Sudden deafness – Early Treatment

In our last article, I wrote about sudden hearing loss, its causes and why it happens. This catastrophic condition is regarded as one of the few ear emergencies where early treatment within the first two weeks has been shown to significantly improve the outcome and potential recovery of the hearing loss.

Often the cause of the hearing loss is not obvious. The hearing suddenly drops and may be associated with a ringing noise in the ear and /or disequilibrium. This depends on whether the effect is limited to the hearing organ only or also affect our balance organ function too as they share the same inner ear fluids. The screening battery tests may not show any obvious diagnosis but treatment for this condition should not be delayed. The current medical thinking is that there is an insult to the inner ear which could be a blocked micro-vessel that starves the cochlear of its blood supply and oxygen or perhaps it is an inflammation of the cochlea by possibly a virus. In either cases, the ear often looks normal and imaging is usually unremarkable. The dilemma that physicians face is do we wait for the condition to declare itself to get the right diagnosis, or do we act with a “shotgun” treatment of different drugs to prevent further ear damage and set the course for early recovery? The answer is we should act “blindly”. We have to remember that we are unable to cut out the inner ear for test sampling as doing so is a major operation and the operation would certainly kill the ear and its hearing.

What constitutes this shotgun rescue treatment? It is thought that perhaps a virus might be the cause so a week’s course of high dose antiviral medication is given. Inflammation from a viral attack, diabetes mellitus event or deoxygenation of the nerves, is treated with a two week course of high dose steroids which is frontloaded at a high dose, slowly tailoring downwards over two weeks to maintain a treatment effect without causing a sudden steroid withdrawal that could affect the body. This steroid treatment has been studied extensively and research has shown that if it is given timely with in two-week golden window from the first reported ate of the sudden hearting loss symptoms, it is statistically beneficial in improving partially or totally the loss hearing. It is this research that effects sudden hearing loss as an emergency, to be recognized early and confirmed so that treatment can be provided. Such a large dose of oral steroids can cause complications. One of them is stomach ulcers so this course is accompanied with a two-week course of proton pump inhibitors that reduces gastric acid production.

Some patients are unable to take such high dose steroids e.g. diabetics, patients with viral hepatitis or known gastric ulcer disease. With these patients, research has shown that liquid steroids can be injected into the middle ear cavity every 2-3 days for 2 weeks to permit the steroid drug to diffuse directly into the inner ear where there is “supposed” to be inflammation and failing nerve function.  This prevents the steroid drug to be in the blood system where it can exert its side effects on the rest of the body organs even though its target is only the ear. Attractive as this may sound, it is more invasive and less economical for the patient, as every two days, the eardrum needs to be pierce by a needle to deliver the drugs on site. The decision is a risk-benefit exercise to be discussed with the patient.

Another reason maybe that the blood vessels are blocked and insufficient blood and oxygen are getting to the delicate hearing cells. Vasodilators are prescribed to dilate the small blood vessels to the brain thereby improving brain blood flow. With any nerve insult, it takes time and ingredients for a nerve to recover so high-dose Vitamin B Complex, the building blocks of nerve function, is also prescribed.

Any improvement in the ear’s hearing would usually be known within the first 6 weeks. Thereafter recovery rates diminish. An MRI scan is naturally important diagnostically to exclude a brain/ nerfve tumour. If seen, treatment may include simply observing with annual MRI scanning (as acoustic neuroma can grow so slowly that no treatment may ever be required), or radiotherapy or neurosurgery to remove a tumor. Again the choice of treatment is an exercise of risk versus benefit for such major operations. If diabetes mellitus is diagnosed, then anti-diabetic medication would be required.

One would think that diagnosing a condition and providing a “shotgun” or highly specific targeted treatment for a known diagnosis will solve and rescue the hearing. In this regard, you would be wrong! In spite of the best efforts and timely care, some patients will continue to have hearing loss on one side. For these patients, the treatment is symptomatic. That is to say that if they are socially and professionally bothered by their one sided hearing loss, normal hearing aids or a surgically implanted hearing system for single sided deafness may help. If the ear generates a disturbing ringing ie tinnitus, medical treatment with tinnitus retraining therapy (TRT) may help.

So losing one’s hearing suddenly should be taken seriously. Early medical attention to confirm single sided sudden deafness and the provision of early treatment within two weeks of the episode, may just arrest and improve the deafness.

The Chinese version of this article was published in Hong Kong Economic Journal on 18 Jul 2016 and 1 Aug 2016

Sudden deafness – The how and why

Have you ever been unfortunate to suddenly lose your hearing, or know of someone who had? This is a disaster if it should happen. Thankfully the likelihood is very uncommon and estimated to happen to 12 out of every 100, 000 persons each year. Nonetheless this condition has a name - it is commonly called sudden sensorineural hearing loss and is regarded as one of the few medical emergencies of the ear.

Why does it happen? There are many reasons why we might suddenly lose our sensorineural hearing. The easiest way to understand this is to consider what could damage our hearing pathway from our inner ear to our auditory nerve (nerve of hearing) and to our auditory cortex, the part of the brain that interprets sound. Sufferers often claim they wake up with reduced or no hearing, or pressure in the ear with a ringing noise, with the hearing gradually getting worse without recovery. This sudden loss of hearing may or may not be accompanied by a sense of unbalance, dizziness, nausea and vomiting. Sometimes there is ear pain with a painful rash around the affected ear.

It should be said that some obvious causes do not come under this medical label of sudden hearing loss even though hearing loss may be a result. This includes history of trauma to the head which can cause concussion and/or bleeds in the brain as well as shock and fracture damage to the cochlea. Surgery to the ear and/or brain for other conditions, may also cause hearing loss. This causes are obvious and treated accordingly.

So what are the possible causes that are not so obvious? At the cochlear and auditory nerve level, viruses have been often cited as a cause especially the Herpes family of viruses. A herpes zoster infection, which is the same as secondary chicken pox viral infection or shingles, can cause an inner hearing loss with a painful shingles rash on the ear and face. Bacterial infection e.g. syphilis, of the cochlear is very rare and patients are usually very sick. Diabetes mellitus has also been said to be a cause. This condition is known to cause small vessel disease, blocking the vessels that feed the cochlea, and hence it dies. Similarly, autoimmune conditions in general are thought to also cause vessel blockage and nerve tissue inflammation, which can damage the cochlea and the auditory nerve. As there are many types of autoimmune diseases, identifying the hearing loss as due to that possibility usually starts the diagnostic process for that autoimmune condition.

Tumors are sometimes the cause of the sudden hearing loss. This is often what the patient fears the most, yet it is even less likely to occur and much easier to diagnose with highly sensitive magnetic resonance imaging of the brain today. The commonest tumor grows from the nerve lining of the auditory nerve. These tumors are called acoustic neuromas and occur in 2-3 out of every 100,000 Hong Kong persons each year. They are almost always benign and grow very slowly. However, as the auditory nerve passes through a narrow bony canal to get to the brain, it can get compressed even with a small growth, starving and paralyzing the auditory nerve and causing hearing loss.

When a patient seeks a medical consultation for sudden hearing loss, it is important to diagnose the reason and to offer the correct treatment. A hearing test is mandatory after a complete ear examination and can confirm or refute cochlear hearing loss. If it is confirmed that a sudden hearing loss event has occurred, then the diagnosis should be established if possible. A battery of tests to view the blood profile, kidney function, inflammatory blood markers, thyroid function, the fasting glucose and cholesterol profile as well as a magnetic resonance imaging of the brain and auditory nerve, are usually performed to seek the cause. Unfortunately, or fortunately, the cause is not usually found with this test battery screen. The true-positive hit rate of this test battery for a diagnosis is about 0.1% i.e. 1 out of every 1000 patients screened. Hence most of the time, the diagnosis is idiopathic sudden sensorineural hearing loss, which is to say we have search for all possible diagnoses but cannot establish one as yet. Nonetheless the test battery is important as it screens for treatable conditions. Understandably the sufferer may not be satisfied that a cause cannot be clearly established. However, in the absence of a clear diagnosis, hearing rescue treatment can still and is given, and this will be discussed later.

The final take home message for readers is that sudden hearing loss is regarded as a medical emergency as the available evidence–based medicine research shows that early treatment within two weeks of the hearing loss event has the best chance of recovery. So here, early medical attention is the rule. If in doubt, do not be. Seek medical advice early.

The Chinese version of this article was published in Hong Kong Economic Journal on 20 Jun 2016 and 4 Jul 2016

Voice loss Part 2 – Treatment options

In the first part of this article, we understand how our voice is produced, and in simple terms, how we lose our voice. Losing our voice is a problem for anyone as we are always communicating our wishes, dreams, love and needs to others.

So what can we do if we lose our voice? Firstly, we should not panic as common things happen commonly, and the commonest cause by far, is an acute viral laryngitis. The swelling from acute laryngitis is usually maximal at three days, after which the swelling subsides gradually, and the voice gradually returns to normal. During the inflamed phase, sufferers are best advised not to use their voice, as continuing voice use could damage and permanently scar the vocal cord lining. This scarring could result in a permanent hoarse voice by impairing the movement of the mucosal lining over the vocal ligaments.

Losing one’s voice is not unusual at all and most voices recover very quickly. If our voice doesn’t return to normal and you remain hoarse beyond three weeks, medical attention to make a diagnosis and to prevent long term irreversible damage would be recommended. Your ENT Surgeon can easily inspect your voice box by performing a flexible endoscopic examination of the larynx. So what conditions can cause chronic loss of voice that can be seen by endoscopy?

A growth on one or both vocal cords can prevent optimal closure of the cords. Excess air then leaks through the gap and voice production is impaired in terms of quality as well as intensity of the voice. Commonly the early formation of vocal cord nodules is the cause. Two non-cancerous thickening of the vocal cords on exactly opposite vocal cord surfaces prevent the cords from coming together well. With the leak, the voice is lost, and we try even harder to produce a voice by speaking louder. This means that the nodules can get bigger, and the hoarseness continues. Treatment here is primarily by speech therapy to re-educate the user how to use their voice better like a singer. If the nodules are too large and /or speech therapy has not worked, then phonosurgery to trim away the nodules may be necessary. If a growth is seen only on one vocal cord, then early surgery may be necessary to exclude cancer. Here the lesion is examined close up, excised and sent for testing. If it is cancerous, then follow up treatment protocols will be advised. However if the lesion looks like a cyst or a polyp under close up endoscopic examination during surgery, the lesion is removed with gentle and careful preservation of the vocal cord lining. This is called phonosurgery and requires great skill. The removal of the lesion is both diagnostic (as we sent the lesion for testing to know what it is) as well as also therapeutic (as the hoarse voice is treated as well)

A total loss of one’s voice is a catastrophe. This is unusual but it happens when one of the two vocal cords is paralysed. They are unable to meet in the midline, the gap is left wide open and therefore no turbulence or voice can be made. The cause here is damage to the nerve that moves the vocal cord. This nerve travels from our brain, down our neck pass our thyroid gland and even as far down as our lung, before turning around to innervate our voice box, one on each side. Cancer in the neck, lung cancer, strokes, penetrating trauma and surgery to the neck and thyroid are the usual causes that damage this nerve. If this is the case and recovery is not forthcoming, the voice can be improved by surgical treatment that pushes the affected cord to the center to a “closed” position. By re-siting the affected vocal cord to the midline “closed” position, surgeons allow the voice to be reproduced again when the normally functioning opposite vocal cord moves and easily close the gap. Rushing air from the lung re-vibrates the cords once again, turbulence of the air is produced and a voice is regenerated again. This particular treatment is important for these paralyzed vocal cords sufferers, as aside from a more normal voice, upper body strength is improved with an improved cough to maintain a clean and sputum free lung.

Remember, our voice is important and most loss of voice conditions are mild, short-lasting with full recovery. A persistent hoarse voice should not be regarded as normal as diagnosis is easily made with endoscopy in a clinic setting. Timely treatment ensures a good quality strong voice either by medication, speech therapy, surgery or all a combination of treatment to suit the problem.

The Chinese version of this article was published in Hong Kong Economic Journal on 22 Feb 2016 and 7 Mar 2016

Voice loss Part 1 – How our voice is produce and lost

Humans are social beings. We communicate with others using our voice as well as body language. So it naturally becomes a problem when we lose our voice.

We make our voice in our larynx. Here sit two ligaments called vocal cords, that are joined together in the front and sit apart at the back, like an open “V”. The vocal cords are covered with a soft mucosa lining, and lie horizontally immediately above our windpipe, acting as two guards protecting our airway.

So how do these two vocal cords make a voice? We need two things to occur for sound to be made. First the two vocal cords are brought together by a muscle, and at the same time, air from our lung is expelled through these closed cords. The air passing through our cords cause the mucosa covering to vibrate, and hence a sound (voice) is made. The pitch of this sound, our voice, is changed by other muscles tightening or relaxing the tension of the vocal ligaments. When the vocal ligaments are tightened, the voice becomes higher pitched, like when we strum a tightly stretched guitar string to create a higher note. For a lower tone sound, the tension is reduced, and a lower, more bass voice is produced. The voice of children, adult males and adult females also vary due to the size of the vocal cords and the “laryngeal” box that it sits in. A shorter vocal cord in a smaller box as in children produce a shriller, high tone voice whilst at the other extreme, a longer vocal cord in a bigger box of an adult male produces a deeper voice. Here the analogy is that of a child ukulele as compared to an adult double bass. The female adult voice is somewhere in between. So that is how the voice is made. Speech and language which strings sounds together to form words is different. Speech that form words of what we want to say, in the form of phonetics as well as the tone in tonal languages like Putonghua and Cantonese, comes from movements of our tongue above our voice box.

So how do we lose our voice? The commonest cause is an acute inflammation of our larynx (acute laryngitis) e.g. when we catch the flu. The lining of the vocal cords become swollen, inflamed and stiff and the inflammation causes pain when we try to speak. As air passes through the cords, the vibration is impaired. Making a sound is difficult as well as painful, and the voice changes to a very hoarse rasp or total loss altogether.

Another way that voice production can be impaired is if there is a growth on a vocal cord that prevents both the vocal cords from coming together perfectly. Conditions that could do this are e.g. cancer of the vocal cords commonly seen in smokers. These growths tents open the gap between the cords, and allows air to leak through the gap, making voice production inefficient at best, and sometimes impossible at worst.

The ultimate voice loss occurs when the vocal cords cannot come together. This is definitely an uncommon condition. We need both vocal cords to vibrate to make a sound. When one of the vocal cords cannot be drawn close, the gap between the vocal cord is too wide for turbulence of the air, and therefore sound, to made by the passing air. It is the same as when we try to whistle. We can only make a whistle with “closed” lips and not an “open” mouth. Here the reasons why a cord cannot “close” is usually due to damage to the nerve that supplies the “closing” muscle of that vocal cord.

To lose one’s voice is not unusual at all and most voices recover very quickly. However, a persistent hoarse voice or loss of voice for more than three weeks is not normal. If this continues, further medical attention for a diagnosis would normally be advised.

  

The Chinese version of this article was published in Hong Kong Economic Journal on 1 Feb 2016

The blocked nose and its impact on your health – What can be done?

In the previous article, we discuss the impact of a blocked nose and how many of us may not be aware we are blocked nor the health implications. So what can we do?

For any blocked nose, there are two components. Firstly a reversible component that is usually due to the congestion of the nasal lining. Secondly there is a non-reversible component due to a bent septum or excessive tissue that has built up over time and has become non-reversible.  These may exist in isolation by themselves, or co-exist and collaborating together to narrow the nasal airway to the detriment of your health.

Saline nose douching, topical steroid sprays and antihistamines as well as rest can reduce the reversible component of the blocked nose. When we are stressed and do not have enough sleep, our nasal vessels are more likely to be congested. In individuals with only allergy related blockage, this is very effective treatment, which is usually required seasonally, or long term for as long as the offending allergen/s is in your environment e.g. house dust, molds, pollens, etc. A good regimen of care will also reduce the severity of the other down line impacts of a congested nose e.g. sinusitis, mouth breathing and sore throats. In some case with headaches, the reduction in contact between the internal nasal tissues as well as reduced congestion and re-venting of the sinuses also reduces or abolishes these headaches.

However even after a trial of medical treatment, you may still find your nose blocked, and the treatment only partially effective. An endoscopic examination of the nose with possible imaging of the sinuses may declare that the obstruction is substantial due to pre-existing anatomical changes in the nose. The septum may be bent, the nasal lining now too swollen and thickened, nasal polyps may have formed which no longer can be reduced and/or the sinuses are chronically infected, and their openings now are too blocked for medical treatment to reverse the condition. Under these conditions, together with a clear history of symptoms and signs, surgery may be the solution. Surgery may include straightening the septum, reducing the turbinate size, removing the nasal polyps, re-venting the sinus openings and rinsing out the sinuses, or any of these combinations. Essentially the aim is to undertake whatever is necessary to improve the nasal airway and to permit natural re-venting of the sinuses.

So we can now breathe better after surgery and our overall health and sleep has improved. But does it end with surgery? Our environment usually remains the same; there is house dust, molds and pollens around us still. Some of us are still going to require saline irrigation of the nose and nasal sprays for the allergic flare-ups. Well funnily enough, opening the nasal airway by surgery does not only just improve airflow, it also improves the access for delivery of saline during nasal douching, and drug delivery via nasal sprays. That is the bad news. The good news is that most of us do not require long-term medical treatment… and all of us will live and sleep better now that the nose breathes better.

The Chinese version of this article was published in Hong Kong Economic Journal on 20 July 2015

The blocked nose and its impact on your health

Who hasn’t had a blocked nose? Especially when we have a cold and, thank goodness that the blocked nose, runny nose, sneezing as well as fever last only a few days. So can you imagine having a blocked nose all the year round? Most of us cannot imagine this! Yet most of us who live in polluted cities like Hong Kong probably are walking around with a blocked nose; a chronically blocked nose that creeps up on us so slowly that we never even guessed it.

Aside from smelling fragrances, the aroma of food, the appreciation of flavor as well as making our face look more beautiful, our nose has another far more important job. It protects our lungs by warming, filtering and cleansing the air before it reaches our delicate lungs. If the air is dirty, it causes our turbinates to swell inside so as to narrow or even block our nasal passages so that the air cannot enter. Our nose secretes mucus to wash away the dust and pollen, and if that is not enough, it gets all itchy and makes us sneeze so we can blow out the dust-filled mucus. So what happens to us when our nose gets chronically blocked? Actually quite a lot can happen. It affects our nose, our sinuses and eyes, our ears, our throat and finally our beauty sleep.

When the nose is blocked, we experience a nasally voice and have a postnasal drip. As the sensitive turbinates inside the nose swell up, they may make contact with one another or with the septum, and this sometimes causes “Sluder’s headaches” with pain of one/both temples, at the top and/or the back of the head. This may sometimes be mistaken for the more uncommon migraine.

When the lining of the nose is swollen, it also blocks the openings of structures that open into the nose. Blockage of any of the sinuses that drain into the nose can cause sinus pressure headaches above, below, between or behind the eyes as well as at the top of the head. A bacterial sinusitis can also occur if the sinuses cannot drain themselves. Our tear ducts also drain into the nose so a blocked nose may cause our eyes to “flood” more with tearing, impairing our clear vision. This can be troublesome indeed.

At the back of the nose lies the opening to the Eustachian tubes that re-pressurise our middle ear compartment. If the nose, and therefore the tube is blocked, a lower middle ear pressure can result. This is the same feeling we experience when a plane lands. Sometimes though it can be very painful especially for children. Longstanding obstruction of this tube often leads to repeated middle ear infections and/or perforated eardrums, and hearing problems especially in children.

So our nose is block. That is not a problem as we can breathe though our mouth, right? Correct…we can breathe through our mouth but why then do we need a nose? Actually most of us would automatically start to breathe though our mouth without realizing it when our nose is blocked. This leads to so many things like dry lips, bad breath, repeated mouth ulcers, sore throats that lead to large tonsils and repeated tonsil infections. Breathing and speaking through our mouth becomes a problem too. As the mouth gets drier, we cannot sense that we are breathing in less air than we should so. So when we speak, we cannot project our voice well. So we compensate by powering up our voice box to do all the work and that is why we end up with a hoarse voice.

Finally the blocked nose and the compensatory mouth breathing affects even our sleep. Although the mouth is a larger opening for air, inside our throat sits our mobile tongue and also tonsils. These sometimes are sucked in and obstruct during sleep, as the nose cannot act as its usual passage for air intake. Snoring, poor quality sleep and maybe even obstructive sleep apnea then occurs. Over time, the poor quality sleep we get every night makes us irritable, easily frustrated, gives us oily skin with acne, eye bags and a generally darker facial complexion.

All the above can occur because of a chronically blocked nose. The interesting thing is that many of us remain unaware that is happening as the process is such a gradual one. However, as quietly as it can be blocked, thankfully it can also be reversed with medication and/or surgery. So yes… we can still get the beauty sleep in our beautiful city…and all because of a nose!in our beautiful city…and all because of a nose! 

The Chinese version of this article was published in Hong Kong Economic Journal on 1 June 2015

Sinus and nose-related headaches – Treatment

In the last article, we discussed the causes of sinus and nose related headaches. These include causes such as:

·        nose allergy,

·        a bent nasal septum blocking the sinus opening or in contact with the    

         opposite nasal lining,
·        a narrowed sinus opening/s with a sinus infection and
·        an obstructed sinus with a negative sinus pressure

Sometimes possibly all of the above can be present in the same person at the same time. All of these conditions can stimulate and irritate the trigeminal nerve, which then generates the headache that we feel.

Treatment begins with the correct diagnosis. A full external and internal endoscopic examination of the nose should be undertaken. In instances when a sinus-related cause is suspected e.g. facial pains above, behind and below the eyes, and at the top of the head, a CT scan of the sinuses can exclude sinus disease. X-ray of the sinuses are traditionally undertaken but for a more comprehensive picture, CT scans provide a great deal more information as well as serve as the roadmap for sinus surgery should that be required.

Usually common things happen commonly, and by far the commonest nasal cause of a headache is inflammation of allergy or infection. If infection is seen, a simple course of antibiotics can be undertaken. Nasal allergy is easily treated also by avoiding the allergen e.g. house dust or pollen, saline nasal irrigation, topical nasal steroids and/or antihistamines. The reduction in the inflammation desensitizes the nasal lining as well as reduces the possibility of nasal lining contact and sinus obstruction.

Perhaps the next most likely cause for nasal irritation is when two opposing nasal linings touch one another forming a trigger point. This is likely to occur when the nasal septum is bent inside the nose. Often the patient would be aware of the bent septum as they are aware of a blocked nose, more on one side than the other although both may be equally blocked.

Sometimes a frank sinus infection is seen on endoscopy. Then antibiotic treatment with nasal decongestants also, would normally suffice, as sinus surgery is not the usual first line treatment modality. However in situations when the sinus condition becomes chronic without relenting or recurrent, then usually a more permanent solution to re-open the sinus drainage and re-vent the sinuses may be indicated. Nowadays, sinus surgery is extremely high tech, using endoscopes for minimally invasive surgery. Surgery is targeted at re-opening the natural openings of the sinuses. To make the surgery even less traumatic, when appropriate, the sinus openings can be re-dilated with inflatable balloons; this technique is known as balloon sinuplasty.

So to summarize, nose and sinus-related headaches are not altogether that uncommon especially today in our polluted modern world. It should be differentiated from all the other causes of headaches by its picture. Treatment of these headaches are usually very successful once the correct diagnosis has been established, as there is often a triggering point that fires off the nerve-endings of the trigeminal nerve that gives us these so-called Sluder’s headaches. You can almost imagine Dr. Sluder himself having a bad headache when he first described it too! 

The Chinese version of this article was published in Hong Kong Economic Journal on 5 Jan 2015