Dizziness and Vertigo

Dizziness – if you have ever had it, it is an awful condition to experience. Whether you are a frail grandmother or a strong, able-bodied fireman, dizziness will affect you both equally and disable you just as surely. There are many causes of dizziness but this article will focus only on the dizziness and vertigo caused by conditions that affect the ear and the balance system. What is vertigo? Why is it important? Vertigo is a special type of ear-related dizziness with a hallucination of movement. This means not only does the patient feels he/she is dizzy, they describe the room or floor as moving but we know it is not. Vertigo is very specific for dizziness from our ear and balance system.

 

Our inner ear system consists of the inner cochlea (for hearing) and the vestibular organs (for balance). The fluid that exists between these two systems is the same. Hence in some conditions, we may experience balance problems with hearing loss. In addition, the balance organ of each ear consists of three semi-circular bony tubes in which the fluid sits. These tubes are orientated to pick up movement in three directions (up-down, rotate right-left and sideways right-left). With the semicircular tubes of the other ear set in a mirror image of one another, the head (therefore the brain) is able to sense head movement in all directions of movement. Hence the combined signals from these semicircular tubes (of the balance organs), from both the eyes and from the positional sense organs in our neck muscles, will tell our brain where our head sits in relation to the body, and whether there is motion. The brain does the rest.

 

Perhaps the simplest way to look at ear-related dizziness is to understand

1.    conditions that affect the entire inner ear (hearing and balance) and

2.    conditions that affect only the balance organs alone (balance).

Inner ear diseases are either stimulative (e.g. Meniere’s disease) or paralytic (e.g. viral-induced labyrinthitis), but both will cause dizziness. With Meniere’s-like diseases, the inner ear fluids are under higher pressure, and therefore the patient experiences hearing loss, ear fullness sensation, and dizziness with vertigo. Conversely when the inner ear organ is paralysed / damaged e.g. by a virus of the inner ear, the patient experiences hearing loss but with their vertigo moving in the opposite direction. Of course this s only of academic interest as the patient would not know this as dizziness is simply dizziness. 

Specific types of surgery and drugs can also cause vertigo, either by stimulating or paralyzing, the inner ear function. Brain tumors and strokes of the brain may also cause vertigo and hearing loss too but usually there are other important symptoms that suggest this like loss of vision, speech, etc.

As for conditions that affect the balance organ only, there is only vertigo without hearing loss or symptoms. Remember the semicircular tubes that measure movement in one direction? When they are stimulated / paralysed, we get vertigo. An example of a common stimulative condition that causes only vertigo is benign paroxysmal positional vertigo (BPPV). Patients suddenly feel the room is turning without experiencing any hearing problems, and that the condition only improves if they keep their head still. They will also feel nauseous, vomit, have a racing heart, look pale and sweaty but these symptoms are all secondary to the vertigo. Treat the BPPV, and the rest gets better!

In the next article, I will explain the rationale of treatment.

The Chinese version of this article was published in Hong Kong Economic Journal on October 28, 2013.

Sinusitis – Current state-of-the-art treatment

The treatment of sinusitis depends upon if it is an acute sudden or chronic longstanding infection.  With the acute infection, there is facial pain and swelling with endoscopic evidence of pus at the openings of the sinuses. The treatment consists of antibiotics, decongestant, nasal saline douching and pain relief. Often this is sufficient although sometimes a sinus washout with a maxillary sinus needle may be required. Uncommonly in severe acute cases, the sinus infection can spread to involve the neighboring vital structures like the eye and brain. This can be easily diagnosed and seen on a CT scan of the sinus. Under these circumstances, the sinus is unable to drain itself effectively enough and the infection finds other routes to spread. Treatment here will include endoscopic surgery to drain the affected sinuses in addition to intravenous antibiotics.

Chronic sinusitis, on the other hand, is not usually painful. Here the sinus openings are blocked and narrowed, and the pus within the sinus cannot effectively escape. However the body is unable to completely clear the sinuses of the infection. Sinusitis can be best diagnosed here with a CT scan of the sinus which shows the anatomy of the sinuses and the infection contained within. Based on this CT scan, the ENT Surgeon has a roadmap to surgically operate on the natural sinus openings with an endoscope through keyhole surgery without having to use his knife. Studies have long shown that sinuses must be drained through their own natural openings for the sinus to re-establish its own function again. Drainage openings made into the same sinus at other places other than their natural openings to drain the pus are ineffective. Here the body’s natural clearance pathway will still direct the remaining pus to the “blocked “ natural sinus opening even when a big drainage opening has been made nearby.

More recently in sinus management, there is a trend to offer balloon dilatation of the sinus openings, very much like the balloon expansion of the heart vessels. These balloon tubes are directed through the narrowed bony sinus openings and then expanded to 12 atmospheres of pressure. This expansive pressure pushes open the bony sinus air cells that surround the opening, and immediately the sinus openings are “widened” allowing them to drain and re-ventilate again with air.

Today sinus surgery is minimally invasive and all the surgical wounds are inside the nose. The concept of the surgery is to widen the natural opening of the affected sinus with endoscopic techniques, and therefore to re-establish the natural function of the sinus. This philosophy directs the way we now term modern sinus surgery as FESS (functional endoscopic sinus surgery).

The Chinese version of this article was published in Hong Kong Economic Journal on July 22, 2013.

What is sinusitis? Cause, Symptoms and Signs

What are sinuses?

Sinuses are air-filled bony cavities located in our bony skull.  Usually we all have 4 pairs of sinuses which develop to different degrees of sizes. They are collectively called the para-nasal sinuses as they all surround, and drain into, the central nasal air cavity. Our para-nasal sinuses are made up by the frontal sinuses (above the eyes), the ethmoid sinuses (between the eyes), the maxillary sinusses (below the eyes) and the sphenoid sinuses (in the middle of the skull below our brain).  Our sinuses start to develop from age 2 years, at different rates until we are teenagers.

No one knows for sure what our sinuses are for, and many theories exist. Some anthropologists say, as mankind evolved from fish, sinuses were to reduce the total weight of the skull and allow the head to float in water. However most human biologists believe it is to increase the surface area of our nasal lining so humidification and warming of the air we breathe is more efficient and effective for oxygen respiration, preparing the air before it reaches our lung.

Each of these sinuses communicates with the nasal cavity through its own bony opening or sinus ostium. These ostia are very narrow, usually 2-5 mm in diameter, depending on the sinus. Mucous from the sinus, will only drain out only through its own natural ostium, even though another hole is made into the sinus e.g. by surgery.

So what is sinusitis and what can cause it?

The word sinus-itis mean inflammation of the sinuses. Our sinuses become inflamed when their openings are blocked.  A nasal allergy, say to house dust mite extracts, pollen and /or pollution, is probably the commonest cause of sinusitis. It causes the nasal lining to become swollen and this may block the sinus openings. Also infections with viruses, bacteria and fungus, are other common cause of sinusitis. Surgery for the nose or accidental trauma to the face and nose, are other causes.

When these sinus openings are blocked, the air pressure in the sinus starts to drop as the oxygen in the sinus air is continually absorbed by the body. The person can experience heaviness of the head as well as pain above, below and behind the eyes when this happens. Our sinuses respond to this insult by secreting more mucous so a runny nose may ensue. This mucous can accumulate in our sinuses if the opening remains blocked. Our sinus now becomes like a “warm bowl of soup”. If relief does not come soon to re-open the sinus drainage opening, this “warm bowl of soup” becomes a perfect growing ground for bacteria, and pus then is formed, transforming the inflammation into a full-blown bacterial sinusitis. As the sinus become inflamed with pus, the patient may also complained of a bad smell whilst others around him do not. This is usually from the collection of pus in his nose and sinus.

With the pus accumulation, now the symptoms change. The increasing pus creates a positive pressure inside the sinus, which becomes painful from the distension whilst the bacteria cause the body to respond with a fever. In uncontrolled bacterial sinusitis, the infection may cause the skin and soft tissue outside the sinus to become red, swollen and painful to the touch. As the brain and the eyes are vital neighboring structures, they are therefore at risk of becoming infected too. Thankfully and usually, by now the patient would have seen a doctor for treatment which would include antibiotics, pain relief & fever medication and decongestant. If not, then a brain infection, epileptic seizures, meningitis, double vision and loss of eyesight, may occur. Equally thankfully, it should be remembered that these brain and eye complications are very uncommon complications of sinusitis. By and large, the acute sinus infection subsides completely especially when the pus eventually drains though the sinus opening.

Can sinusitis recur or become long-standing and chronic?

Usually an acute sinusitis attack resolves. However sometimes it can become chronic, which is to say, that the infection remains long term. It is always partially draining (so pain is not a significant symptom) but never draining completely. This occurs as the opening of the sinus has been scarred by infection previously and has become even narrower, limiting the drainage of the pus. A bad smell, recurrent running postnasal drip, vague sinus pressure or pain is usually the symptom at this stage of the disease. Complete healing would usually not occur without some surgery to drain the sinus at this stage of the condition. Also in 30% of cases with maxillary sinusitis, where there is pain and swelling below the eye, the cause is usually the infected root of the premolar tooth on the upper jaw. This root may sit in the floor of this sinus, and will require additional dental treatment before the sinusitis can be cured. Often an X-ray of the sinuses will identify this as the problem.

Sinusitis is a common infection. But sinusitis requiring medical attention and sometimes surgery is uncommon. Facial discomfort with postnasal discharge, odd smell with or without a fever, might suggest an early and ensuing sinusitis. If this progresses, an endoscopic examination of the sinus openings +/- X-ray of the sinuses will usually confirm the diagnosis.

The Chinese version of this article was published in Hong Kong Economic Journal on July 4, 2013.

Otitis media with effusion ( Part 2 ) – Treatment options

Otitis media with effusion, (OME) describes an inflammatory condition of the middle ear cavity where a fluid effusion that fills the middle ear space and dampens the movement of the eardrum; hence hearing is reduced.

This occurs due to a dysfunction of the naturally venting Eustachian tube that connects the middle ear space with the back of our nose. This Eustachian tube normally allows air to enter the middle ear space during swallowing. Hence the eardrum vibrates freely, and normal hearing is maintained. When this fails to take place, the middle ear pressure drops, and a fluid effusion fills the middle ear space.

What are the treatment possibilities? If OME persists, the discomfort and hearing impairment may need treatment. This is especially so for children who need to hear well to speak well, and especially so when the OME condition is affecting both ears at the same time. Hearing aid/s are a possibility but most children and adults do not find them practical for the treatment of OME.

The best treatment is to ventilate the middle ear through another route i.e. via the eardrum. A small surgical cut in the eardrum is first made, and then the fluid effusion is suction out of the middle ear space. A ventilation tube is then placed through the man-made eardrum hole. This ventilating tube is very small and no larger than the tip of a large ballpoint pen. It is made usually of inert silicone and designed to allow passive air entry from outside into the middle ear space. Hence the pressure is equilibrated, the fluid effusion no longer apparent, and the eardrum vibrates as usual with almost minimal hearing loss.

In a cooperative adult with OME, the tube can be placed under local anaesthesia with an operating microscope. In children who are more likely to move or easily frightened, these ventilation tubes are best placed under a quick short general anaesthesia.

The average tube stays in 6-18 months and fall out by themselves without the patients even realising. Longer stay tubes are available which remain until the doctor removes them. These longer stay special tubes are designed for patients who have ear conditions that require repeated reinsertions.

Otitis media with effusion causes hearing loss similar to having water in your ears after a shower. Ventilating tubes are simple solutions to improve the hearing especially if OME persists and is affecting hearing and speech development and learning.

The Chinese version of this article was published in Hong Kong Economic Journal on June 20, 2013.

A good friend of mine was recently treated by me for sleep apnea last year. He is happy to share his personal experience so I thought it would be an educational thing for my blog visitors to understand his experience and recount... from the most important person ever...the patient! Here goes......

James (not his real name), Caucasian, 47 years old, obese 102 kg, hypertension 140/95.  Below is his reported experience.

Q: How did you become aware of your sleep apnea?

A: I started waking around five times a night in a hot sweat after a bad dream that involved a near death experience. At first I thought I was suffering from stress but then did some googling and remember I had heard about sleep apnea from a friend. After reading about it on the Internet, I made an appointment with my family doctor who referred me to Dr Gordon Soo. He was the same ENT Specialist who had removed some nasal polyps from my nose and sinuses a few years earlier.

The consultation in the clinic confirmed I had obstructive sleep apnea which was compounded by my current weight. Dr Soo found I had enlarged turbinates and my septum (the nose bone) was crooked. I could relate to the enlarged turbinates but could not see how bent my septum was inside as my nose looked straight outside. Dr Soo used a nasal spray to reduce the size of the turbinates before scoping my nose to show me. With also a little stretching of the skin on either side of my nose to widen the nasal passages, I breathed better than I could ever remember.

Dr Soo suggested surgery to reduce the size of the turbinates, straighten my nasal septum and to widen the nasal passages. He said the lower extent of any airway obstruction could be further diagnosed by conducting a sleep endoscopy prior to the surgery.

Q: So how did the surgery go?

A: The worst thing you can do is read too much about this or any procedure on the Internet J. A lot of the discussions tend to highlight problems or mention procedures that involved old technology. I had my operation done at the Union Hospital and it is like a hotel. I actually looked forward to it as I knew I would have a couple of days being taken care of and was interested to know how I would recover.

On the day of the surgery, I checked in the morning of the operation after fasting overnight. The sleep endoscopy and the rest of the procedure went smoothly and I awoke a few hours later. I was eating the same evening and able to walk around without assistance.

Q: What was the recovery like?

A: Here’s where it gets interesting. Forget the horror stories about black eyes and pain. Firstly, my eyes were fine and I was watching TV and using my iPad within hours. Secondly, there was little or no pain. That was taken care of with the pharmaceuticals J. Also forget about a blocked nose, difficulty breathing and the painful removal of any nasal packs. Yes, my nose was blocked, but it had been so prior to the operation anyways. Since I only stayed in hospital for one night, I was douching my nose within 24 hours of the operation. Coupled with the nose drops, the special nasal packing I had, started to dissolve and the stitches tightened. The more I douched, the more I started to breathe.

On the third day, with some gentle blowing, big red boogers started to flow out of my nose. This continued for a couple more days and before I knew it, the remaining packing came out, and I was breathing like never before.

Q: It’s been two months, so what’s new?

A: Well, I resumed daily walks within a week of the operation and returned to the pool a fortnight later. As time went by, I felt more energetic. It was a strange feeling of wanting to conquer the world. I have resumed my swimming and walking schedule with vigour. Coupled with Xenical, I have lost about four kilos. I am also sleeping much better and wake only once in the middle of the night. I do not suffer from the urge to wake and pee.

Q: Do you have any other comments?

A: One thing that surprised me was the effect of air pollution in Hong Kong. A couple of weeks after the operation, I traveled to rural Australia where I continued to douche and walk. I slept through the whole night there. When I returned to Hong Kong, I had a blocked nose and I was worried. I kept douching and exercising and found that my sinuses adjusted to the change in weather. I had the same experience when I made trip a few weeks later. In my opinion, I think it’s the pollution, but we’ll have to leave that to the experts.

The other thing I want to say is that if you are suffering from sleeplessness and you have a blocked nose – do something about it. Don’t put up with it. Have the life you deserve. Don’t let sleeplessness endanger you or the people around you….

p.s. I forgot to add that since my surgery, my trough blood pressure is now 120/62 and even lower at other times of the day. I will probably have to revise my hypertension medication.

At our last record, James’ bodyweight had dropped to 92 kg. He has had to change his wardrobe several times and never felt fitter. Probably a good thing, as he recently became a father once again.

Gordon

Otitis media with effusion ( Part 1 )

Otitis media with effusion (OME) describes perfectly the pathology. It describes an inflammatory condition of the middle ear cavity caused by a negative middle ear cavity pressure. This results in fluid being drawn out from the inflamed mucosal lining, into the middle ear space as an effusion.

So how this comes about? What are the symptoms? Our middle ear space cavity connects with the back of our nose by the Eustachian tube. This tube is usually closed, to prevent bacteria from entering the sterile middle ear. However during swallowing, tiny muscles open this tube for a fraction of a second, and air is pushed up the tube, into the middle ear space. This maintains a middle ear air pressure that is the same as the atmospheric pressure outside the eardrum. When the air pressures on either side of our eardrums are the same, our eardrums are at their most flexible and responsive to sounds, and our hearing is at its best.

Normal Eardrum

When middle ear pressure drops, the eardrum is drawn inward and cannot vibrate easily to sounds; hence our hearing becomes impaired. As the inflammation increases, effusion fluid fills the middle ear space. When this fluid contacts the eardrum from within, it prevents it from moving. Now our hearing gets even worse. Hence patients with partial or complete OME suffer with the following symptoms:

• ear pressure sensations  during the descent in an aeroplane,

• bubbling noises during swallowing,

• hearing loss like having water in the ears after a shower,

• ringing noises called tinnitus from within their ears and

• sometimes pain in the ear.

Otitis media with effusion

Any condition that can cause obstruction of the Eustachian tube can cause OME in one or both ears. So what conditions would make the tube less easier to open during swallowing, or cannot open at all. Common causes are nose allergies, viral infection of the upper nasal airway and middle ear infections. Less commonly are tumours like cancers of the naso-pharynx. Of these, treating your nose allergy and taking precautions not to catch a cold, may help in preventing OME.

OME is quite common in children. A Chinese University of Hong Kong study by MCF Tong et al shows that OME in Hong Kong is present in one/both ears of 9% of children aged 2-10 years. This prevalence is no different from similar studies in the West. OME in children can causes hearing difficulties, and therefore speech delay, inattention, poor behaviour and poor school performance as they cannot hear well.  As middle ear infection is the commonest infection of childhood, it is naturally a major cause of OME in kids. A child’s nose is small and narrow, and the immunity of the child remains underdeveloped against the challenge of viruses and bacteria. In addition the rising trend of nasal and food allergies is thought also to be a factor.

In teenagers to adulthood in Hong Kong, middle ear infections are less common. So for adults, when OME is noted, cancer of the nasopharynx is a possible cause and should be excluded by an ENT examination. The south China region has the highest incidence of nasopharyngeal cancer in the world, with about 30 new cases per 100,000 population diagnosed each year. Early diagnosis is vital to good prognosis.

In summary, otitis media with effusion causes blocked ears and hearing loss. It is usually temporary and lasts a few weeks especially after a cold. If it persists, an ear and/or nasopharynx examination is recommended with your doctor. In children, it can cause speech delay whilst in aduts, cancer of the nasopharynx has to be excluded.

The Chinese version of this article was published in Hong Kong Economic Journal on June 6, 2013 and Part 2 will be published in Hong Kong Economic Journal on June 20, 2013.

Hi Friends,

Share with you all a clipping of my interview in TVB Weekly recently on sleep apnea and how it can affect us. Apologies to non-Chinese reading visitors.

Hope that readers will find the article educational. 

This article was published in TVB Weekly 13 May, 2013