Earache, most disturbing human experience

Earache (or ear-pain ) is one of the most disturbing of human experiences .Mostly it is due to problem in the ear itself and diagnosis is simple after accurate history and thorough examination of ear, nose and throat.

 Sometimes earache may be referred from pathology of remote areas (known as referred earache). Nerves supplying sensation to ear also supplies to other areas and because of some unexplainable reasons brain gets confused and perceives as earache when in fact problem may be in another part of the body.

 To find out the cause then is a challenge to E.N.T. specialist.

In children sometimes it may be just a reason to escape from school. 

Causes of earache- 

Most common causes of earache are otitis externa, acute otitis media, Eustachian tube blockage and impacted wax

 

I. Causes in the ear-

Pinna- Trauma, Infection, Swelling, Frost-bite, Sunburn. 

Ear-canal- Otitis externa, Impacted wax, Furuncle (boil), Herpes Zoster, Tumor. 

Middle ear- Acute otitis media, Eustachian tube blockage, Glue ear, Aero-otitis media. 

II. Causes outside ear (Referred earache)– 

 1. Via 5th nerve (Trigeminal nerve)-

* Lesion from teeth and jaw- carious tooth, impacted wisdom tooth,

*Temporo-Mandibular joint disorder, 

* Oral cavity and tongue-ulcers,

* Nose and sinuses,

* Nasopharynx- ulcer/infection/after adenoids surgery,

 * Lesions in the salivary glands-mumps/ parotitis.

2. Via IX nerve  (Glossopharyngeal) 

*Lesions of base of tongue- ulcer, tumor,

*Lesions of oropharynx-  Pharyngitis/tonsillitis, Abscess of spaces around tonsil area, Ulcer, After tonsillectomy surgery

*Elongated styloid process stretching IX nerve. 

3. Via X nerve (Vagus nerve)- 

*Lesions in the laryngopharynx -t.b/malignancy,

*Lesions in the larynx-laryngitis,

*Lesions in the oesophagus-F.B./tumor 

4. Via Cervical 2nd and 3rd nerve

*Cervical disc lesions, *Cervical spine arthritis

 

 Otitis externa- it is infection of skin of outer ear and ear canal. Usually it is caused by moisture trapped inside the canal or injury to skin of ear canal during attempts of cleaning the ear.

Touching the ear or pulling the ear worsens the pain and there may be swelling of the ear with blocked ear feeling.

Treatment -Mostly combination antibiotic and steroid ear drops for 7-10 days is required. If swelling is severe a wick soaked with ear drops or ointment is placed in the canal.

Oral antibiotics and analgesics may be prescribed.

Small cotton ball soaked in Vaseline can be used during bathing to avoid water entry into the ear.

If abscess (accumulation of pus) develops, incision and drainage may be required. 

 Impacted wax and foreign bodies- Ear wax is not a disease rather it makes protective layer in the ear canal. Obsessive attempts to remove the wax at home may be dangerous. Impacted wax causing obstruction and foreign bodies are removed by instruments or syringing. If wax is very hard then wax-softening ear drops may be prescribed for 5-7 days before attempting cleaning of ear. 

Eustachian-tube block and glue ear-Eustachian tube communicates the middle ear with nasopharynx. It helps in ventilation of middle ear and drainage of fluid from middle ear. Tube blockage may be because of cold, allergy, sinusitis, adenoids or sore throat, and is more common in children due to shorter tube. Fluid accumulates behind the ear drum (glue ear) and increasing pressure may cause pain in the ear.

Treatment is by antibiotic, oral decongestants, nasal drops and if fluid persists for more than 3 months then a small tube (Grommet) may be placed into ear drum.  

Otitis media-Otitis media is infection of middle ear often spread from cold, flu, sore throat or allergy.

Treatment -antibiotics, pain killer, decongestants oral/nasal and antibiotic ear drops.

 

 Earache may be because of myriad of reasons. A cold pack or hot pack may be applied to the ear to reduce pain along with some safe over the counter pain-relievers. If pain is severe, continuous or associated with hearing problem, dizziness, headache, fever or is simply unexplainable you should visit some medical professional. Please don’t try to experiment with your ear.

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Sinus, Acute sinusitis and treatment

Management of sinusitis has witnessed fundamental change in the last two decades. Nasal endoscopy and CT scan has revolutionized visualization of nose and sinuses.

 

 

 

Basic understanding- (What is Sinus?)

Human skull contains four pairs of hollow air filled cavities connected to the space between nostril and nasal passage; these are called Sinuses (or Para Nasal Sinuses). Sinuses help insulate the skull, reduce its weight and add resonance to voice.

There is 4 major pair of sinuses–
1.Frontal (in the forehead), 2. Maxillary (behind the cheek bones) 3.Ethmoid (between the eyes), 4. Sphenoid (behind the eyes).

sinusitis

 

 

 

Sinuses are lined by respiratory epithelium with Goblet cells to secretes mucus (forming mucus blanket) and cilia (fine hair like structure) to help trap and propel pollutant and bacteria outward to nose through osteum (opening) of sinuses.

 

Most of the sinuses drain into a key area (Osteo-Meatal complex). Thus treatment of sinusitis is focused on this area.

Acute sinusitis


Infection of sinuses is called sinusitis–acute or chronic based on the time span.
Sinusitis may be caused by anything that interfere with airflow into the sinuses and mucous drainage out of the sinuses, usually follow a viral infection, allergy, or irritants.

Most common bacteria involved are streptococcus pneumonae, Haemophilus influenzae, and moraxella catarhalis.

 

 

 

Signs and symptoms of sinusitis depend on which sinus is involved–usually present with:
-nasal congestion and discharge or post nasal drip
-headache, or facial pain, or pain under or around the eyes
-fever

 

 

 

Treatment of acute sinusitis:-

Maxillary sinus is most commonly involved followed by ethmoid, frontal and sphenoid.

 

 

Aims of management are:-

1. To achieve normal healthy sinuses

2. To decrease duration of the symptom

3. To prevent complications

4. To prevent development of acute sinusitis.

 

 

 

 

Most patients of acute sinusitis can be benefitted without many investigations as diagnosis is mainly clinical. Nasal endoscopy for proper visualization of nose and sinuses is important for appropriate management. Endoscopic assessment of nose guide therapy and at the same time accurate pus-swab can be obtained for bacteriological examination.

Sometimes if symptoms persist for longer duration further investigation may be required like examination of mucocilliary mechanism, allergic and immune status of patient and computerized tomography (CT scan) of sinuses.

 

 

 

Medical management:-

Analgesics, antibiotics and decongestants are given to reduce swelling and thus increase clearance and drainage from the sinuses.

Antibiotics–studies have confirmed that acute bacterial sinusitis treated with antibiotics have more rapid resolution of symptoms.

Antibiotics should be effective and should cover wide range of organisms.

In general antibiotics are required for 10 days but in some cases especially recurrent cases up to 2 weeks course may be given.

Usually amoxicillin, ampicillin, co-amoxyclav and cephalosporins are primary drugs of choice. If first line drugs fail then second line treatment is based on culture and sensitivity report of pus aspirated from sinuses by antral lavage.

 

 

 

Nasal decongestant drops–Nasal decongestant or steroid drops or sprays are used to decongest sinus osteum and thus encourage drainage.

Clinicians prefer long acting preparation because of less rebound phenomena. Topical decongestant drops should not be used for long duration as it back fires and person develops “rhinitis medicamentosa.”

 

 

 

Oral decongestant or mucolytics–may be used to reduce mucosal inflammation. In general antihistamines are to be avoided in acute bacterial sinusitis because it will thicken and dry the secretion.

 

 

 

Analgesics–any suitable and safe pain killer medicine acetaminophen or ibugesic are prescribed to relieve pain.

 

 

 

Home care–

Steam inhalation— plain water or medicated steam with menthol provides relief from symptoms and helps in improving sinus drainage.

 

Hot fomentation–application of warm cloth, hot water bottle or gel pack to face for 5-10 minutes relieves pain and inflammation to some extent.

 

Saline irrigation, Nasal wash or “jala neti” –-nose and sinuses should be washed by ¼ tsf salt in 1 cup water using bulb syringe or alternatively commercially available saline nasal sprays can be used.

 

Avoidance of allergy if any

Use of humidifier
Avoidance of irritants

 

Baloon Sinuplasty it’s new nonsurgical technique which is cost effective.

A balon is placed in the affected nasal cavity, inflated for short duratin to open up sinus passageways.  

Surgical management-

 

Usually acute sinusitis is treated by medicines. Most cases of acute maxillary sinusitis resolve with effective and proper medical management. Very rarely when medical treatment fails surgical approach is required.

 

Surgical treatment is reserved for-

Failure of medical management

Severe pain

Impending complications.

 

Antral lavage-

This is opd procedure under local anaesthesia where medial wall of maxillary sinus is punctured in the region of inferior meatus, sinus is drained and irrigated. Now this technique is rarely employed and endoscopic enlargement of middle meatus is preferred.

Frontal sinuses wash outs-

This is done in general anaesthesia. Small incision is given below eyebrow medially.

 

 

 

Functional Endoscopic sinus surgery-

Recurrent acute bacterial sinusitis or sinusitis of long duration unresponsive to medicine is major indication for endoscopic sinus surgery.

Endoscopic surgery is minimally invasive surgery. It does not require skin incisions and done by endoscope inserted through nose.

CT scanning is must before surgery.

One thing to be remembered-meticulous postoperative cleaning is equally important for success as is the expertise of surgeon.

 

 

 

 

Treatment plan for acute sinusitis may vary according to experience of treating physician, but it is crucial to understand the importance of “osteomeatal region”.

 

Effective medical management requires good doctor-patient understanding. Medical professional should take time for patient to educate them on importance of taking antibiotics regularly and in proper doses as advised. Often it is irregular time interval and missed doses which create resistant bacteria leading to failure of medical treatment.

 

From my article at helium.com- http://www.helium.com/items/1269826-treatment-of-acute-sinusitis

How to clean the wax?

Most frequently asked question by people visiting ENT clinic is how to clean the ear and if I tell them it is not required, they will look at me puzzled and ask “then how to clean the wax?”

earwax1

Wax is normal secretion by glands of skin of ear canal just as sweat produced by glands of skin. Wax is normal protective layer for the sensitive skin of ear canal. This coating helps repel water& traps dust particles & when you clean it out you make your ear more vulnerable to infection.

 

Usually small amount of wax is secreted which comes out by its own, a process helped by jaw movement.

 


Chronic cleaning of ear causes dryness leading to itching, scratching and if you are cleaning it daily you know vicious circle. Continues itching may cause damage of skin and in turn bacterial & fungal infections.
Sometimes accidentally if you dig down too deep you may hurt your ear-drum (I have seen patients having ear bleed when they were doing cleaning jobs religiously & there kids just jumped over them). You will be amazed to see the concentration focused on ear cleaning.

 


Excess, hard wax causing obstruction is to be removed (20% of population have tendency to accumulate wax because of anatomical reasons), but if you try this by yourself you tend to push it further inside causing impacted wax and related problems like blocked ear, ear-pain, swelling in the ear and list doesn’t end here.

Even most educated patients are very ignorant about ear and use anything they have in their hands to insert in the ear. Anything means anything they find which can go inside the ear- hair-pins, pen, pencil, paper, keys, and recently I removed a bulb of decoration-lights for “diwali” accidently trapped inside the ear while trying to clean it.

 

But really nothing is safe not even so called sterile ear-buds available at chemist shop.

 

Now, I hope you got the point, I usually tell my overenthusiastic patients “ear cleaning is useless job, you don’t need it if you don’t have the excess wax & you won’t be able to remove it if you have excess wax.”


And yes it becomes a habit. People will often deny this fact, very difficult at times to convince them.

Management of hearing loss; Hearing loss is more evident than Hearing-aids

Hearing loss in adult should be evaluated and managed properly taking care of emotional and social impact of condition on patient & his family. Bilateral hearing loss may affect professional life of a person. Aim is to know the treatable cause and manage effectively to prevent further loss. Sensori-neural loss which can not be cured by medicines should be started with rehabilitation by hearing-aids.

Symptoms of hearing loss:

  • Sound may be distorted, quieter and less clear
  • Patients usually have difficulty in hearing in noisy area or while in a group
  • Problem in hearing over telephone
  • Turn up volume of television/Mp3 player
  • Ask people frequently to repeat the sentence/words
  • Patients often misunderstand what others are saying
  • Patients think others are not speaking well

Evaluation of patient:

Thorough medical history(ear infection, giddiness, tinnitus, past medical illness or medication, trauma, exposure to noise-occupational or otherwise if any).

Clinical examination of Ear-Nose and Throat and patient.

Investigation-Audiometry tests to know degree and type of hearing impairment. Depending on clinical clues CT/MRI may be required.

Most common cause of hearing-impairment in adult is wax and after exclusion of wax tympanic membrane perforation is most common cause.

Management of Hearing loss

Management depends on type and cause of hearing loss; loss is of two types conductive and sensori-neural. Sometimes it may be mixed loss.

Conductive hearing loss:

When something hampering conduction of sound from your ear-canal, ear-drum and ear ossicles to reach inner ear or nerves of hearing.

Can be corrected by medicine and/or surgery, like-

  • Wax or foreign body-removal
  • Eustachian tube blockage or fluid in the middle ear -medicines or by procedure of putting small tube (grommet) in ear drum
  • Infection(otitis media)-Medicines
  • Perforation in ear drum-Surgery(Tympanoplasty)
  • Otosclerosis-stapedectomy& piston placement
  • Any cause in nose/throat is managed by medicine/surgery.

Sensorineural hearing loss:

When problem is in inner ear or nerves of hearing (same as one has weak eye-sight).

Causes-

  • Age -hearing loss after age of 65
  • noise-trauma
  • Menieres disease
  • Post viral infections like mumps, measles, influenza, herpes
  • Ototoxic drugs like aminoglycoside antibiotics (neomycin, streptomycin, amikacin, gentamicin, netilmycin), Salycylates, certain diuretics, antimalarial ( quinine & chloroquine), erythromycin and cisplatinum.
  • Hereditary
  • Immune mediated
  • Endocrine& metabolic disorders
  • Vascular or neurogenic
  • tumor

Management of sensorineural hearing loss

Mostly chronic sensori-neural loss can not be cured and person is prescribed to wear hearing-aids. In bilateral severe to profound hearing loss cochlear implant (electronic device, a part is implanted under skin by surgery) may be successful.

Some treatable causes:

If it is sudden loss, spontaneous recovery may be expected assisted by steroids. Underlying etiology present in 10-15 % should be identified & treated.

Immune mediated -steroids

Tumor-surgery

Ototoxicity-Medicine stopped.

Hearing-Aids–

Though hearing aids are not as good as normal ear but if properly met with fitting requirements it can compensate well for hearing loss.

Hearing aids should be fitted and customized to individual after thorough hearing evaluation by by E.N.T. specialist and audiologist.

Most patients are benefited but there is limitation of sound quality and back ground noise that means it works well in quiet environment but some users have trouble enjoying music and listening in a crowded room.Improving FM (frequency modulation) boosts the performance of hearing aid and hearing aids can be optimally set for music.

Quality of hearing aid is of utmost importance and it takes few days to adjust but eventually initial chaotic sound disappear and person is able to appreciate the difference. Usually patients are happy after few weeks of use often coming to tell us that it has improved their quality of life.

Sensori-neural hearing loss may be shocking news to the patient and his relatives. Good doctor-patient relationship and understanding is required to help accept the fact. Talk with your doctor, friends, family and person with same problem to support you.

Hearing loss in children : Early intervention

  • Why earliest intervention?

 

Our ears are filled with music of our child’s first talk and our heart tries to retain the memory of that sound. But imagine a situation where all you hear is “silence…”.

Hearing loss in children can impair normal development of speech & language, his emotional balance, and academic & intellectual skills. Profound hearing loss can lead to dumbness which can be avoided.

 

 

From birth to first three years of life are important for a child to learn speaking, so early detection and intervention are very important. Babies should be screened for hearing at birth especially high risk ones. Child with mild hearing loss is generally labeled as inattentive or slow learner. But care for your kid and try to find out if he is hearing normally. Hearing should be tested as child grows on slightest suspicion of hearing-deficit by parents, care givers, teachers and family doctors.

 

 

Simple observation at home:

           ·     Birth to 3 months: child startle to loud sound

·     3 to 6 months : turns eyes or head towards sound

·     6 to 12 months : listen attentively to familiar sound, respond to name, initiate some sound and few words like bye-bye

·     15 to 24 months: follow simple commands, repeat phrases.

 

 

When to visit a specialist: warning signs:

·     Delayed mile stones/speech

·     Kid isolating/irritable

·     Difficulty in following verbal instructions

·     Ask for repetition of sentence/word

·     Difficulty listening in noisy surroundings

·     Turn up volume of T.V./radio

·     Have academic problem

·     Have repeated ear infection/blockage.

 

On slightest doubt child should be seen by an Ear-Nose-Throat (ENT) specialist for thorough examination and evaluation of cause of hearing impairment. Audiologist may perform tests to assess degree & type of hearing-loss. Conductive hearing loss is largely preventable and can be managed by medicine or surgery. Sensorineural loss should be managed by hearing-aids.

 

 

 

Management of hearing-impairment:

 

Depends on types of hearing-loss

Conductive: When sound is blocked to reach the inner ear. Causes may be wax, foreign body, allergy, fluid in the middle ear(glue ear), repeated ear infection, or perforation of ear-drum.

Usually it can be prevented and managed by medicine and/or surgery

Sensori-neural: Damage to nerve of hearing or inner ear. May be present at birth or may develop after some fever, oto-toxic medication, loud noise, head/ear trauma, tumors.

Usually it is permanent and requires rehabilitation in the form of hearing-aids or cochlear implants.

 

 

Management of deaf child is team effort. Fitting of hearing aids should be considered as soon as deafness severe enough to impede natural speech development is diagnosed.

Fitting should be done by experts with wide experience in the field for this age group.

Auditory training, speech therapy and psychological counseling are required along with supportive handling by parents, family and teacher.

 

 

Hearing-Aids:-

Hearing-aids are instruments to amplify the sound so that you hear well.

Hearing aids should be customized and fitted as per individual children’s needs.

They come in several shapes and sizes; pocket type, behind the ear, in the ear, in the canal, and smallest completely in the canal.

Digital hearing aids are example of advancing technology in the field and known for greater precision. They convert sound waves and modify the sound to provide clear amplified signal, so noise discomfort can be avoided. Some hearing aids have special characteristics direction setting, telephone setting, audio zoom and FM technology.

 

 

Cochlear implant:–

Child with profound hearing-loss which can not be helped by hearing-aids may be considered for cochlear-implant.

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