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.

Ear drum perforation – Causes and Problems

Our ear and hearing is a most fantastic creation of nature. Sound waves that travel down our ear canal, vibrate our ear drum. This tightly stretched three-layered skin membrane will move. The three ear bones of our ear’s conducting system magnify this movement, and therefore the energy. This magnified energy moves the liquid of our inner cochlea, and their movement in turn, displaces sensory cells that create the electrical impulses that our brain finally understands as sound. Just think about how amazing this simple act of hearing is. Imagine how difficult it is to move the water in a cup just by gently blowing on it as you whisper!

This amplification phenomenon is made possible by our middle ear system that consists of our eardrum and ear bones. The ear drum which is made of a thin skin membrane, acts like a sail that picks up the wind energy of sound, moving the three ear bones that further amplify the energy. Nowhere else can engineers improve on this amplification system and the simplest analogy we have is the hydraulic lift pressure systems we have in our car braking system or in a car hydraulic lift of a garage!

So what happens if this system is broken as sometimes our eardrum can be broken or perforated. When this happens, less energy can be picked up, and naturally we hear less. Also our eardrum seals our sterile middle ear cavity from the bacterial outside world. So when there is a hole, however small it may be, if  irritant soapy water, or dirty contaminated fluid, enters through it into the middle ear, we end up getting a smelly ear discharge and a middle ear infection.

So what can cause us to have ruptured eardrums? Eardrums may perforate due to injury to them either from within or from the outside. Middle ear infections are the commonest infection in children; here pus is formed that bulges and painfully stretches the eardrum until in some cases, it bursts through. Usually these holes healed quickly, but sometimes if they are too large or the infection is not quick in settling, a permanent perforation may ensue. The eardrum can also be broken from the outside; this usually occurs from injury like a toothpick or ear bud, or sometimes from a slap or hit to the side of the head. Here the column of air in the ear canal suddenly acts like a bullet, breaking the eardrum from outside.

Irrespective of the cause, if there is a hole, the possibility of infection arising due to soiling from the outside is always a possibility. In addition, with the formation of a perforation in the eardrum, Mother Nature’s most efficient amplification system becomes less efficient, and the hearing is reduced.

The Chinese version of this article was published in Hong Kong Economic Journal on December 16, 2013.

Dizziness and Vertigo - Treatment

So you have dizziness or know someone who has. What to do and who should one see? If the dizziness also comes with hearing loss, tinnitus or the sensation that the room is turning (vertigo), it is likely that the problem lies with the ear so seeing an ENT Specialist would be appropriate. 

Inner ear problems affecting both the hearing and the balance are generally uncommon. If the hearing reduces suddenly with dizziness, it may be denoted as idiopathic sudden hearing loss. The cause is usually never found (and never known hence idiopathic) but it is suspected to be probably viral or inflammatory in nature. The principle of treatment here is to save the hearing, and the golden period for effective evidence based treatment is within the first 2 weeks. As it is thought to be inflammatory, a 2-week high dose steroid regime to reduce inflammation of the nerve and/or inner ear is prescribed. Medication to improve the blood flow, and therefore the oxygen delivery, to the inner ear is also given. Full or partial hearing recovery, in up to two-thirds of patients, treated in this golden window, may be expected. 

Equally, and thankfully, uncommon is hearing loss associated with tinnitus and an ear fullness sensation, combined with severe vertigo. The dizziness here is so severe, the sufferer is usually unable to stand and starts vomiting. This condition is called Meniere’s disease (after Dr Prosper Meniere, a 19^th Century French Physician). It recovers suddenly, usually within 24 hours, as fast as it attacks out of the blue. Luckily Meniere’s disease is uncommon as sufferers can have several attacks without warning, and can slowly lose their hearing over time. We treat this condition symptomatically, that is to say, we prescribe anti-vomiting medication as required, together with other treatments. Surgery may also be considered for some severe cases. 

A commoner cause of vertigo (dizziness with turning of the room or floor) is a treatable condition called benign paroxysmal positional vertigo (BPPV). Here the sufferer experiences vertigo and nausea whenever he moves the head; they prevent the diziness by keeping the head still. There is no hearing loss or tinnitus. The condition lies with a problem in our balance system. As mentioned in the previous article, our 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 through sensors called otoconia. Sometimes one of these otoconia in one of the tubes becomes hyper-stimulated. When this occurs, the wrong signals are sent to the brain every time the head moves; hence the brain gets confused and “dizzy”. If recognized correctly, the treatment for BPPV is a series of targeted exercises to recalibrate the sensors. It is very effective if diagnosed and done well. 

Finally for all dizziness, we must mention the prescription of the anti-dizzy medications. They work very well and can make a patient feel better very quickly. However they work because they cross our blood-brain barrier, to damp down the brain’s responses, and in doing so can cause the patient to feel drowsy. As the brain is “numbed”, it is also unable to recognize the actual problem, and full recovery may be delayed. Nonetheless they are very helpful in managing dizziness.

Dizziness is really an awful and unpleasant condition to have, and numerous conditions can cause it. If vertigo, tinnitus, ear fullness sensation and/or hearing loss are associated with the dizziness, these are clear signs to the dizzy patient that the ear is probably the cause.

 

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