)
  • Iodine deficiency. The thyroid gland needs iodine to make thyroxine(T4) and T3. If you lack iodine in your diet the thyroid swells as it tries to make enough of its hormones which are so vital for our bodily functions like metabolism and control our heart rate and many other functions
  • Some medicines can cause the thyroid to swell as a side-effect. For example, lithium and treatment of Hepatitis C
  • Hereditary factors – some people inherit a tendency for a thyroid to swell. In particular, it may swell at times of life when you may make more thyroxine and T3. For example, when you are pregnant, or during puberty.

Nodular goiter

A thyroid nodule is a small lump which develops in the thyroid gland, in front of the neck. There are two types:

  • A multinodular goiter. This means the thyroid gland has developed many lumps or ‘nodules’. The thyroid gland feels generally lumpy.
  • A single nodule. Causes include:
    • a cyst (swelling with fluid in it)
    • an adenoma (a solid lesion in the gland composed of glandular cells)

      large multinodular goiter

    • a benign or malignant tumor
  • In many people with a goiter it does not affect the amount of thyroxine T4 or T3 that they make. You are then Euthyroid which means you make the correct amount of these hormones.
  • In some people, the goiter is associated with an abnormality of thyroid function. You may make too much thyroxine or T3 (hyperthyroidism) or too little thyroxine or T3 (hypothyroidism) For details please see related posts in this blog.


1. Blood samples are taken to evaluate the amount of circulating thyroid hormones in the body. Normal T4, T3, and TSH means you are Euthyroid while over active and under active thyroid gland is also established and then the treatment starts according to the condition.

2. An ultrasound scan of the thyroid is done. This may be done if you have a single nodule. An ultrasound scan is a safe and painless procedure which uses sound waves to create images of organs and structures inside your body. It can tell if a nodule is a cyst or a solid lump.

3. A radioactive iodine scan. This scan is done (details given in the next post) to establish the uniformity or nodularity of the gland and whether some part of it is HOT or COLD. The hot spots on a radionuclide scan mean this portion of the gland is making more hormones (T4 and T3) than the surrounding gland and a COLD nodule means this area of the gland is not properly functioning. If on scan results there is a COLD NODULE, it is usually suggestive of malignancy (Thyroid cancer) and appropriate medical opinion must be sought immediately.

4. Biopsy: A small piece of tissue (a biopsy) may be taken from a nodule to look at it under the microscope. The biopsy is done by inserting a fine needle into the nodule. (It is like taking a blood sample but the needle is smaller.) It is a simple and safe procedure.


  • If you have a small goiter, and your thyroid is making the correct amount of thyroxine and T3, then you may not need any treatment. It happens in patients who has simple diffuse goiter
  • You will need treatment if you make too much or too little thyroxine T4 or T3
  • An operation to remove some or all of the thyroid may be an option in some cases
  • Radioactive iodine treatment may be an option for a goitre causing an overactive thyroid. This involves taking a drink, or swallowing a capsule, which contains radioactive iodine (I-131). The radioactive iodine builds up in the thyroid gland. As the radioactivity is concentrated in the thyroid gland, it destroys some thyroid tissue mainly by it beta emissions. If too much of thyroid is destroyed, there is replacement therapy in the form of thyroxine tablets. Their use and the fact that radioactive Iodine treatment is not particularly harmful (it is not given in pregnant or lactating mothers or prospective mothers), this form of treatment for Grave’s disease (toxic goiter) is very useful.
  • If you have cancer of the thyroid, you will probably need an operation to remove the cancer and some of the thyroid gland. The strategy to deal with this cancer will be outlined by an Oncologist with the aid of a surgeon.
  • Iodine replacement, if the goiter is due to lack of iodine in the diet.

NOTE: If you have any questions, you can always ask the author who is a thyroid diseases consultant.

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What do I do if I am told to have a radioisotope scan: Things to know about Isotope scan & nuclear medicine.

A radioisotope scan (also known as a nuclear medicine test) uses a small amount of radioactivity to produce pictures on a special camera. The radioactive dose is usually injected into a vein in your hand or arm. The radioactivity circulating in your body emits radiation (gamma rays) which are detected by a ‘gamma camera‘ and leave an image on the computer. From that computer image the doctor working in the area will draw conclusions and write a report which will be given to you or your doctor. It contains very useful information about a disease process in the body and is also used to know about any organ under study.

How does a radionuclide scan work?

A radionuclide (sometimes called a radioisotope or isotope) is a chemical which emits a type of radioactivity called gamma rays. A tiny amount of radionuclide is put into the body, usually by an injection into a vein.

There are different types of radionuclides. Different ones tend to collect or concentrate in different organs or tissues. So, the radionuclide used depends on which part of the body is to be scanned. For example, if radioactive iodine is injected into a vein it is quickly taken up into the tissues of the thyroid gland. So, it is used to scan the thyroid gland.

Cells which are most ‘active’ in the target tissue or organ will take up more of the radionuclide. So, active parts of the tissue will emit more gamma rays than less active or inactive parts.

Gamma rays are similar to X-rays. The gamma rays which are emitted from inside the body are detected by the gamma camera, are converted into an electrical signal, and sent to a computer. The computer builds a picture by converting the differing intensities of radioactivity emitted into different colors or shades of grey.

What preparation do I need?

Usually you don’t need much of anything. Your doctor/ reception of the hospital should give you specific information (if any) to help you prepare for these tests. As these tests involve a small amount of radiation, pregnant women should not have them. Let your doctor know if you are, or think you could be, pregnant. You should also let your doctor know if you are breast-feeding. For some types of scan, you may be asked to have lots to drink to help to flush the radionuclide from your body or help in better accumulation of isotope in the body organs like skeletal system.

What happens during a radionuclide scan?

Depending on the type of scan you have, you either swallow a small quantity of radionuclide, or it is injected into a vein in your arm. It then takes some time for the radionuclide to travel to the target organ or tissue, and to be ‘taken’ into the active cells. You will not need to remove any of your clothes for the examination, but you will be asked to remove any metal objects as this may interfere with the scan. So, after receiving the radionuclide you may have to wait for a few hours. You may be able to go out and come back to the scanning room later in the day.

When it is time to do the scanning, you lie on a couch while the gamma camera detects the gamma rays coming from your body. The computer turns the information into a picture. You need to lie as still as possible whilst each picture is taken. During the scan you are not shut down in a metal tube.

The number of pictures taken, and the time interval between each picture, varies depending on what is being scanned. Sometimes only one picture is needed. However, for some scans (such as bone scans or heart scans), two or more pictures are needed.

Are there any side effects?

There are no side effects. Radiation received by the human body during a nuclear medicine scan is not dangerous. It is comparatively, less harmful than an ordinary x-ray examination.

Can I continue with my tablets?

Yes. You can continue to take all your tablets or medication as normal. If you have any worries at all please contact your GP.

Can I bring someone with me?

A relative, partner or close friend is welcome to accompany you to your radioisotope scan. Once the test is over you may eat and drink as normal. The procedure will not affect your ability to drive or operate machinery.


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