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

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

Ear drum perforation – Treatment Options

From our first article, you now understand what might cause a perforated eardrum. Patients with perforated eardrum/s  are likely to suffer from one /both of two related problems. The first is a reduction in hearing as the eardrum is unable to capture the sound waves and effectively translate this into hearing. With some patients, this might be accompanied by a ringing noise in the ear called tinnitus. This happens as our inner ear has a background nerve discharge or “noise” which appears louder when outside voices or environmental noise no longer can enter as well and cover it.

The second condition is a recurrent and infectively discharging ear especially after showering or swimming. This is because the usually middle ear cavity is now easily contaminated from the outside. The perforated eardrum no longer forms an effective seal and barrier of protection for the middle ear cavity.

So what can be done? Usually surgery is undertaken to repair a perforated eardrum that has not healed. This surgery is called a “myringoplasty” which in Latin means myringo = ear drum ; -plasty = repair. This repair can be undertaken either under local or general anesthesia, depending upon the size of the hole and the patient’s condition. In most instances, it is successful in sealing the perforation with a success rate of usually >80%. Sealing the perforation will mean that repeated infections will no longer occur. Usually with the successful myringoplasty surgery, the hearing will also improve as the eardrum is now able to fully capture the sound energy, effectively translating this air energy to move the ear bones more effectively. However this hearing improvement is not always guaranteed. Due to the repeated infections before, there may be scarring in the middle ear cavity which prevents the ear bones from vibrating fully. Or sometimes, the ear bones have been partially or fully destroyed by the repeated toxic infection in the past. If this is so, the ear surgeon would normally repair/replace the ear bone/s either at the same time of the ear drum repair or at a second procedure, depending upon the health of the middle ear tissues.

A perforated ear drum is not a life threatening condition though it can impair one’s quality of hearing. Hence surgery is not the only option. If the ear has not had any infection or the hearing impairment is minimal, a more conservative approach to prevent water getting into the ear and to wear hearing aid, for better hearing, may suffice. This is particular true for the older patient who may not want surgery or be regarded as sufficiently fit for surgery.

For the younger and healthy patient, surgery would probably be the best treatment solution. The high success rate of eardrum repairs as well as the added quality of life years benefit gain, would be immeasurably valuable. After all, hearing well at home, at work and at play, will grant more meaningful social interactions and human relationships with our family, friends and work colleagues.


The Chinese version of this article was published in Hong Kong Economic Journal on December 23, 2013.