COMMON ENT
CONDITIONS IN ADULTS
Your ENT health and wellbeing is important. At Barrie Tan ENT Head & Neck Surgery, we are your expert resource and specialist clinic for the possible conditions you may be experiencing.
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NOSE
Allergic Rhinitis
What is it?
A medical condition where the tissues in the nose develop an allergic reaction on exposure to inhaled respiratory allergens, allergic rhinitis is the allergic reaction that usually manifests as swelling of the nasal tissues leading to nasal obstruction. There is also excessive mucus production leading to a runny nose.
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What causes the symptoms?
The underlying mechanism is the release of histamine due to the production of IgE antibodies. It is the histamine that is released from the mast cells (special immune response cell) that causes the blood vessels in the nose tissues to dilate and thereby engorging the tissues. It also leads to the nasal tissues producing extra mucus and is responsible for the sneezing tendency.
How do I know I have allergic rhinitis?
Consult an ENT surgeon. He will begin with a history and physical examination. The history likely will probe the possible triggers and symptoms of the allergic rhinitis. Examination would include a Flexible Nasoendoscopy, in which a flexible tube with a camera located at the end allows the surgeon to visualize the insides of the nose and also the throat.
How is allergic rhinitis treated?
There are 2 main forms of treatment. The first is allergen avoidance. You must know what respiratory allergens you are allergic to first before you will know which to avoid. The second is using medication to treat the symptoms and also to reduce the underlying allergy response such as intranasal steroid, antihistamines, topical nasal decongestants and antileukotrienes - a new class of medication that acts on certain immune response pathways to reduce the allergic reaction.
Sinusitis
What is it?
Sinusitis is the inflammation and infection of the air-filled spaces in the bones surrounding the nasal cavity called the paranasal sinuses. It is broadly classified into Acute Sinusitis and Chronic Sinusitis according to the duration of the symptoms. Sinusitis that persists for more than 12 weeks despite medical therapy is termed Chronic Sinusitis.
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What are the symptoms?
For Acute Sinusitis, some symptoms include thick yellowish mucus from the nose, loss of smell, nasal obstruction, facial pain around the eyes, cheeks and forehead, headaches, fever, cough, post nasal drip and bad breath.
How do I know I have Acute Sinusitis?
History and physical examination will be necessary to evaluate the state of the nasal cavity and the openings of the paranasal sinuses and also exclude the presence of complications.
Certain investigations by an ENT surgeon may be necessary to determine the severity of the sinusitis and exclude other conditions or the presence of complications. Investigations can include nasendoscopy, CT or MRI to examine the inside of the sinuses and the bony walls that form the walls of the sinuses, nasal and sinus cultures and allergy testing.
How is sinusitis treated?
Medical treatment includes oral antibiotics, intranasal steroids, antihistamines, topical decongestant sprays and drops, nasal douches, mucolytics and/or painkillers. Occasionally medical treatment as described above fails to treat the sinusitis adequately and the sinusitis persists. In such cases, surgery to open up the openings of the sinuses and debride the infected material from within the sinuses is very helpful. Other situations in which surgery may be warranted is in the presence of any complications of sinusitis. In such cases, emergency surgery may be necessary to prevent worsening of the complications.
Loss of Smell
What is it?
The medical term for loss of smell is called Anosmia. Oftentimes there isn’t a true complete loss of smell but rather a decreased sensitivity to smell, which is known as Hyposmia. Hyposmia and Anosmia can occur suddenly or be progressive.
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How does it happen?
Broadly there are 2 main reasons why patients lose their sense of smell. The first is due to nasal obstruction to the passage of air up towards the roof of the nose. Common causes would include nasal polyps and also excessive turbinate hypertrophy. The other main reason is due to damage to the olfactory nerve fibres. Common causes include sinusitis which may directly damage the nerve fibres during an acute or prolonged period of inflammation. Trauma to the skull base may also sever or damage the nerve fibres as they exit the floor of the brain into the nose. Tumours of the skull base may either obstruct the nasal passage or directly affect the olfactory nerve and compromise its function. Examples include esthesioblastoma. Sometimes inhaling toxic fumes may also cause chemical damage to the nerves.
How is loss of smell treated?
The treatment would depend on the underlying pathology. Nasal polyps are usually treated with oral, intranasal steroids and occasionally with surgery. Sinusitis will need to be treated with systemic antibiotics and surgery may also be necessary to bring the infections under control. Tumours of the skull base will often have to be removed surgically.
Nose Fractures & Trauma
How does it happen?
Because the nose projects from the front of the face, it can be easy to damage it. When there is a knock to the nose, there may be some degree of bleeding from the nose as the skin lining of the nasal cavity is thin and can break easily leading to active bleeding from the broken skin lining. This usually stops within a few minutes with some active compression of the nostrils.
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How does it happen? (Continued)
Trauma to the nose is usually in the form of a knock to the front of the nose. This may cause fractures of the nasal bones. This may result in a deviation of the nose appearance externally. Soon after the trauma, there will be swelling and sometimes bruising around the nasal bridge that will obscure the deviation or prevent an accurate appreciation of the degree of deviation. These nasal fractures should be assessed early by an ENT surgeon especially if there is significant obstruction to nasal breathing. One of the complications of fracture and trauma is bleeding into the nasal septum, which is the wall of cartilage and bone in the centre that separates the right from the left nasal cavities. This leads to a septal hematoma and a swelling that will obstruct the flow of air into the nasal cavities.
How is trauma / fracture treated?
During evaluation of a nasal trauma and nasal bone fracture, a flexible naso-endoscopy will be performed to evaluate the status of the nasal septum to exclude a septal hematoma as well as assess for underlying septal deviations. An x-ray of the nasal bones is often performed to determine if there is any fracture. Then the external appearance of the nose is assessed.
If there is no deviation or deformity to the appearance, nasal fractures can be treated conservatively. If however, there is an external deviation or deformity, then surgery is advocated to reset the bones to a straighter appearance. This can be done within the first 24 hours if the nose swelling is not significant. Otherwise, if there is significant swelling of the external nasal bridge, it is often wise to delay the operation till at least a few days later when the swelling subsides. Surgery can be performed under local or general anaesthesia and involves manipulation of the fracture nasal bones to reduce or reset it into its original straight conformation. This depends if the nasal bones are still fairly mobile. Such simple manipulation is not possible if there has been a long delay after the nasal trauma and the bones have started to fuse and become immobile. As a general rule, manipulation procedures can be performed within the first 14 days of the trauma.
Once the nasal trauma and fracture is fixed, there may be a need to perform a different type of surgery to correct the deformity. This is often called a rhinoplasty or septorhinoplasty. This is necessary not just from a cosmetic point of view but also from a functional point of view as the displaced fragments may cause significant deviation of the nasal septum that leads to nasal breathing obstruction. The rhinoplasty procedure is done under general anesthesia and will require an incision and exposure of the cartilage and bone of the nose with subsequent procedures to refracture the bone, mobilize it and reshape it as well as to augment certain portions of the nose that require more support by reinforcing these portions with additional cartilage.
EAR
Ear Infection
What is it?
The ear can be broadly classified into the outer ear, the middle ear and the inner ear. Infections can occur in any of these three parts of the ear. By far the most common is an infection of the external ear canal. It can happen in an otherwise fully healthy individual and is related often to retained moisture in the ear canal.
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What causes the symptoms?
Otitis Externa (external ear canal infections) usually present with pain and discharge from the ear canal. The ear may oftentimes feel blocked and hearing is often decreased as well. There may be an associated fever in young children but oftentimes adults do not have a fever. The external ear may also appear red and scaly at the opening of the ear canal. These infections are mostly caused by bacteria. However, in quite a few individuals, the infection is caused by special fungi.
Otitis Media is an infection of the middle ear space. This is often the result of an ascending infection from the upper respiratory tract, where bacteria travels up the Eustachian tube opening, located at the back of the nose, up the tube into the middle ear space. This often leads to a sensation of a blocked ear, pain in the ears and occasionally discharge from the ears. In a young child, the signs and symptoms are also a lot more subtle. The child may be irritable, crying and running a fever. At the same time, the child may be seen rubbing the ears and looking generally unwell. A visit to the doctor will reveal that the eardrum is bulging and red on the affected side, with fluid sometimes seen behind the eardrum.
Inner ear infections are often caused by viruses. The infection may involve only the hearing organ, or just the vestibular organ or both organs. The patient may therefore feel one or more of several effects: dizziness that is spinning (vertigo), hearing loss and tinnitus (often described as “ringing in the ear”).
How is it treated?
The treatment of Otitis Externa involves primarily the use of topical antibiotic and antifungal ear drops. This helps to coat the entire ear canal with the medicines to kill the bacteria and fungi. A GP may also sometimes prescribe a course of oral antibiotics. A visit to the ENT surgeon allows the debri and infected material in the ear canal to be thoroughly cleaned. This aids the delivery of the topical ear drops and speeds up the treatment of the infection. This cleaning of the ear canal may have to be performed regularly in the first few weeks.
Treatment of Acute Otitis Media infection traditionally involves a course of oral antibiotics. This is often coupled with the use of nasal decongestants to relieve nasal obstruction. However, the fluid behind the eardrum may remain. If persistent for more than a month, this fluid is often drained by means of a simple procedure called a myringotomy and grommet tube insertion, where a small cut is made on the eardrum and a small plastic tube inserted to allow the fluid to drain out through the ear canal. In children with recurrent episodes of Acute Otitis Media, they should be seen by an ENT specialist who may need to evaluate the child for enlarged adenoids (tissue at the back of the nose) which serve as a reservoir of bacteria in the respiratory tract and a source of obstruction of the eustachian tube. These may need to be removed in a surgery called Adenoidectomy, to prevent further recurrences of Acute Otitis Media.
Treatment of inner ear infections involves the use of steroids to reduce the inflammation and anti-viral medications. Oftentimes, the body clears the infection spontaneously with good and full recovery of function. However, if symptoms persist, it is important to see an ENT specialist as there may be other causes of the symptoms of hearing loss or dizziness.
Ear Wax
What is it?
Vast majority of ear canals are self-cleaning. There are however certain situations where ear wax may accumulate and become impacted in the ear canal. The ear canal then becomes obstructed, such as in patients who wear hearing aids in their ear canals, or where the ear canal is narrow or crooked, thereby making it difficult for ear wax to clear naturally.
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How is it treated?
There are several ways to dislodge and remove ear wax. The "gunshot wash" method is known as ear syringing. In this method, water is rapidly pushed and syringed into the ear canal to dislodge the ear wax. This is available in certain General Practice Medical Clinics as well as in the Ear, Nose, Throat Specialist Clinics. There may be a few problems with this method. The first problem is that it is a "blind" procedure since the ear canal is not visualized while doing this procedure. This may lead to inadvertent damage to the eardrum or ear canal during the procedure. In some patients who have a hole in the eardrum (Tympanic Membrane perforation), water flushed will also enter the middle ear and predispose to infections. Lastly, the water may also lead to rapid expansion of the ear wax which may actually aggravate the impaction.
The safer way to remove ear wax is to have it removed professionally by an ENT surgeon who directly visualizes the external ear canal with a microscope to directly visualize the wax while removing it with suction apparatus or various microscopic instruments. As the surgeon is able to see the ear canal during the procedure, accidental damage to the eardrum and external ear canal can be avoided.
Pulsatile Tinnitus
What is it?
If you are able to hear your own heart beating in your ear(s) and it truly beats in rhythm with your heartbeat or pulse, then this is called pulsatile tinnitus. The cause for your pulsatile tinnitus is due to the pulsation of blood flow being transmitted to the inner ear which then hears the blood flow.
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What causes the symptoms?
The most common cause is when there is blockage of the eustachian tube that ventilates the middle ear space, which is an air filled space located behind the eardrum. This oftentimes leads to accumulation of fluid in this space, a condition called middle ear effusion. Blood vessels in the middle ear effusion then transmits the sound through the fluid to be heard by the inner ear, located directly next to the middle ear. The easiest way to diagnose an effusion would be to perform an otoscopy (examination of the ear canal with a special instrument called an otoscope) and see a yellowish coloration of the eardrum. There are several confirmatory investigations such as a Pure Tone Audiogram (Hearing Test) and Tympanogram (testing mobility of the eardrum) which will reveal a special pattern of hearing loss called conductive hearing loss as well as a poorly mobile eardrum.
The treatment of a Middle Ear Effusion includes treating any associated middle ear infection (Otitis Media) with a course of antibiotics. Persistent Middle Ear effusions, especially one sided effusions, need to be carefully evaluated with a Nasal Endoscope to examine the space at the back of the nose to exclude any tumours that may be occluding the opening of the Eustachian tube that ventilates the middle ear space.
Another cause could be due to an abnormal connection between the arteries and the veins in and around the ear, called Arterio-Venous malformations. These result in abnormally high speed flow of blood in the connecting channels that can be heard by the ear. An auscultation (listening with a stethoscope) of all regions around the ear, on the scalp and cheek and also the eyes is necessary. This will reveal the audible blood flow, called a bruit.
Another potential cause is a tumour of the middle ear that is very vascular and so has substantial blood flow, such as a paraganglioma. The pulsation of the blood through this tumour gets transmitted to the inner ear resulting in the pulsatile tinnitus. An otoscopy will usually reveal the reddish or bluish hue of the tumour behind the eardrum.
How is it treated?
Special imaging investigations such as CT scans and MRI scans, including MR Angiograms and Venograms may be necessary to more fully evaluate these conditions. The treatment of these conditions depends on the size, location and extent of these lesions. Options of treatment include surgery, radiotherapy and embolisation (occlusion of the blood vessels with a catheter threaded up to the vessel).
THROAT
Hoarseness & Loss of Voice
What is it?
In assessing hoarseness, it would be useful to find out whether there had been any preceding vocal overuse, trauma, infections, smoking, inhalation of other toxic chemicals or fumes and reflux symptoms to determine whether there were any aggravating factors that may have led to damage of the laryngeal structures.
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What is it? (Continued)
It would be useful to think about whether the voice change is more accurately described as change in the volume of voice generated, the quality and pitch of the voice that has changed, or a matter of how breathy the voice sounds. Accompanying symptoms of pain and difficulty swallowing are also important clues to the underlying problem.
What are some common conditions that present with hoarseness?
Acute Laryngitis: This is an acute infection and inflammation of the larynx leading to swelling of the tissues of the voice box. The vocal cords usually look swollen and this impairs their mobility leading to a gap in the closure of the vocal cords when speaking, resulting in a leak of air and a breathy voice. This usually is associated with other Upper Respiratory Tract symptoms of sore throat and a cough.
Vocal Cord Nodules: These are sometimes called singer’s nodules or teacher’s nodules. This is due to overuse of the vocal cords leading to a reaction of the vocal cords and small nodules forming on the vocal cords. These nodules prevent the vocal cords from coming together in the midline completely, thereby allowing air to leak through and a resultant breathy voice. These are usually located at the junction of the anterior third and posterior two thirds of the vocal cord and usually occur on both vocal cords.
Vocal Cord polyps and cysts: Polyps may arise from the surface lining of the vocal cords and results again in the vocal cords being unable to come together at the midline to generate a strong clear voice.
Laryngeal Cancer: A tumour of the larynx would impair the fine movement characteristics of the vocal cords and also may impair the mobility of the vocal cord itself if it invades to the deeper structures such as the muscles that move the vocal cords. Smoking is a significant risk factor for the genesis of laryngeal cancer.
Recurrent Laryngeal Nerve Palsy: The nerve that controls most of the movement of the muscles of the voice box is known as the Recurrent Laryngeal Nerve. This nerve runs a long course down the neck into the chest before coming back up to supply the voice box. It runs very close to the thyroid gland. As such, cancers of the thyroid or top of the lungs may damage this nerve and paralyse it leading to hoarseness. Surgery of the thyroid and also the lung and the large blood vessels of the chest may also inadvertently damage this nerve leading to paralysis and hoarseness.
Laryngopharyngeal Reflux Disease: When fluid contents of the stomach reflux up towards the throat, it leads to a condition called laryngopharyngeal reflux. Contact of the stomach acid and fluids will result in swelling and irritation of the larynx which is located just adjacent to the openings of the esophagus (swallowing pipe).
How is it treated?
Treatment of the hoarseness would depend on the underlying medical condition. Surgery may be necessary to remove nodules and polyps or to obtain tissue for biopsy and confirmation before further definitive therapy.
SNORING & BREATHING
Snoring
What is it?
Snoring can affect individuals of all ages including children. They can affect both males and females. It not only disturbs the sleeping partners but may also be an indication of a more serious health hazard called Obstructive Sleep Apnea.
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What is it? (Continued)
Fundamentally, snoring occurs when air passing through the upper airway during sleep causes the soft tissues of the throat to vibrate. Snoring can be measured in terms of its loudness in decibels. Extremely loud snoring which can be heard through walls is called Heroic Snoring. The more the soft tissues of the upper airway vibrate during sleep, the louder the snoring.
Snoring in itself is not a health issue for the snorer. It is a problem for everyone else around the snorer, often leading to poor sleep of bedpartners because they are unable to tolerate the snoring. For the snorer however, snoring is often associated with Obstructive Sleep Apnea. This is a situation where the upper airway narrows during sleep, oftentimes completely. This leads to episodes where the patient is not able to breathe or get any air into his lungs. It is akin to holding your breath under water. This inevitably leads to a drop in the oxygen levels in the blood. When this happens, the brain will attempt to wake the patient up to breathe harder and overcome the obstruction. These wakening attempts break up the sleep during the night and lead to excessive tiredness during the day.
How is it treated?
Snoring may sometimes be position related. Lying supine (face upwards) is often associated with louder snoring for many who are affected. Their snoring improves when they lie on their side. This is because their tongue does not fall backwards when they lie on their side and therefore does not contribute to a narrowing of their airway. A simple solution for snorers is to make it uncomfortable to lie on the back thereby encouraging them to lie on their side so that they snore less.
Obstructive Sleep Apnea (OSA)
What is it?
Obstructive Sleep Apnea (OSA) is a medical condition where the upper airway is narrowed during sleep resulting in poor airflow intake into the windpipe and lungs. This leads to a whole myriad of medical problems.
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What are the symptoms?
The most common symptoms of OSA are snoring, mouth breathing at night during sleep, choking and gasping attacks at night and excessive sleepiness or tiredness during the day. Snoring occurs when the soft tissues of the upper airway vibrate when the air passes through. This often happens because the air passes through at higher speeds due to the narrowed airways and pulls in the surrounding soft tissues, which also tend to be very floppy and lax. Mouth breathing occurs often because the nasal passages are obstructed and narrowed and so breathing through the mouth bypasses the obstruction in the nasal passages.
Choking and gasping attacks at night are due to the brain sending messages to the body to breathe harder to overcome the obstruction in an attempt to get more air. Excessive daytime sleepiness occurs because of frequent interruptions to sleep caused by awakenings. These awakenings happen because the brain is also telling the body to wake up and take a deeper breath. Coupled with the poor oxygenation that accompanies the sleep during much of the night leads to unrefreshed sleep and poor rejuvenation of the brain at night.
How is it treated?
There are many ways to treat OSA. See an ENT for a thorough investigation.
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