Sinus and nose-related headaches – Why? & Causes

Headaches! We have all had them. There are many causes of headaches but this article relates to that arising from conditions that affect the nose and sinuses. Our nose is very sensitive. It has to be as it forms one of our earliest sense organ for finding food as well as arousing us to the presence of danger from predators or our changing environment. Many of us know the nose as an organ of smell (and therefore flavor) and this sensation comes from the olfactory nerve. The nose however has another nerve supply that provides us with the sensation of heat, cold, dry, humid and of course, pain. This sensation arises from the fifth nerve of our brain called the trigeminal nerve.

 

You all know this nerve, which innervates your face, eyes, nose, sinuses and teeth. It burns and gives you a headache if you do somersaults underwater in the swimming pool or take too much wasabi on your sushi. Your face burns from the inside and your eyes water. This is when your trigeminal nerve is being hyper-stimulated.

 

This same nerve is responsible for the headaches one can get from sino-nasal disease. If someone has nasal allergy, and especially if the septum (the bone inside your nose that separates the right from the left nostril) is bent, the lining of the nose expands considerably. When the hypersensitive linings touches one another, they can cause a localized headache at the top of the head, the temples or the back of the head. This kind of headache, or nerve pain, is known as Sluder’s neuralgia or Sluder’s headache.

 

Our sinuses are air-filled cavities inside our skull. These cavities have very narrow openings into the nose. Again, due to:

 

·        a nose allergy,

·        a bent septum blocking the sinus opening,

·        a narrowed sinus opening/s from recurrent infection

·        or all of the above in the same person at the same time,

 

The sinus opening/s become blocked. When this happens, a negative pressure is generated within the sinus and this can cause facial pains and headaches. If, on the other hand, there is a bacterial infection with pus formation, the pus will build up an intense pressure from within the sinus causing pain too. This change in pressure stimulates the nerve endings in the nose and sinuses, causing a sinus headache.

 

If only specific sinuses are affected like the frontal sinuses above the eyes, then a headache above and behind the eye may be felt.  Sinus headaches are peculiar in that the pain changes in intensity with position, being usually more painful when the head is lowered i.e. tying the shoelaces or picking something from the floor. Also the bony surface of the face just outside the inflamed sinus is painful to applied pressure from outside the face.

 

Naturally, as you now understand that sino-nasal inflammation can cause headaches, you will realize that any infection of the inside of the nose can do this too. Even when we are stressed, the nose lining inside swells up and this can manifest as a headache. Equally cancers of the nose, sinuses and nasopharynx can cause headaches as they stimulate the trigeminal nerve or block the sinus openings. Cancers are thankfully much, much less common than allergies. However in any case, any persistent or recurring headaches is best investigated for its cause and the correct treatment offered.

 

 

The Chinese version of this article was published in Hong Kong Economic Journal on 22 Dec 2014

Epistaxis / Nosebleeds – What to do

Nosebleeds can happen when you least expect it. At the very least, they are alarming especially with small children, and at the worst, possibly life threatening. So what can you do about the bleeding nose and what action should you take after it has stopped bleeding?

The first thing is to stop the “stoppable” bleeding. Bleeding that comes from the front of the nose can be stopped by pressure. All other bleedings from the middle or back of the nose stops only by your own blood clotting or with medical attention. The first thing to do in a nose bleed is place your head forward, breathe through the mouth and press gently but firmly on the soft part of the nose. This is the lowest third of the nose that you can wiggle with your fingers. Placing your head forward means that you will be less likely to choke and swallow your blood, and any continuing bleeding is clear to see. Pressure should be applied for 15 minutes and this is usually more than enough to stop the small bleed, as our blood will effectively clot in less than 3 minutes. If you are on blood-thinning medication, this can take much longer.

After releasing the pressure, if there is no further active bleeding, this suggests that the bleeding is from the front of the nose. Dry weather and a long flight travel in a dry cabin may be the cause and applying some Vaseline ointment inside the nostrils will help. Seeking the early attention of your ENT Physician would be recommended so that a good check up can be done to prevent further bleeds and treating the underlying cause. You can usually expect that the nose will be clearly visualized with an endoscope of the front, middle and back of the nose. Sometimes a scan of the sinuses may be required as the cavities of the sinuses are not usually visible to the naked eye or endoscope. If a bleeding point is identified, it can be electro-cauterized and this is very successful in preventing future bleeding in 90% of cases. If a nasal allergy causing rhinitis exists, this is also easily treated with medication.

If the bleeding is especially heavy and/or does not stop, it is usually from the middle to the back of the nose. Here the reason is because the vessels are larger and we cannot physically press on them as they are situated inside the face. Situations such as this will require immediate attention at your nearest hospital as you may have lost a lot of blood. Your attending doctor’s priority would be to stop the bleeding first. This is usually undertaken with nasal packs placed into the nose. They are uncomfortable to put in but their intention is life saving. They may then possibly refer you to the ENT Physicians to identify with their special endoscopes where the bleeding is coming from, and treat you accordingly. Nowadays modern endoscopes for the body cavities have revolutionized epistaxis care. After identifying the bleeding point, if appropriate, the source maybe cauterized.

 

Nosebleeds are frightening for the sufferer as well as family and friends. Thankfully the majority of nosebleeds are minor and easily stopped by pressure as mentioned above. If the bleeding is unduly heavy and does not stop, urgent hospital attention should be sought.

The Chinese version of this article was published in Hong Kong Economic Journal on 29 Sept 2014

 

Epistaxis / Nosebleeds – Why? & Causes

 

“Epistaxis” is the Latin word for the nosebleeds. Nose bleeding is very common and every one of us has experienced it at least once in our lifetime. As common as it is, 90% of nosebleeds do not have an identifiable cause after investigation. This is not a bad thing as it means that most nosebleeds have no sinister causes.

Our nose is supplied by blood from an internal and external arterial system. The external vascular supply comes from the vessel that brings blood to our face; hence it enter the nose from outside, causes the bleeding from the front of the nose where we get most of the bleeding. The internal vascular supply is more elaborate, coming off the vessels that bring blood directly to the brain. They supply the nose from the back under higher pressure and therefore nose bleed from the internal system tends generally to be more heavier; this is because we cannot press and stop the bleeding at the back for the nose with our fingers and also as the arterial blood pressure is stronger too.

So what causes nose bleeding? Several factors affect and cause nose bleeds. Firstly we need a blood vessel as the source, preferably near the surface of the lining. Vessels in the front of the nose are nearer the surface as the lining is thinner so nose bleeds from the front is therefore commoner. Next we also need a condition that makes the vessel more prone to bleeding. So, for example, if there is an existing inflammation like a nose allergy, infection or sinusitis, there is inflammation of the vessel with an engorgement by blood. Perhaps the wall of the vessel might be weak and breaks easily; we sometimes see this as the sole reason in the elderly population. Trauma from an accident to the nose or repeated trauma by the patient picking his/her nose can break the vessel too.  Obviously nasopharyngeal cancers, cancers of the nose and sinuses, vascular tumors and malformations can cause bleeding too. All tumor growths require a good blood supply to feed their growth and hence may present as a nosebleed early on.

 

Our environment also plays an important part in causing nosebleeds.  Our nose should be moist, and not dry. If it is dry, the lining breaks down and we bleed.  So sudden changes in the environment make the nose drier and can cause bleeding. This happens if we fly especially for long journeys or go from a warm, humid climate to visit a dry climate like a winter skiing holiday in the Alps or if the temperature suddenly drops like during the Winter Solstice in Hong Kong. An underlying condition or drug may also cause dryness of the nose. Patients with radiotherapy to the nose for previous cancer or atrophic rhinitis (an inflammatory condition of the nose that has caused a reduction in the mucus secreting cells of the nose) will predispose the lining of the nose to easy breakdown and bleeding.

Interestingly also the internal passage size of our nose also affects our frequency of nose bleeding too, by creating a drier environment. If one’s nose is narrower on one side, there is more turbulence generated when we breathe normally. This turbulence causes local drying effects, lining breakdown and therefore bleeding. This narrowing can be caused by a deviated septum of the nose, enlarged turbinate from nose allergy or sinus polyps that narrow the passages themselves.

So epistaxis/nosebleeds are common. The cause/s of any nosebleed is varied and is the interplay between the anatomy of the nose, an underlying condition and environment factors. As mentioned earlier, most nosebleeds have no significant cause. However if any nose bleeding persists, recurs and/or is unusually heavy, it is always best to seek an assessment by your ENT Specialist to exclude all causes. Thankfully here too, most causes are easily

treated.
 

The Chinese version of this article was published in Hong Kong Economic Journal on 15 Sept, 2014
      

Nose and throat causes of bad breath

Bad breath….we all have this sometimes, perhaps far more often than we know, and almost always when we do not want it like when we are about to meet an important client or on that important date, wanting to impress. Usually the causes of bad breath are due to foods, drinks and habits like garlic and onions, alcohol and smoking cigarettes, cigars or pipe tobacco. But bad breath can occur in health as much as in illness. Often we are able to tell if the bad breath is due to foods, drinks, smoking or illness.

So what causes bad breath in illness? Essentially our nose, mouth, throat and lower aero-digestive tracts (esophagus, lung, stomach, intestines) are colonized with bacteria at all times. The distribution of the different bacterial types ensures a nice equilibrium for health usually, and the continuous production of saliva and nasal mucus ensures that this population of bacteria remains well controlled. However when a nose and throat condition occurs to change this environment, especially to make it drier than the normal, the balance can change to favor bacterial overgrowth and/or the wrong bacterial type. In any and all situations for diseases causing bad breath, it is the change in the bacterial growth that causes the bad smells.

Let’s first look at the commonest causes of bad breath - a dry mouth. Whether the nose is blocked due to nose allergy or infection, the mouth tends to be drier as the mouth is now used to breath. This slowly changes the bacterial environment. This dry mouth feature is seen amongst us with obstructive sleep apnea and snoring where our noses tend to be blocked especially at night. Also some conditions may cause our salivary glands to shrink and produce less saliva e.g. Sjogren’s disease, radiation therapy, etc.

Mouth breathing has other consequences too. In addition to the bacterial change, a dry mouth predisposes us to gum disease and tonsil infections with consequently more infective bacterial colonization. If you have ever flossed your teeth, you will realize the fetor (bad smell) of the bacterial overgrowth that collects in the gum line. “Furring” of the tongue also occurs with mouth breathing. This means that the skin lining of the tongue becomes thicker and therefore can support more bacterial overgrowth. As for our tonsils, they have craters on the surface with sometimes deep skin-lined fissure that go deep into it. These fissures can collect bacteria with dead skin, be a source of bad breath and in some of us, produce “tonsils stones” which are the smelly soft and yellow-brown balls sometimes seen in the saliva we spit out.

Sinusitis is another cause of bad breath, with the smell coming from the nose. When the sinus openings are blocked, infection with pus can build up in the sinuses. This bad smell may sometimes be noted by the person himself and we call this “cachosmia”.  A more horrible Latin word is “ozaena” where the bad smell is noted by others, and not necessarily by the sufferer. Sufferers with “ozaena” include unfortunate patients with previous radiation therapy to the nose and sinuses, or any disease that can severely damage the natural mucus production of the nose. If it becomes so excessively dry, sometimes with crust formation, “saprophytic bacteria” (bacteria with a liking for dead tissue) dominates, and is the cause for the bad breath. In children, an interesting cause of ozaena is a foreign body e.g. bead, cotton bud, etc., placed in the nose, usually by the child. This becomes a source of infection and bad breath. Removal is necessary as well as to understand if the child is trying to tell us that they have a nose condition that requires treatment.

Thankfully the treatment philosophy is straightforward. Your doctor should investigate the cause and then treat the underlying problem either by medication, surgery or both. In addition, and at all times, good oral and nasal hygiene with good oral rehydration, tooth brushing, flossing, tongue scrapping, and saline nasal douching, should help to ensure  a sweeter breath for the day and night.

The Chinese version of this article was published in Hong Kong Economic Journal on  16 Jun, 2014

Snoring – Cause and possible implications

Snoring! We all have it … but we all deny it … until we are recorded on tape. So what is snoring and what causes this music of the night. 

Snoring in itself is harmless to the person who produces it. It can and does create domestic problems whereby it disturbs the sleep of the partner, and many marriages can be strained by it. Snoring suggests that insufficient air is passing through the airway from the nose to the windpipe. Now this may sound like obstructive sleep apnea syndrome (OSAS) which is a condition that is linked to heart disease, strokes and high blood pressure but (noisy) snoring and (life-changing) OSAS are two very different conditions. How are their linked? Simply put, not every snorer has OSAS but anyone with OSAS will snore. Hence as a sign, snoring should alert someone to the possibility that they may have an underlying obstructive sleep problem, blocked nose, large tonsils, etc. that require medical attention. 

What causes snoring? To understand this, let’s look at the physics of sound production. If we pass air through a small tube fast enough, we create a sound either by the vibration of the turbulent air molecules e.g. by whistling, or when our soft tissue vibrates against another structure e.g. snoring. This explains why not every snorer has OSAS. With OSAS, during the sleep cycle, airflow is reduced until finally no air can pass through, and hence no (snoring) sound is produced. This second part explains why all OSAS patients with upper airway obstruction, will snore. 

In snoring, we are unable to maintain an adequately open upper airway passage (e.g. from blocked nose or large tonsils). Hence our soft tissues are drawn together by the lowered air pressure in our throat when we try to breath. But almost as suddenly as it happens, the soft tissue is pulled back again by its soft tissue attachment that resists this collapsing effort. This vibrating cycle happens very fast. The result is our soft tissue will flap and clap together against one another very fast, producing (the snoring) noise. 

Snoring occurs at one or more than one level of our throat, and at the same time. If the nose is blocked, the low pressure behind our uvula and soft palate causes this to vibrate very quickly hitting the back of the throat, creating a beating sound. The same occurs when the tonsils are large and they clap together very quickly like cymbals. Further down, just as we fall into a deep sleep, all our muscles of the body relax including our tongue and /or epiglottis. The tongue can drop back, momentarily obstructing our airway, and then re-opening again; this again creates a noise like releasing the air from air-filled sausage balloon. 

All of this explains why snoring is so “melodious”. Each level creates its own sound. As each level plays its own music, snoring is like an orchestra to the usually distressed listener. It should be said that although we all laugh and joke about snoring, you can now understand that, in science terms, it suggests a partially blocked and insufficient airway during sleep with poor sleep quality for both “musician” and listener. No one is ever born to snore, and “the music of the night”, may not be such good music after all.

 

In the next article, I will discuss what can be done to investigate and exclude OSAS in snorers, and how snoring can be treated.

The Chinese version of this article was published in Hong Kong Economic Journal on 3 March, 2014