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Your Nose

Posted on August 5th, 2010 - Blog, General

Your Nose: The Guardian Of Your Lungs

You might not think your nose is a “vital organ,” but indeed it is! To understand its importance, all that most people need to experience is a bad cold. Nasal congestion and a runny nose have a noticeable effect on quality of life, energy level, ability to breathe, ability to sleep, and ability to function in general.

Why Is Your Nose So Important?

It processes the air that you breathe before it enters your lungs. Most of this activity takes place in and on the turbinates, located on the sides of the nasal passages. In an adult, 18,000 to 20,000 liters of air pass through the nose each day.

Your Nose Protects Your Health By:

Filtering all that air and retaining particles as small as a pollen grain with 100% efficiency.

Humidifiing the air that you breathe, adding moisture to the air to prevent dryness of the lining of the lungs and bronchial tubes.

Warming cold air to body temperature before it arrives in your lungs.

For these and many other reasons, normal nasal function is essential. Do your lungs a favor; take care of your nose.

TIP: Keep a list of all your medications; know all the potential side effects; and discuss possible interactions with your doctors.

Because the connection between the nose and lungs is so important, paying attention to problems in the nose–allergic rhinitis for instance – can reduce or avoid problems in the lungs such as bronchitis and asthma. Ignoring nasal symptoms such as congestion, sneezing, runny nose, or thick nasal discharge can aggravate lung problems and lead to other problems:

Nasal congestion reduces the sense of smell.

Mouth breathing causes dry mouth, which increases the risk of mouth and throat infections and reduces the sense of taste. Mouth breathing also pulls all pollution and germs directly into the lungs; dry cold air in the lungs makes the secretions thick, slows the cleaning cilia, and slows down the passage of oxygen into the blood stream.

Ignoring nasal allergies increases the chance that you will develop asthma; it also makes asthma worse if you already have it.

So, it is important to treat nasal symptoms promptly to prevent worsening of lung problems.

Tips To Improve The Health Of Your Nose And Lungs:

If your nose is dry, its various functions will be impaired. Try over-the-counter salt-water (saline) nasal mists and sprays to help maintain nasal health. These can be used liberally and at your discretion.

Beware of over-the-counter nasal decongestant sprays; prolonged use of these sprays may damage the cilia that clear the nose and sinuses. Decongestants can become addictive and actually cause nasal congestion to get worse.

Think of your nose when you’re traveling. Air-conditioned cruise ships may have high levels of mold in the cabins. Airplane air is very dry and contains a lot of recirculated particles and germs; a dry nose is more susceptible to germs. Use saline nasal mist frequently during the flight, and drink lots of water.

Medications Prescribed To Treat Nasal Problems:

Be aware of the nasal effects of other medications

  • Diuretic blood pressure medications cause dryness in the nose and throat, making them more susceptible to germs and pollens.
  • Many anti-anxiety medications also have a drying effect on the nose and throat.
  • Birth control pills, blood pressure medicines called beta-blockers, and Viagra can cause increased nasal congestion.
  • Eye drops can aggravate nasal symptoms when they drain into the nose with tears.

Be sure you understand their purpose. Each one is important and plays a separate role in treating nasal symptoms.

The foundation of the treatment of chronic nasal conditions is the regular use of an anti-inflammatory prescription nasal spray, which address all types of nose and sinus inflammation. These sprays should be used only as directed by your doctor. This is in contrast to medications that are inhaled by mouth into the lungs, which often have high levels of absorption into the blood stream. Always aim nasal sprays to the side of the nose; spraying into the center of the nose can cause too much dryness.

Antihistamines effectively relieve sneezing, itching and runny nose, but they have no effect on nasal congestion at least in the short term. Over-the-counter antihistamines cause drowsiness, slow the cleaning function of the cilia, and increase the stickiness of nasal mucus–causing germs and pollens to stay in the nose longer. There are prescription antihistamines that do not have any of these side effects. To achieve this safety, the relief is often slower starting, so patience is required.

Decongestants help to unclog stopped up noses but do very little for runny noses and sneezing. They work much faster to unclog the nose, but to achieve this quick action, there are often side-effects such as dry mouth, nervousness, and insomnia. The correct dose often has to be customized to get the benefit without the side-effects.

Be aware of medication side effects; no medicine works well for all people, and all medications can cause side effects.

Why Do Children Have Earaches?

Posted on August 5th, 2010 - Blog, General

Why Do Children Have Earaches?

To understand earaches you must first know about the Eustachian tube, a narrow channel connecting the inside of the ear to the back of the throat, just above the soft palate. The tube allows drainage — preventing fluid in the middle ear from building up and bursting the thin ear drum. In a healthy ear, the fluid drains down the tube, assisted by tiny hair cells, and is swallowed.

The tube maintains middle ear pressure equal to the air outside the ear, enabling free eardrum movement. Normally, the tube is collapsed most of the time in order to protect the middle ear from the many germs residing in the nose and mouth. Infection occurs when the Eustachian tube fails to do its job. When the tube becomes partially blocked, fluid accumulates in the middle ear, trapping bacteria already present, which then multiply. Additionally, as the air in the middle ear space escapes into the bloodstream, a partial vacuum is formed that absorbs more bacteria from the nose and mouth into the ear.

Why do children have more ear infections than adults?

Children have Eustachian tubes that are shorter, more horizontal, and straighter than those of adults. These factors make the journey for the bacteria quick and relatively easy. A child’s tube is also floppier, with a smaller opening that easily clogs.

Inflammation of the middle ear is known as “otitis media.” When infection occurs, the condition is called “acute otitis media.” Acute otitis media occurs when a cold, allergy or upper respiratory infection, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube.

When fluid forms in the middle ear, the condition is known as “otitis media with effusion,” which can occur with or without infection. This fluid can remain in the ear for weeks to many months. When infected fluid persists or repeatedly returns, this is sometimes called “chronic middle ear infection.” If not treated, chronic ear infections have potentially serious consequences such as temporary or permanent hearing loss.

How are recurrent acute otitis media and otitis media with effusion treated?

Some child care advocates suggest doing nothing or administering antibiotics to treat the infection. More than 30 million prescriptions are written each year for ear infections, accounting for 25 percent of all antibiotics prescribed in the United States. However, antibiotics are not effective against viral ear infections (30 to 50 percent of such disorders), may cause uncomfortable side effects such as upset stomach, and can contribute to antibiotic resistance. Medical researchers believe that 25 percent of all pneumococcus strains, the most common bacterial cause of ear infections, are resistant to penicillin, and ten to 20 percent are resistant to amoxicillin.

Is surgery effective against recurrent otitis media and otitis media with effusion?

In some cases, surgery may be the only effective treatment for chronic ear infections. Some physicians recommend the use of laser myringotomy, using a laser to create a tiny hole in the eardrum. The treatment is done in the doctor’s office using topical anesthesia (ear drops). Laser myringotomy works by providing several weeks of ventilation for the middle ear. Proponents suggest this can reduce the many courses of antibiotic treatment for severe ear infections and eliminates the need for surgical insertion of tubes with general anesthesia.

Before the procedure:

Prior to the procedure, the otolaryngologist will examine the patient for a description of the tympanic membrane (eardrum) and the middle ear space. An audiometry may be performed to assess patient hearing. A tympanometry will be performed that tests compliance of the tympanic membrane at various levels of air pressure. This test provides a measurement of the extent of middle ear effusion, Eustachian tube function, and otitis media.

The procedure: During the procedure, a small incision is made in the ear drum, the fluid is suctioned out, and a tube is placed. In young children, this is usually done under a light, general anesthesia; older patients may have the procedure performed under local anesthesia. There are over 50 different tube designs, all in different shapes, color, and composition. In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time. Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.

After the procedure: Immediately after the procedure, the surgeon will examine the patient for persistent or profuse bleeding or discharge. After one month, the tube placement will be reviewed, and the patient’s hearing may be tested. Later, the physician will assess the tube’s effectiveness in alleviating the ear infection.

What is the most common surgical treatment for ear infections?

The most common surgical procedure administered to children under general anesthesia is myringotomy with insertion of tympanostomy tubes (TT). A tube is inserted in the middle ear to allow continuous drainage of fluid. The procedure is recommended for treatment of: chronic otitis media with effusion (lasting longer than three months), recurrent acute otitis media (more than three episodes in six months or more than four episodes in 12 months), severe acute otitis media, otitis media with effusion and a hearing loss greater than 30 dB, non-responsiveness to antibiotics, and impending mastoiditis or intra-cranial complication due to otitis media.

If the patient is age six or younger, it is recommended that tubes remain in place for up to two years. Most tubes will fall out without assistance. Otherwise, the specialist will determine when the tubes should be removed.

Your ENT physician will recommend the most effective treatment for your child’s ear infection.

When Your Child Has Tinnitus

Posted on August 5th, 2010 - Blog, General

When Your Child Has Tinnitus

Tinnitus is a condition where the patient experiences ringing or other head noises that are not produced by an external source. This disorder can occur in one or both ears, range in pitch from a low roar to a high squeal, and may be continuous or sporadic. This often debilitating condition has been linked to ear injuries, circulatory system problems, noise-induced hearing loss, wax build-up in the ear canal, medications harmful to the ear, ear or sinus infections, misaligned jaw joints, head and neck trauma, Ménière’s disease, and an abnormal growth of bone of the middle ear. In rare cases, slow-growing tumors on auditory, vestibular, or facial nerves can cause tinnitus as well as deafness, facial paralysis, and balance problems. The American Tinnitus Association estimates that more than 50 million Americans have tinnitus problems to some degree, with approximately 12 million people have symptoms severe enough to seek medical care.

This condition is not uncommon in the pediatric population. Although tinnitus in children is as common as in the adult population, children generally do not complain spontaneously of having tinnitus. Researchers believe that the child with tinnitus considers the noise in the ear to be a normal event, as it has usually been present for a long period of time. A second explanation of this discrepancy lies in the fact that the child may not distinguish between the psychological impact of the tinnitus and its medical significance.

Continuous tinnitus can be annoying and distracting, and in severe cases it can cause psychological distress and interfere with your child’s ability to lead a normal life. The good news is that most children with tinnitus seem to eventually outgrow the symptom. It is unusual to see a child carry the problem into adulthood.

If you think your child has tinnitus:

You should first arrange an appointment with your family physician or pediatrician. If the child does not have a specific problem with the ears such as middle ear inflammation with thick discharge then it may be necessary to have your child referred to an otolaryngologist or ear, nose, and throat specialist.

What treatment your child may be offered.

Most people, including children, who are diagnosed with tinnitus find that there is no specific problem underlying their tinnitus. Consequently, there is no specific medicine or operation to ‘cure’ tinnitus. However, experts suggest that the following steps be taken with the child diagnosed with tinnitus:

(1) Reassure the child: Explain that this condition is common and they are not alone. Ask your physician to describe the condition to the child in terms and images that they can understand.

(2) Explain that he/she may feel less distressed by their tinnitus in the future: Many children find it helpful to have their tinnitus explained carefully to them and to know about ways to manage it. This is partly due to a medical concept known as “neural plasticity,”resulting in children’s brains being more able to change their response to all kinds of stimulation. If it is carefully managed, childhood tinnitus may not be a serious problem.

(3) Use sound generators or provide background noise: Sound therapy has been used to treat adults with tinnitus for some time, and can also be used with children. Sound therapy aims to make tinnitus less noticeable. If tinnitus occurs on a regular basis, then the child’s nervous system can, with soundtherapy, adapt to the condition. The sound can be environmental, such as a fan or quiet background music.

(4) Have hearing-impaired children wear hearing aids: A child with tinnitus and a hearing loss may find that hearing aids can help improve the tinnitus. Hearing aids do this by picking up sounds your child may not normally hear, which in turn will help their brain filter out their tinnitus. It may also help them by taking the strain out of listening. Straining to hear can make your child’s brain focus on the tinnitus noises.

(5) Helping your child to sleep with debilitating tinnitus: Severe tinnitus may lead to sleep difficulties for the young patient. Ask your otolaryngologist the best strategy to adopt when the child cannot sleep.

Finally, help your child to relax. Some children believe their tinnitus gets worse when they are under stress. Discuss appropriate stress relieving techniques with your pediatrician or family physician.

What you should know about otosclerosis

Posted on August 5th, 2010 - Blog, General

What you should know about otosclerosis

What Is Otosclerosis?

The term otosclerosis is derived from the Greek words for “hard” (scler-o) and “ear” (oto). It describes a condition of abnormal growth in the tiny bones of the middle ear, which leads to a fixation of the stapes bone. The stapes bone must move freely for the ear to work properly and hear well.

Hearing is a complex process. In a normal ear, sound vibrations are funneled by the outer ear into the ear canal where they hit the ear drum. These vibrations cause movement of the ear drum that transfers to the three small bones of the middle ear, the malleus (hammer), incus (anvil), and stapes (stirrup). When the stapes bone moves, it sets the inner ear fluids in motion, which, in turn, start the process to stimulate the auditory (hearing) nerve. The hearing nerve then carries sound energy to the brain, resulting in hearing of sound. When any part of this process is compromised, hearing is impaired.

Who Gets Otosclerosis And Why?

It is estimated that ten percent of the adult Caucasian population is affected by otosclerosis. The condition is less common in people of Japanese and South American decent and is rare in African Americans. Overall, Caucasian, middle-aged women are most at risk.

The hallmark symptom of otosclerosis, slowly progressing hearing loss, can begin anytime between the ages of 15 and 45, but it usually starts in the early 20’s. The disease can develop in both women and men, but is particularly troublesome for pregnant women who, for unknown reasons, often experience a rapid decrease in hearing ability.

Approximately 60 percent of otosclerosis cases are genetic in origin. On average, a person who has one parent with otosclerosis has a 25 percent chance of developing the disorder. If both parents have otosclerosis, the risk goes up to 50 percent.

Symptoms Of Otosclerosis

Gradual hearing loss is the most frequent symptom of otosclerosis. Often, individuals with otosclerosis will first notice that they cannot hear low-pitched sounds or whispers. Other symptoms of the disorder can include dizziness, balance problems, or a sensation of ringing, roaring, buzzing, or hissing in the ears or head known as tinnitus.

How Is Otosclerosis Diagnosed?

Because many of the symptoms typical of otosclerosis can also be caused by other medical conditions, it is important to be examined by an otolaryngologist (ear, nose and throat doctor) to eliminate other possible causes of the symptoms. After an ear exam, the otolaryngologist may order a hearing test. Based on the results of this test and the exam findings, the otolaryngologist will suggest treatment options.

Treatment For Otosclerosis

If the hearing loss is mild, the otolaryngologist may suggest continued observation and a hearing aid to amplify the sound reaching the ear drum. Sodium fluoride has been found to slow the progression of the disease and may also be prescribed. In most cases of otosclerosis, a surgical procedure called stapedectomy is the most effective method of restoring or improving hearing.

What Is A Stapedectomy?

A stapedectomy is an outpatient surgical procedure done under local or general anesthesia through the ear canal with an operating microscope. (No outer incisions are made.) It involves removing the immobilized stapes bone and replacing it with a prosthetic device. The prosthetic device allows the bones of the middle ear to resume movement, which stimulates fluid in the inner ear and improves or restores hearing.

Modern-day stapedectomies have been performed since 1956 with a success rate of 90 percent. In rare cases (about one percent of surgeries), the procedure may worsen hearing.

Otosclerosis affects both ears in eight out of ten patients. For these patients, ears are operated on one at a time; the worst hearing ear first.

What Should I Expect After A Stapedectomy?

Most patients return home the evening after surgery and are told to lie quietly on the un-operated ear. Oral antibiotics may be prescribed by the otolaryngologist. Some patients experience dizziness the first few days after surgery. Taste sensation may also be altered for several weeks or months following surgery, but usually returns to normal.

Following surgery, patients may be asked to refrain from nose blowing, swimming, or other activities that may get water in the operated ear. Normal activities (including air travel) are usually resumed two weeks after surgery.

Notify your otolaryngologist immediately if any of the following occurs:

  • Sudden hearing loss
  • Intense pain
  • Prolonged or intense dizziness
  • Any new symptom related to the operated ear

Since packing is placed in the ear at the time of surgery, hearing improvement will not be noticed until it is removed about a week after surgery. The ear drum will heal quickly, generally reaching the maximum level of improvement within two weeks.

Voice Disorders

Posted on August 5th, 2010 - Blog, General

Voice Disorders

Most changes in the voice result from a medical disorder. Failure to seek a physician’s care can lead to hoarseness and more serious problems.

Laryngitis

Laryngitis is a swelling of the vocal cords usually due to an infection. A viral infection (a “cold”) of the upper respiratory track is the most common cause for infection of the voice box. When the vocal cords swell in size, they vibrate differently, leading to hoarseness. The best treatment for this condition is to rest or reduce your voice use and stay well hydrated. Since most of these infections are caused by a virus, antibiotics are not effective. It is important to be cautious with your voice during an episode of laryngitis, because the swelling of the vocal cords increases the risk for serious injury such as blood in the vocal cords or formation of vocal cord nodules, polyp, or cysts.

Vocal Cord Lesions

Benign noncancerous growths on the vocal cords are caused by voice misuse or overuse and from trauma or injury to the vocal cords. These lesions (“bumps”) on the vocal cord(s) alter vocal cord vibration. This abnormal vibration results in hoarseness and a chronic change in one’s voice quality, including roughness, raspiness, and an increased effort to talk. The most common vocal cord lesions include vocal nodules also known as “singer’s nodes” or “nodes” which are similar to “calluses” of the vocal cords. They typically occur on both vocal cords opposite each other. These lesions are usually treated with voice rest and speech therapy (to improve the speaking technique thus removing the trauma on the vocal cords). Vocal cord polyp(s) or cyst(s) are other common vocal cord lesions caused by misuse, overuse, or trauma to the vocal cords and frequently require surgical removal after all nonsurgical treatment options (i.e., speech therapy) have failed.

Gastroesophageal Reflux Disease And Laryngopharyngeal Reflux Disease

Reflux (backflow of gastric contents) into the throat of stomach acid can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a foreign body sensation, or throat pain are common symptoms of gastric acid irritation of the throat, called laryngopharyngeal reflux disease (LPRD). LPRD is difficult to diagnose because approximately half of the patients with this disorder have no heartburn symptoms which traditionally accompany gastroesophageal reflux disease (GERD).

Your gastric acid can flow up to the throat at any time. The at-night aspect of LPRD is thought to be the hardest to diagnose because there are usually no specific symptoms while the reflux occurs. Consequently, patients will awake with throat irritation, hoarseness, and throat discomfort without knowing the cause. An examination of the throat by an otolaryngologist will determine if stomach acid is causing irritation of the throat and voice box.

Poor Speaking Technique

Improper or poor speaking technique is caused from speaking at an abnormally or uncomfortable pitch, either too high or too low, and leads to hoarseness and a variety of other voice problems. Examples of this condition are when young adult females, in a work environment, consciously or subconsciously choose to speak at a lower than appropriate pitch and with a heavy voice. Percussive speaking, a voice too loud or focusing on the first syllable of each word, is another improper speaking technique that may result in injury or trauma to the vocal cords and muscles causing “vocal fatigue”.

Other factors leading to improper speaking technique include insufficient or improper breathing while talking, specifically breathing from the shoulders or neck area instead of from the lower chest or abdominal area. The consequence of this practice is increased tension in the throat and neck muscles, which can cause hoarseness and a variety of symptoms, especially pain and fatigue associated with talking. Voice problems can also occur from using your voice in an unnatural position, such as talking on the phone cradled to your shoulder. This requires excessive tension in the neck and laryngeal muscles, which changes the speaking technique and may result in a voice problem.

Vocal Cord Paralysis

Hoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common condition is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rare and is usually manifested by noisy breathing or difficulty getting enough air while breathing or talking. However, one vocal cord can become paralyzed or severely weakened (paresis) after a viral infection of the throat, after surgery in the neck or cheek, or for unknown reasons.

The immobile or paralyzed vocal cord typically causes a soft, breathy, weak voice due to poor vocal cord closure. Most paralyzed vocal cords will recover on their own within several months. There is a possibility that the paralysis may become permanent, which may require surgical treatment. Surgery for unilateral vocal cord paralysis involves positioning of the vocal cord to improve the vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to reposition the vocal cord. Sometimes speech therapy may be used before or after surgical treatment of the paralyzed vocal cords or sometimes as the sole treatment. Treatment choices depend on the nature of the vocal cord paralysis as well as the patient’s voice demands.

Throat Cancer

Throat cancer is a very serious condition requiring immediate medical attention. When cancer attacks the vocal cords, the voice changes in quality, assuming the characteristics of chronic hoarseness, roughness, or raspiness. These symptoms occur at an early stage in the development of the cancer. It is important to remember that prompt attention to changes in the voice facilitate early diagnosis thus early and successful treatment of vocal cord cancer can be obtained.

Persistent hoarseness or change in the voice for longer than two to four weeks in a smoker should prompt evaluation by an otolaryngologist to determine if there is cancer of the larynx (voice box). Different treatment options for this cancer of the voice box include surgery, radiation therapy, and/or chemotherapy. When vocal cord cancer is found early, typically only surgery or radiation therapy is required, and the cure rate is high (greater than 90 percent).

Hoarseness or roughness in your voice is often caused by a medical problem. Contact an otolaryngologist—head and neck surgeon if you have any sustained changes to your voice.

Vocal Cord Paralysis

Posted on August 5th, 2010 - Blog, General

Vocal Cord Paralysis

What Is Vocal Fold (cord) Paresis And Paralysis?

Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box muscles (laryngeal muscles).  Paralysis is the total interruption of nerve impulse resulting in no movement of the muscle; Paresis is the partial interruption of nerve impulse resulting in weak or abnormal motion of laryngeal muscle(s).

Vocal fold paresis/paralysis can happen at any age – from birth to advanced age, in males and females alike, from a variety of causes. The effect on patients may vary greatly depending on the patient’s use of his or her voice: A mild vocal fold paresis can be the end to a singer’s career, but have only a marginal effect on a computer programmer’s career.

What Nerves Are Involved In Vocal Fold Paresis/Paralysis?

Vocal fold movements are a result of the coordinated contraction of various muscles. These muscles are controlled by the brain through a specific set of nerves. The nerves that receive these signals are the:

Superior laryngeal nerve (SLN), which carries signals to the cricothyroid muscle, located between the cricoid and thyroid cartilages. Since the cricothyroid muscle adjusts the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in abnormalities in voice pitch and the inability to sing with smooth change to each higher note. Sometimes, patients with SLN paresis/paralysis may have a normal speaking voice but an abnormal singing voice.

The recurrent laryngeal nerve (RLN) carries signals to different voice box muscles responsible for opening vocal folds (as in breathing, coughing), closing vocal folds for vocal fold vibration during voice use, and closing vocal folds during swallowing. The recurrent laryngeal nerve goes into the chest cavity and curves back into the neck until it reaches the larynx. Because the nerve is relatively long and takes a “detour” to the voice box, it is at greater risk for injury from quite different causes – such as infections and tumors of the brain, neck, chest, or voice box; as well as complications during surgical procedures in the head, neck, or chest regions – that directly injure, stretch, or compress the nerve. Consequently, the recurrent laryngeal nerve is involved in majority of cases of vocal fold paresis or paralysis.

What Are The Causes Of Vocal Fold Paralysis/Paresis?

The cause of vocal fold paralysis or paresis can indicate whether the disorder will resolve over time or whether it is most likely permanent. When a reversible cause is present, surgical treatment will most likely not be recommended given the likelihood of spontaneous resolution of the paresis or paralysis. Despite advances in diagnostic technology, physicians are unable to detect the cause in about half of all vocal fold paralyses. These cases are referred to as idiopathic (due to unknown origins). In idiopathic cases, paralysis or paresis might be due to a viral infection affecting the voice box nerves (RLN or SLN) or the vagus nerve, but this cannot be proven in most cases. Known reasons for injury can include:

Inadvertent injury during surgery: Surgery in the neck (e.g., surgery of thyroid gland, carotid artery) or surgery in the chest (e.g., surgery of the lung, esophagus, heart, or large blood vessels) may inadvertently result in RLN paresis or paralysis. The SLN may also be injured during head and neck surgery.

Complication from endotracheal intubation: Injury to the RLN may occur when breathing tubes are used for general anesthesia and/or assisted breathing (artificial ventilation). However, this type of injury is rare, given the large number of operations done under general anesthesia.

Blunt neck or chest trauma: Any type of penetrating, hard impact on the neck or chest region may injure the RLN; impact to the neck may injure the SLN.

Tumors of the skull base, neck, and chest: Tumors (both cancerous and non-cancerous) can grow around nerves and squeeze them, resulting in varying degrees of paresis or paralysis.

Viral infections: Inflammation from viral infections may directly involve and injure the vagus nerve or its nerve branches to the voice box (RLN and SLN). Systemic illnesses affecting nerves in the body may also affect the nerves to the voice box.

What Are The Symptoms Of Vocal Fold Paralysis/Paresis?

Both paresis and paralysis of voice box muscles result in voice changes and may also result in airway problems and swallowing difficulties.

Voice changes: Hoarseness (croaky or rough voice); breathy voice (a lot of air with the voice); effortful phonation (extra effort on speaking); air wasting (excessive air pressure required to produce usual conversational voice); and diplophonia (voice sounds like a “gargle”).

Airway problems: Shortness of breath with exertion, noisy breathing (stridor), and ineffective or poor cough.

Swallowing problems: Choking or coughing when swallowing food, drink, or even saliva, and food sticking in throat.

How Is Vocal Fold Paralysis/Paresis Diagnosed?

The otolaryngologist—head and neck surgeon will conduct a general examination and then question you regarding your symptoms and lifestyle (voice use, alcohol/tobacco consumption). The examination of the voice box will be undertaken to determine whether one or both vocal folds (cords) is/are abnormal. Determining whether one or both vocal folds are affected is important in the treatment plan. Other tests may be required:

Laryngeal electromyography (LEMG): LEMG measures electrical currents in the voice box muscles that are the result of nerve inputs. Measuring and looking at the pattern of the electric currents will indicate whether there is recovery or repair of nerve inputs (re-innervation) and the  degree of the nerve input problem.   The test involves the insertion of small needles that can measure electrical currents in the vocal fold muscles. During LEMG patients perform a number of tasks that would normally elicit characteristic actions in the tested muscles.

Other tests: Because there is a wide list of diseases that may cause a nerve to be injured, further testing is usually necessary (blood tests, x-rays, CT scans, MRI, etc.) to identify the cause(s) of vocal fold paresis/paralysis.

What Is The Treatment For Vocal Fold Paralysis/Paresis?

The two treatment strategies to improve vocal function are voice therapy, the equivalent of physical therapy for large muscle paresis/paralysis; and phonosurgery, an operation that repositions and/or reshapes the vocal fold(s) to improve voice function.  Normally, voice therapy is a first treatment option. After voice therapy, the decision for surgery is dependent on the severity of the symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for recovery, and cause of paresis/paralysis if known.

If you have notice any change in voice quality, immediately contact an otolaryngologist—head and neck surgeon.

Tonsils and Adenoids PostOp

Posted on August 5th, 2010 - Blog, General

Tonsils and Adenoids PostOp

The tonsils are two pads of tissue located on both sides of the back of the throat. Adenoids sit high on each side of the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both are usually performed concurrently; hence the procedure is known as a tonsillectomy and adenoidectomy or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for about four hours after surgery for observation. An overnight stay may be required if there are complications such as excessive bleeding or poor intake of fluids.

When the tonsillectomy patient comes home

Most children require seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids. Milk products should be avoided in the first 24 hours after surgery. Offer juice, soft drinks, popsicles, and Jell-O (pudding, yogurt, and ice-cream after 24 hours). Some patients experience nausea and vomiting after the surgery caused by the general anesthetic. This usually occurs within the first 24 hours and resolves on its own. Contact your physician if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).

Eating: Generally, there are no food restrictions (other than milk products) after surgery. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of sore throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed several days after surgery. Contact your physician if the fever is greater than 102º.

Activity: Bed rest is recommended for several days after surgery. Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication ceases, and the child sleeps through the night. Travel away from home is not recommended for two weeks following surgery.

Breathing: The parent may notice abnormal snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is not unexpected. Most scabs fall off in small pieces five to ten days after surgery and are swallowed.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room. Bleeding is an indication that the scabs have fallen off too early, and medical attention is required.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (because stimulation of the same nerve that goes to throat also travels to the ear), and a few may incur pain in the jaw and neck (due to positioning of the patient in the operating room).

Pain control: Your physician will prescribe appropriate pain medications for the young patient such as codeine, hydrocodone, Tylenol with codeine liquid, or Lortab (hydrocodone with Tylenol). Generally, an acetaminophen (Tylenol, Tempra, Panadol) teaspoon solution is recommended for regular administration to the patient for three or four days after surgery.

If you are troubled about any phase of your child’s recovery, contact your physician immediately.

Tonsillitis

Posted on August 5th, 2010 - Blog, General

Tonsillitis

What is tonsillitis? Tonsillitis refers to inflammation of the pharyngeal tonsils. The inflammation may involve other areas of the back of the throat including the adenoids and the lingual tonsils (areas of tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent, and chronic tonsillitis and peritonsillar abscess.

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.

Who gets tonsillitis?

Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than two years. Tonsillitis caused by Streptococcus species typically occurs in children aged five to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient’s history often helps identify the type of tonsillitis (i.e., acute, recurrent, chronic) that is present.

What causes tonsillitis?

The herpes simplex virus, Streptococcus pyogenes (GABHS) and Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis.

What are the symptoms of tonsillitis?

The type of tonsillitis determines what symptoms will occur.

  • Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days but may last up to two weeks despite therapy.
  • Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
  • Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical nodes.
  • Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).

 

What happens during the physician visit?

Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history.

A physical examination of a young patient with tonsillitis may find:

  • Fever and enlarged inflamed tonsils covered by pus.
  • Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis associated with the presence of palatal petechiae (minute hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children aged 5-15 years.
  • Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
  • Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
  • Signs of dehydration (found by examination of skin and mucosa).
  • The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise and low-grade fever accompany acute tonsillitis.
  • A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
  • Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.
  • Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw may be present in varying severity.

Treatment

Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended.

Tonsillectomy Procedures

Posted on August 5th, 2010 - Blog, General

Tonsillectomy Procedures

Unfortunately, there may be a time when medical therapy (antibiotics) fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils, causing loud snoring, upper airway obstruction, and other sleep disorders. The best recourse for both these conditions may be removal or reduction of the tonsils and adenoids. The American Academy of Otolaryngology—Head and Neck Surgery recommends that children who have three or more tonsillar infections a year undergo a tonsillectomy; the young patient with a sleep disorder should be a candidate for removal or reduction of the enlarged tonsils.

The tonsillectomy today

The first report of tonsillectomy was made by the Roman surgeon Celsus in 30 AD. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. Today, the scalpel is still the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:

Cold knife (steel) dissection:

Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The procedure requires the young patient to undergo general anesthesia; the tonsils are completely removed with minimal post-operative bleeding. 

Electrocautery:

Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400 degrees Celsius) results in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.

Harmonic scalpel:

This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.

Radiofrequency ablation:

Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil.  The procedure can be performed in an office setting under light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.

Carbon dioxide laser:

Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.

The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in two to five percent of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are adverse to outpatient procedures without sedation.

Microdebrider:

What is a “microdebrider?” The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device.

The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.

Bipolar Radiofrequency Ablation (Coblation):

This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 C°. The advantages of this technique are less pain, faster healing, and less post operative care.

Consult with your specialist regarding the optimum procedure to remove or reduce your child’s tonsils and adenoids.

Tongue-tie (Ankyloglossia)

Posted on August 5th, 2010 - Blog, General

Tongue-tie (Ankyloglossia)

Most of us think of tongue-tie as a situation we find ourselves in when we are too excited to speak. Actually, tongue-tie is the non-medical term for a relatively common physical condition that limits the use of the tongue, ankyloglossia.

Before we are born, a strong cord of tissue that guides development of mouth structures is positioned in the center of the mouth. It is called a frenulum. After birth, the lingual frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins. This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason having tongue-tie can lead to eating or speech problems, which may be serious in some individuals.

When Is Tongue-tie a Problem That Needs Treatment?

In Infants

Feeding

A new baby with a too tight frenulum can have trouble sucking and may have poor weight gain. Such feeding problems should be discussed with your child’s pediatrician who may refer you to an otolaryngologist—head and neck surgeon (ear, nose, and throat specialist) for additional treatment.

NOTE: Nursing mothers who experience significant pain while nursing or whose baby has trouble latching on should have their child evaluated for tongue tie. Although it is often overlooked, tongue tie can be an underlying cause of feeding problems that not only affect a child’s weight gain, but lead many mothers to abandon breast feeding altogether.

In Toddlers and Older Children

Speech

While the tongue is remarkably able to compensate and many children have no speech impediments due to tongue-tie, others may. Around the age of three, speech problems, especially articulation of the sounds – l, r, t, d, n, th, sh, and z may be noticeable. Evaluation may be needed if more than half of a three–year–old child’s speech is not understood outside of the family circle. Although, there is no obvious way to tell in infancy which children with ankyloglossia will have speech difficulties later, the following associated characteristics are common:

  • V-shaped notch at the tip of the tongue
  • Inability to stick out the tongue past the upper gums
  • Inability to touch the roof of the mouth
  • Difficulty moving the tongue from side to side

As a simple test, caregivers or parents might ask themselves if the child can lick an ice cream cone or lollipop without much difficulty. If the answer is no, they cannot, then it may be time to consult a physician.

Appearance

For older children with tongue-tie, appearance can be affected by persistent dental problems such as a gap between the bottom two front teeth. Your child’s physician can guide you in the diagnosis and treatment of tongue-tie. If he/she recommends surgery, an otolaryngologist—head and neck surgeon (ear, nose, and throat specialist), can perform a surgical procedure called a frenulectomy.

Tongue-tie Surgery Considerations

Tongue-tie surgery is a simple procedure and there are normally no complications. For very young infants (less than six-weeks-old), it may be done in the office of the physician. General anesthesia may be recommended when frenulectomy is performed on older children. But in some cases, it can be done in the physician’s office under local anesthesia. While frenulectomy is relatively simple, it can yield big results. Parents should consider that this surgery often yields more benefit than is obvious by restoring ease of speech and self-esteem.