WHY THE PALATAL MUSCLES ARE TWITCHING ?

Various causes of tinnitus had been  mentioned  in my previous post and one type of tinnitus was objective , which means others can hear the sound. One of the causes of objective tinnitus is due to repetitive contraction of the muscles  of middle ear and palate ( roof of the mouth). This causes involuntary palatal  movement

also known as palatal tremor or palatal MYOCLONUS and is heard as a click sound.

WHAT ARE THE CAUSES ? 

Two types of palatal myoclonus are there. SYMPTOMATIC  which  is associated with lesions in the brain (brain stem) like stroke and second type is the most common one ESSENTIAL   which is idiopathic (with out any cause) 

WHAT ARE THE FEATURES  ? 

Strong muscle spasms of the soft palate along with clicking sound which is manifested as tinnitus. Palatal myoclonus may be associated with myoclonus in other muscles, like that of face,  tongue, (pharynx ) and larynx( sound box). Contraction of the muscles of the soft palate can cause eustachian tube pressure variations resulting in tympanic membrane vibration. 

WHAT CAN BE DONE? 

Symptomatic  myoclonus has to be investigated for any pathology in the brain stem and treated accordingly. Idiopathic myoclonus are without  any causes. So patient needs reassurance, counselling, medicines given for muscle relaxation. Tinnitus treated by tinnitus retraining therapy. 

This post was for a patient with  the above mentioned condition.  Even though this condition is rare, it can be worrisome to the affected patients. 

DO YOU FEEL INTENSE DISLIKE TO THE SOUND OF SOMEONE CHEWING FOOD?

Some people have strong dislike towards hearing certain repetitive sounds like lip smacking, throat clearing or chewing sound made by others. This condition is known as SELECTIVE SOUND SENSITIVITY SYNDROME or MISOPHONIA. 

WHAT  ARE THE CAUSES ? 

It could be  due to involvement of higher centers, like a problem of Central auditory( hearing) processing pathway, or abnormal activation of certain parts of the brain. It could also be  due to psychological conditioning to repetitive sounds or a defect in serotonin and  of dopamine utilization. Studies are going on to find further cause for this condition. 

WHAT ARE THE  FEATURES  ? 

Trigger factors  are sound produced by other persons, while eating, breathing, whistling, gum chewing, lip smacking, finger nail clipping or clicking top of a pen. These sounds will cause anger, disgust and irritation and the affected person will display avoidance behavior. Sometimes this will lead on to confrontation or the affected person will develop tics. Fewer times the person will try to cope with the situation by mimicking the sound. 

WHAT IS THE TREATMENT ? 

Audiological and sometimes mental health evaluation had to be done. Reassurance, educating the person including his or her family and counseling can be done. Cognitive behavioral therapy, sound therapy, tinnitus retraining therapy or wearing a headphone while the trigger factor is happening also useful. 

Hope this post was useful. 

 

WHY VEHICULAR HONKING IS VERY UNCOMFORTABLE TO SOME

Do you feel like covering your ears tightly , when exposed to sounds like vehicular honking, dog barking or at the sound of your door bell?  It is due to decreased or unusual tolerance to ordinary sounds or it could be a dislike to some sounds. This condition is known as HYPERACUSIS. 

WHAT CAUSES HYPERACUSIS? 

It is due to increased perception of the intensity of sound by the auditory or hearing area in the brain. Sometimes there will be a tingling sensation associated with hearing loss also. 

WHAT ARE THE CONDITIONS WHERE HYPERACUSIS IS PRESENT? 

Facial paralysis ( Bells palsy, Ramsay hunt) as there is dysfunction of normal  protective mechanism (stapedial reflex) . People having migraine, depression, post traumatic stress disorder and hearing loss also will have this. 

WHAT TO DO  ? 

Perform an audiology test and find out the loudness discomfort level, but for some this will cause  discomfort. 

TREATMENT 

Use ear protection devices like ear plugs and  go for counselling and meditation .Tinnitus retraining therapy is also helpful in some cases. 

FUNGAL SINUSITIS... HOW IT CAN TROUBLE YOU

Fungal infection of the nose and sinuses can be troublesome. They are classified  on the basis of invasion into surrounding tissues like blood vessels, and bones and noninvasion. Invasive type is life threatening if not treated promptly. 

WHAT ARE NONINVASIVE TYPES ? 

There are different types of noninvasive, one type is characterized by fungus growing over nasal crusts. The patient will complain of foul smelling odour coming from the nose, and are treated with removal of the crusts and cleaning the area to prevent formation of a fungal ball. FUNGAL BALL  is an accumulated fungal elements within the sinus to form a ball, usually seen in middle aged patients. Treatment is to remove the  fungal ball. 

ALLERGIC FUNGAL SINUSITIS is another type of noninvasive, which is due to an allergic reaction to the fungal elements in the sinuses. Patients are usually  young, with presence of nasal polyp, hypersensitivity reaction and often have  asthma history. There will be eosinophilia and usually it is one sided. They present with nasal block, nasal discharge which is thick sticky yellowish or greenish and  associated polyp . Allergic tests,  radiological investigation and fungal culture will aid in diagnosis. Treated with topical and systemic antifungals. 

WHAT ARE INVASIVE TYPES ? 

They are life threatening, seen in patients with low immunity like uncontrolled DIABETES, malignancy, those on immunosuppressive drugs and other immunodeficiency diseases. Fungal elements invade the soft tissue, blood vessels and  bones  causing destruction and bleeding. There will be cough,  headache, fever ,crusting of nasal mucosa, nasal bleeding with ulceration of nasal mucosa. Bone erosion can cause spread into the orbit  (eye) and brain. Treatment should be done immediately using antifungals. 

Other type is FUNGAL GRANULOMA  where granulomatous tissue  causes bulging of the eyeball nose and sinuses. Granuloma has to be removed and treated with antifungals. 

CHRONIC INVASIVE type are slowly destructive seen in Diabetes, those on immunosuppressive drugs. Fungal elements are seen in nose and sinuses and has to be removed and given antifungals. 

This  topic was  selected to create awareness about fungal infection. 

WHY YOUR SINUSITIS NOT GOING AWAY

When the sinusitis doesn't subside even after  12 weeks, then it has turned chronic. Chronic sinusitis is  of two types, one  associated with nasal  or sinus polyp and  the other without any polyp. 

WHAT ARE THE CONDITIONS PREDISPOSING TO  CHRONICITY

Persistent mucosal edema  or the lining of the nose and sinuses , will have persistent inflammatory edema or  congestion . Persistent infection by bacteria or fungus, be it drug resistant bacteria, or inadequate or irregular treatment in some cases . Impairment or defective mucus drainage from the sinus, due to mucociliary defect  is another cause, it may be congenital or hereditary in some cases . Allergies,  those with asthma, aspirin sensitivity and nasal polyp,  smoking, poor nutrition, acid reflux, immunodeficiency,  patients with chronic inflammatory conditions are also contributory factors. Structural or functional abnormalities also another cause. 

WHAT ARE THE FEATURES ? 

Persistent nasal block, nasal discharge, postnasal discharge, occasional facial pain. Some times nasal polyp will be present, which are basically edematous mucosa, seen as grape like lesions with inflammatory cell infiltrate (on tissue microscopy) . Polyp can be visualized in the nasal cavity, if it's long standing. In some patients there will be only polypoidal changes of the  nose and sinus lining. 

WHAT IS THE  PATHOLOGY ? 

Persistent mucosal inflammation leads to congestion, mucosal edema leading to polypoidal changes or polyp obstructing the sinus openings leading to retention of mucus discharge and infection  by bacteria or fungus. 

HOW CAN IT BE TREATED? 

Medical management is the mainstay of treatment. I am emphasizing this point because some of my patients told me ,that they were initially hesitant to visit an ENT  as they thought that we do only surgeries. We treat  the cases medically first and surgery is for selected cases like those with nasal polyp or any complications, or no response to medicines. 

Medical treatment is aimed at reducing mucosal edema of nose and sinuses in the form of topical and oral medicines. Antibiotics for exacerbations due to infections. Other supportive measures for drainage of mucus also to be done. 

Surgical treatment is reserved for polyp, those people where medical treatment not responding and  for complications of sinusitis. Endoscopic sinus surgeries  and others are performed in such  situations. 

Hope this post was useful. 

(Fungal sinusitis will be dealt later) 

COMPLICATIONS OF SINUSITIS

When the disease progress and extend beyond the sinuses, that means complications has set in , be it from acute or chronic sinusitis. 

WHO ARE PRONE FOR COMPLICATIONS  ? 

Usually children and young adults  because of the thin bony walls of the sinus and the septum. Other factors  are like low immunity, virulence of the infective  bacteria, structural abnormalities of the nose and sinusitis, close relationship of orbit ( eyeball and socket) with the  paranasal sinus, and skull bone with brain. 

MECHANISM OF SPREAD

Infection can spread through the blood and reach adjacent structures, or through bony defect or natural foramina or canal for the passage of blood vessels and nerves. Veins  of the nose have connection with that of dura ( outer covering of brain), so infection spread to the brain from the sinus especially frontal and ethmoid sinuses. 

WHAT ARE THE COMPLICATIONS  ? 

Orbital, intracranial, bony and chronic complications. 

ORBITAL or EYE  complications  manifest as eye swelling, pus or cellulitis  involving the eyelids and orbital contents, double vision , opthalmoplegia ( weakness or paralysis of eyeball muscles) and other symptoms.. If not treated immediately, vision loss ( blindness) and spread to dangerous area like cavernous sinus and brain occurs. Cavernous sinus if involved ,both eyes will be affected and patient will be having high fever ,chills and rigor . 

INTRACRANIAL COMPLICATIONS

Brain  involvement may manifest as headache, fever,  neck stiffness ( meningitis) seizure, drowsiness, double vision and eyepain, 

BONY COMPLICATIONS

Frontal bone over forehead when  affected, there will be osteomyelitis or abscess ( pus collection). Maxillary  bone over the cheek if involved can result in pus collection, osteomyelitis and formation of oroantral fistula, which is a connection between maxillary antrum and oral cavity. 

Other  complications are laryngitis, pharyngitis, bronchitis, ear infection

Mucocele which is a progressive cystic swelling develops as a complication of chronic sinusitis. 

HOW DO YOU MANAGE   ? 

Detail history of illness and Radiological investigations to be done  ,manage according to the area involved. Pus has to be drained. Broad spectrum antibiotics to be given. Supportive treatment also needed. 

THIS POST WAS WRITTEN TO MAKE YOU AWARE OF THE COMPLICATIONS THAT CAN ARISE FROM A SINUSITIS. 

GET TO KNOW ABOUT SINUSITIS

Sinusitis is an inflammation of sinus mucosal lining along with involvement of nose most of the time.

WHAT ARE THE CAUSES? 

 It usually starts after a viral or bacterial infection. Sometimes it can be due to a  secondary bacterial infection after a viral illness. Usually it subsides within 1 to 2 weeks, but if it extends beyond 12 weeks it becomes a chronic condition. Smoking, allergies, some structural and functional abnormalities of nose and sinuses and associated illnesses can predispose a person to  frequent sinusitis. 

WHAT ARE THE SYMPTOMS ? 

Nasal ( nose) block or congestion, nasal discharge, pain over the face, disturbances of smell, discharge from the nose trickling to the throat are some of the symptoms. Those having a eustachian tube dysfunction may experience ear pain or block. 

WHAT IS THE  PATHOLOGY INVOLVED? 

A viral infection invade the mucosal lining causing inflammation and damage, leading to swelling or edema of the mucosa of the sinus opening, there by causing obstruction of the opening. There will be discharge  in the sinus cavities, which will cause pressure sensation and pain and leads  to secondary bacterial infection. It can be due to primary  bacterial infection also. From the associated symptoms we can make out whether it's a bacterial or viral infection usually. Sometimes it could be due to fungal infection also. 

WHY TO TREAT A  SINUSITIS ? 

 it is self limiting in some patients, but there are instances where it can lead on to complications  or become a chronic problem ( will be writing later) . 

Treatment is given to reduce mucosal edema or congestion, to decrease the mucus production and to drain the discharge, along with antibiotics in cases which are having bacterial sinusitis. It includes antihistamines oral and or topical) , mucolytics, decongestants and others. Other measures like steam inhalation also  needed. 

Care should be taken to prevent complications, which can be very serious. 

FLUID IN THE MIDDLE EAR...... WHAT DOES IT MEAN ?

Sometimes fluid collection or effusion can occur in the middle ear ( back of the eardrum). It can lead to various problems.

 WHY DOES IT OCCUR ? 

Usually it occurs after an  upper respiratory infection like common cold. Can be seen in adults and children ( after an acute infection of the ear like acute otitis media, which will be explained later). Other causes of effusion are allergy like NASAL  ALLERGY leading to eustachian tube dysfunction, Barotrauma during flight especially take off and landing time. 

Eustachian tube obstruction  due to adenoid hypertrophy (enlargement) or a tumour like  skull base tumour ( meningioma) which occurs rarely and acid reflux can cause fluid in the middle ear. 

WHAT ARE THE SYMPTOMS OF EFFUSION ? 

The symptoms are hearing loss, ear fullness, tinnitus ( crackling sound) and sometimes imbalance. Sometimes history of smoking, ear infection, nose block,  nasal allergy will be there. IF ONLY ONE EAR IS INVOLVED IT HAS TO BE INVESTIGATED THOROUGHLY AS NASOPHARYNGEAL CANCER CAN CAUSE IT. 

In cancer other symptoms will be there. 

Ear findings in effusion can be present as  tympanic membrane bulge, retraction or as fluid. 

HOW IS IT TREATED  ? 

Patient has to be investigated and audiological test like tympanometry is one of them. Manoeuvres are there which helps in equalizing the middle ear pressure. Medical management includes treating nasal congestion and antiallergic treatment. 

Some patients ask me why they have to use nasal drops when their problem is inside the ear. This is one of such conditions where tube has to be opened in order to relieve the  fluid. 

Sometimes we have to do surgical treatment to let out the sticky glue like fluid from the middle ear. If fluid is present for a longer time it can lead to various problems like  conductive hearing loss. Balloon dilatation of eustachian tube ( ET) is done for recurrent problems. 

WHEN DOES IT RECUR  ? 

This condition occurs recurrently in those patients who have associated NASAL ALLERGY, ET   ABNORMALITIES, AND CHRONIC SINUSITIS. 

If this condition is not treated, it can lead on to  various complications like infection of the middle ear,  hearing problems , tympanic membrane atrophy, perforation and other serious conditions.

Effusion in children will be  explained  later

A TUBAL CAUSE FOR EAR BLOCK

Whenever a patient comes with ear block  which has been there for a long period or present on and off, with normal external ear canal ,we have to suspect tubal dysfunction . 

WHAT IS THIS TUBE ? 

It is Eustachian tube (ET) which connects back of the nose ( nasopharynx) to  the middle ear. The function of the tube is to provide middle ear ventillation, pressure equalization and drainage of secretion from the middle ear. 

HOW CAN IT CAUSE EAR BLOCK? 

Any dysfunction of  the (ET) be it  due to obstruction or patulous nature of the tube can lead to middle ear problems. It can be acute or chronic when it  lasts for more than 3 months. 

WHAT CAUSES  EUSTACHIAN TUBE DYSFUNCTION? 

It occurs after a bout of common cold, nasal congestion, allergic rhinitis  or acidic reflux into the nasopharynx, chronic sinusitis or obstructive causes. There will be mucosal edema (swelling) due to acute or chronic respiratory  tract infections. Cleft palate and adenoid hypertrophy or tumours predispose to tubal dysfunction. 

WHAT ARE THE FEATURES? 

Ringing sensation in the ear, hearing loss, canal fullness, pressure sensation,  giddiness,  recurrent fluid in the middle ear . sometimes it can cause serious ear problems. 

HOW IS IT TREATED? 

Depends on the predisposing factors, medical management, certain manoeuvres, and sometimes surgery in  chronic cases with middle ear effusion ( will be writing later). 

HOPE THIS POST WAS USEFUL. 

THYROID GLAND.... HOW IS IT IMPORTANT

Thyroid  is an endocrine gland and it is situated in front of the neck. It plays a very crucial role in our daily life by  releasing thyroid hormones. 

HOW ARE THEY PRODUCED? 

Gland utilizes the iodine from our food, oxidises it and bind  to tyrosyl residues in the thyroglobulin ( produced by  thyroid cell organelle like EPR) to form iodothyronine which  undergo oxidative coupling to form thyroid hormones. Hormone production is regulated by higher centres like pituitary gland and hypothalamus.

WHY THYROID HORMONES ARE IMPORTANT? 

Function of various organs depend on this hormone, by stimulating the metabolism of the cell and activity. There by, these hormones regulate energy homeostasis( maintaining stability or balance in the tissues or organs) . Thyroid hormones are essential for the development of fetus( baby inside the uterus) and newborn babies, especially for their brain development and normal growth. So it is very important to know the hormone levels of a person especially pregnant person. 

OTHER HORMONE PRODUCED BY THYROID

Calcitonin is produced by parafollicular C cells of the thyroid gland. It is important in maintaining calcium level in the body. Calcium is important for various functions of our body. 

FACTORS AFFECTING THE THYROID HORMONES

Iodine deficiency, Disorders of the thyroid gland,  autoimmune conditions affecting the gland,  problems  of the pituitary and hypothalamus can affect the hormone levels.

 INCREASED OR OVER PRODUCTION AND DECREASED OR UNDER PRODUCTION OF THYROID HORMONES CAN AFFECT WELL BEING OF THE PATIENT AND SOMETIMES IT CAN BE  POTENTIALLY LIFE THREATENING ALSO. 

Will be writing about various conditions of the thyroid gland   one by one. 

SLEEP AND IT'S IMPORTANCE

 TODAY ( March 19th) is world sleep day. So  thought  of writing about sleep. Sleep is very important to maintain a good quality of life  and for our mental, physical and emotional wellbeing. Work productivity and cognitive performance will be affected if sleep is affected. 

WHAT HAPPENS DURING SLEEP? 

Sleep onset leads to hypoventilation and decrease in metabolic rate along with loss of voluntary and emotional control of breathing . We have a cycle of light and deep sleep.  During Deep sleep there will be a stage  in which brain is well rested and refreshed  and REM ( rapid eye movement) sleep  ,during that time brain is active . 

WHAT HAPPENS WHEN SLEEP IS DEPRIVED ? 

SUDDEN  sleep deprivation leads to  impaired  psychomotor, cognitive and executive function. There will be hormonal changes also. Sleep deprivation for a longer period, leads to increase in insulin resistance, leading to risk of developing diabetes, high cholesterol, leading to ailment  of the heart and other serious side effects. 

CAUSES OF DECREASED SLEEP 

Emotional stress, work shift, obesity and various sleep disorders like insomnia, sleep related breathing disorders which can lead on to excessive day time sleepiness especially those who snore or have obesity, diabetes and kidney problems. 

WHAT IS INSOMNIA ? 

It is difficulty in initiation of sleep or waking up early or difficulty in sleeping which leads to fatigue, concentration problem and affect intellectual performance. 

SLEEP  DISORDERS CAN BE  DUE TO VARIOUS CAUSES. DETAILED HISTORY HAS TO BE TAKEN  TO IDENTIFY THE CAUSE  AND TREAT ACCORDINGLY , BE IT BEHAVIORAL AND  OR DRUG THERAPY. 

A VERY SERIOUS CONDITION OF THE EAR

There are a few  dangerous or serious  conditions which affects the ear and adjacent structures. One such condition is MALIGNANT OTITIS EXTERNA. 

WHAT IT IS? 

It is a life threatening infection of outer ear canal and base of the skull caused by some bacteria ( gram negative) rarely by fungus  ( aspergillus) also . Rapid spread of infection from the skin and soft tissues of the external ear canal occurs, and if  not controlled by treatment, it can affect bone and structures in the skull base. 

WHO  ARE AFFECTED ? 

DIABETIC patients mainly if it ( diabetes) is uncontrolled, and also patients with low immunity, or those who have other immunocompromised illness. IN Diabetic patients certain changes occur in the body( will be  posting later) so  they are more prone to this. 

WHAT ARE THE FEATURES ? 

Usually it may start as an infection affecting the skin of outer ear canal, then soft tissues like perichondrium (outer covering of cartilage)  and cartilage. If not treated promptly or if diabetes is not controlled, bone and nerves will be affected. When the bone is affected, abscess ( pockets of pus) are formed which leads to necrosis or destruction of the bones. 

SYMPTOMS AND SIGNS

History of otitis externa ( already posted before) will be there usually, and patient will have severe 👂ear pain and purulent or pus containing ear discharge. ON examining the ear ,  if granulations( red  lesions) are present on the   bony cartilaginous junction of external ear canal, it is an omnious sign. Other symptoms depends on the structures involved, if nerves are affected, paralysis of the muscles innervated or supplied by it occurs. Biopsy from the granulations to be done, to rule out cancer or other malignancy

WHAT CAN  BE DONE ? 

TREAT  the condition with antibiotics or antifungals if  fungal elements are present. 

CONTROL DIABETES

NECROTIC tissues has to be removed. 

IF bones are involved as in skull base osteomyelitis,long term treatment is needed, or it can affect structures inside the skull like covering of the brain, nerves, blood vessels and brain itself. 

Cases I have seen were   either  limited to ear canal or complicated with  diabetes, and few patients were having nerve involvement. 

THOSE WHO HAVE DIABETES OR ANY IMMUNOCOMPROMISED CONDITIONS PLEASE TAKE CARE OF YOUR EARS. DON'T POKE  THE EAR  WITH ANY OBJECT AS A MILD INJURY  CAN LEAD ON TO MALIGNANT OTITIS EXTERNA OR NECROTIZING OTITIS EXTERNA. 

JUST BE AWARE OF THIS CONDITION. 

CAUSE FOR EAR ACHE IN A NORMAL EAR

Sometimes you go to an ENT doctor  for earache and the doctor will say your ear is normal. Won't you be confused ?  Yes this condition is known as REFERED  OTALGIA or  REFERED EARACHE. Few days back a patient asked me the same question, he was having  some lesions on his uvula (part of oropharynx) and was experiencing earache . 

WHY IS IT SO ? 

Referred  earache is caused by the nerves, which are sensory (sensation). Few cranial nerves ( arising  from brain) and few cervical ( spinal) nerves  innervate the ear and other structures  equally , so when there is a pathology  ( inflammation or any lesion) on that part, the ear👂 also will experience that pain which is REFERED from the other area. 

MECHANISM

The FIFTH cranial nerve   (trigeminal)  branches into THREE ( am  not going to explain the anatomy in detail as this post is mainly for nonmedicos) and supply upper, middle and lower part of the face and other structures   including a part of the ear. 

The THIRD division of the nerve carries sensation  from anterior ( front) two third of the tongue, floor and roof ( palate) of the mouth, lower teeth, TMJ ( jaw joint) , lower jaw bone and  salivary glands ( which  produce saliva). Any pathology or inflammation in these areas will cause earache as the external ear canal is also supplied by one of its branches. 

Sensory part of SEVENTH cranial  nerve innervates POSTERIOR  (back portion)  and nasal cavity and sphenoid sinus along with the ear. 

NINETH  cranial  nerve  innervates posterior ( back) one third of the tongue, tonsils, nasopharynx ( back of the nose), hypopharynx( part of pharynx near sound box or upper airway structures), parapharyngeal ( side of the pharynx) and retropharyngeal  ( back of the pharynx) spaces along with the ear. 

TENTH cranial nerve supplies vallecula ( behind the tongue) supraglottis( upper part of the larynx or airway) thyroid gland, tracheobronchial tree and esophagus ( food pipe). 

CERVICAL nerves (upper part) supplies muscles and facet joints of cervical region (  back of the neck) along with a part of the ear. So neck muscle spasms or joint problems can cause refered earache. 

CONDITIONS THAT CAUSE REFERED EARACHE

Acute ( sudden onset) tonsillitis, ulcers, injuries  ( ulcer) or cancer  ( late stage in some cases) of oral cavity and oropharynx   like lips, gums, buccal mucosa ( inner lining ) , tongue, uvula and pharynx. 

LPR( laryngopharyngeal reflux), stylalgia( enlargement of a bone ) 

Neck, any pathology in the upper cervical spine, neck muscles can manifest as earache

 Nasal pathologies, Sinusitis, Nasopharyngeal cancers  and other pathologies can cause earache.

 TMJ   and dental  problems can also cause earache

These are some of the causes for referred otalgia( earache)  and other symptoms  and signs will be there, so the source  can be identified. 

WHENEVER YOU HAVE EARACHE AND YOUR EAR IS NORMAL,THESE ARE THE AREAS TO LOOK AT. 

Hope this post was useful. 

WHY MY EAR PAINS ? KNOW THE CAUSES

Ear ache is very troublesome and it can happen to anyone,  at any time. Ear is innervated ( supplied) by numerous nerves which are sensory ,dealing with pain mainly. 

WHAT ARE THE CAUSES ? 

PINNA  or external part of the ear 👂, when it is INJURED ( trauma ,burns like chemical burns or boxing) or when there is inflammation or  ALLERGY leading to redness and swelling of skin. This can lead on to perchondrial ( cartilage covering) involvement . Here pain will be very severe. 

Sometimes  INFECTION  can lead on to pus collection or  Cellulitis( caused by trivial injuries like scratching especially in diabetics). Viral infections like Varicella zoster( chicken pox) cause severe ear pain if vesicles ( fluid filled pimple like)  are present over the ear. Vesicles can be present on the ear canal and if nerve is involved it causes facial palsy ( paralysis) also. Other causes of earache is when there is cancer of the ear or temporal bone ( that houses the ear  and structures of hearing and balance) 

EXTERNAL EAR CANAL  causes are inflammation and infection like otitis externa ( explained already ) malignant otitis externa, chicken pox, any furuncle or boil .Keratosis obturans (already discussed),  hard impacted wax, injury, burns, cancer can lead to severe ear pain. 

TYMPANIC MEMBRANE ( eardrum)  inflammation  , bullous lesion after a viral infection,  injury by using buds or any other materials like pin, or accidents, blasts, crackers, by a LIVE INSECT can cause very severe ear pain. 

MIDDLE EAR infection  causing ear discharge, granulations, bleeding, bone erosion ( destruction) can result in severe pain. EUSTACHIAN TUBE  (that connects  back of the nose and ear ) DYSFUNCTION along with fluid in the middle ear after  acute respiratory infection can cause severe ear pain. 

INNER EAR injury, noise induced  or baro trauma( due to pressure difference)  can also cause  ear pain. 

These are some of the causes for ear pain. 

TREATMENT DEPENDS  UPON THE CAUSE. INFECTIONS  NEED ANTIBIOTICS AND ANALGESICS. PUS HAS TO BE LET OUT. DAMAGED  OR NECROSED CARTILAGE HAS TO BE REMOVED. 

HOPE THIS POST WAS USEFUL. ( Pain in a normal ear will be discussed next) 

WHY THE EAR IS BLOCKED, IF THERE IS NO WAX ?

One question I often been asked is 'why my ears are blocked, if wax is not present ? . Wax is NOT the only cause for earblock. It takes lot of time convincing some patients. Sometimes I will have to show their byestander the patient's ear where the eardrum will be clearly visible . 

I thought of  narrating this because ,thinking  that ear block is due to wax some people self medicate, by using curd, warm oil, hydrogen peroxide, worse incident was using crushed garlic and the patient came with ear bleeding. Some times patients will use OTC medicines, or buy and use, any waxsolvent to dissolve their nonexistent wax and come with inflammation in the ear , or use buds or wick to clean the ear and come up with injury to the ear canal or eardrum or get cotton  inside their ear. 

WHAT ARE THE CAUSES FOR EAR BLOCK? 

EXTERNAL EAR causes like, narrow or stenosed canal, furuncle ( boil), wax, otitis externa, fungal ball, keratosis obturans( already written about it), polyp, granulations, exostosis , foreign body ( especially among kids) 

MIDDLE  EAR  causes are EUSTACHIAN TUBE BLOCK or dysfunction   ( tube that connects the ear and back of the nose( nasopharynx) which aerates  the middle ear ( behind the ear drum). 

Other causes are  fluid , discharge or pus in the  middle ear due to infections like common cold, allergies, sinusitis where tube becomes blocked. Or it could be due to infections of middle ear  with perforation ( hole) in the eardrum or polyp arising from middle ear, or ossicular  (small bones behind the eardrum) pathology.

 INNER EAR  causes  are Barotrauma  (due to pressure difference,while flying or diving) and Noise induced hearing loss ( NIHL)  to name a few. 

Sometimes other  lesions from neighbouring area may press on to the ear and cause ear block, like tumours or vascular ( blood vessels) lesions or malformations . 

MOST OF THE TIME IT'S DUE TO EUSTACHIAN TUBE BLOCK( ETD) OR DYSFUNCTION. 

This post was to make you aware of the various causes of earblock, so that  next time when you experience an ear block, won't instill anything into your ear without  checking.

 HEARING is a precious gift ,when a patient comes to us for a serious bone and soft tissue destroying infections, like cholesteatoma, or tumours, they will be worrying of hearing  rather than clearance of the deadly disease. 

SO  PLEASE TAKE GOOD CARE OF  YOUR EARS 

Will write about eustachian tube block and dysfunction  in detail later. 

HEARING LOSS WITH AGEING....... KNOW THE REASON

As the age advances many changes occur in the body, be it vision, hearing, smell, taste, balance to name a few. Presbycusis or age related hearing loss affects elderly in the age of 60's and it is progressive and affects both ears. This type of hearing loss can affect a person's mental and physical wellbeing as there will be DIFFICULTIES in communication, localizing sound and warning perceptions. 

WHAT ARE THE RISK FACTORS?

Those who had occupational exposure to noise, alcohol consumption, cigarette smoking, associated comorbidities like hypertension( high blood pressure), increased viscosity of the blood, cardiovascular ( heart and blood vessels), cerebrovascular( brain and blood vessels),and gene mutation are some of the risk  or predisposing factors. 

WHAT ARE THE CHANGES THAT OCCUR? 

There will be changes in the tympanic membrane ( ear drum) ossicles( small bones in the middle ear) , degeneration of hair cells( sense organ ) and nerve fibers and also some changes in the hearing  (auditory) processing and pathway. 

HOW DO YOU NOTICE  HEARING LOSS? 

Difficulty in hearing a conversation in presence of background noise, others will have to repeat a sentence, will have to increase the television volume. Tinnitus or ringing sensation in the ear will be present . Sometimes there will be abnormal growth in loudness perception, which can  be annoying if someone talks loudly and can lead on to hesitancy in mingling with a crowd. 

HOW TO MANAGE THE CONDITION ? 

Hear the problem of the person patiently and do audiological( hearing) tests, which will confirm the diagnosis. Condition is progressive, try to REDUCE the background noise while talking to them, try to have a FACE to FACE conversation. Some will need counseling and support. 

Use of wireless headphones for television, louder door bells, alternative alert system, lip reading  can help. Tinnitus retraining therapy and sound therapy for associated tinnitus if it's bothersome. In SEVERE cases ,opt for HEARING AID. Some  are opting for cochlear implant as well in some countries. 

UNDERSTAND THEIR PROBLEM  AND HAVE SOME PATIENCE WHILE DEALING WITH PRESBYCUSIS  PERSONS. 

ENT MANIFESTATIONS OF A REFLUX DISEASE

Symptoms of GERD have been discussed in my previous post like heartburn, dyspepsia, waterbrash and central type of chest pain. Aspiration symptoms appear if GERD is associated with LPR ( laryngopharyngeal reflux). Both the conditions are associated with laxity of lower esophageal sphincter, so gastric ( stomach) secretions enter esophagus and some enter respiratory tract ( nose, nasopharynx, larynx,trachea and bronchus) 

WHAT ARE THE SYMPTOMS OF LPR? 

Patient will have difficulty in swallowing, feeling of a lump in the throat, frequent throat clearing, sore throat,  bad breath, coughing or choking. Breathing may be difficult due to constant  mucus trickling . These are worsened by smoking, alcohol consumption, allergies and GERD. 

WHAT HAPPENS TO THE AFFECTED STRUCTURES? 

The gastric secretions (contain acid and pepsin,) can cause inflammatory changes in the larynx resulting in acidic laryngitis and patient will have voice changes or tiring of voice, and can lead on to swelling, granulations, stricture on the posterior( back)  part of the larynx. Reflux contents can reach nose, nasopharynx and eustachian tube resulting in sinusitis, nasopharyngitis, and fluid in the middle ear( pain or burning sensation  and ear block), aspiration symptoms and infections ( pneumonia especially in immunocompromised) 

COMPLICATIONS

Chronic laryngitis, frequent sore throat, vocal cords edema, ulcer or granulations, worsening of asthma, bronchitis or other respiratory ailments, aspiration pnuemonia and or ear infections. 

HOW TO MANAGE IT? 

Life style  and dietary changes like quit  or decrease alcohol consumption, carbonated drinks, caffeine, fatty  and spicy food and smoking. Weight reduction, frequent small meals, sleeping with head end elevation also can be done. 

Medical management with anti acid and antireflux   medicines. Resistant or complicated cases can be treated with antireflux surgeries. 

LIFE STYLE AND DIETARY CHANGES CAN CONTROL REFLUX TO SOME EXTENT. 

GERD...... REFLUX DISEASE AND HOW TO TACKLE IT ?

Gastroesophageal reflux disease (GERD or GORD) is a condition characterised by certain symptoms which are often precipitated by food, gastric contents  like  gastric acid or by bile from duodenum ( small intestine). 

WHAT ARE THE SYMPTOMS ? 

It may present as heartburn, dyspepsia ( symptoms of indigestion like 

abdominal discomfort, burning sensation ,bloating, nausea ) Waterbrash ( water filling your  mouth) , central or retrosternal chest pain, pain on swallowing, vomiting or regurgitation. Some  ( including me) will have voice changes, sore throat, coughing,  and sinusitis especially if it's associated with laryngopharyngeal reflux or LPR. Aspiration can cause respiratory problems. 

WHAT ARE THE  FACTORS LEADING TO  IT? 

Overweight, overeating, smoking, taking spicy food ,alcohol, and taking food just before going to sleep.  Exercises that cause increase  in  abdominal  pressure can act as a trigger factor ( my personal experience) .Another cause is hiatus hernia  (laxity of sphincter ), which I have explained  before ( previous post). 

WHEN YOU SHOULD WORRY ? 

Investigations to be done, if it's a longstanding problem and if you are over 40 years of age. 

Presence of any pathology, stricture, inflammation has to be checked by performing an endoscopy. Esophageal manometry ( pressure) also to be  done. 

WHAT CAN BE DONE ? 

Life style changes, weight reduction, dietary changes( small frequent feeds) less spice and fat in the diet, medications to reduce acid secretion and reflux.  Some cases need antireflux surgery. 

HOPE this post was useful. 

ENT manifestations of Reflux and LPR will be dealt in my next post. 

DEALING WITH REFLUX.... GERD

Today I will share my experiences as a GERD( gastroesophageal  reflux disease) patient. Since 40 years I have been having the problem of gastritis whenever I have any spicy food. so try to avoid this type of food as often I can. Since 14 years , I have been having reflux and severe aspiration, rendering me breathless and it happens whenever I eat out or have anything a little spicy, sour or fried food items or have coffee. Now my condition is complicated by food allergies ( to gluten, peanut, cheese to name a few)  also . 

Endoscopy revealed diffuse gastritis with hiatus hernia ( stomach herniating up through diaphragmatic opening) and advised surgery, which I didn't opt for and took medication and dietary changes .So from 2014 followed a strict alkaline diet , no coffee, tea, fried or spicy food. 

Once in a while I try to experiment with my diet and end up with severe reflux and aspiration( like yesterday night which was worse) . 

Why I have narrated my  personal experience is that,  some patients with reflux hesitate to follow an alkaline diet and end up with severe aspiration and respiratory infections. 

Will write in detail about Reflux  (GERD) in my next post. 

A CONFUSING TYPE OF HEADACHE

This post is dedicated to a patient who had  terrible headaches, redness of  an eye  and underwent medication for several months, without any relief. Her radiological investigation was suggestive of sinusitis affecting frontal and ethmoid sinus and was treated for the same. After  that she again developed redness of eyes, watering and head ache, and  finally arrived at a diagnosis of CLUSTER HEADACHE (was also seen by a neurologist to rule out any pathology  of higher centres like brain) 

WHAT IS CLUSTER HEADACHE? 

This headache mimicks, migraine and sinusitis. Patient may present with excruciating headaches occuring in clusters, usually one sided. There will be nasal discharge, nasal block, watering and redness from  the eyes. Headache of sudden onset and intense pain involving forehead and jaw of affected side and  it can go on for months. 

PREVENTIVE measures often opted like avoiding direct exposure to sunlight, not to take too much strain on the eyes to name a few. 

When a  headache patient comes with eye and nasal symptoms  always keep in mind the possibility of CLUSTER HEADACHE. This patient had both sinusitis and cluster headache. She is now better after treatment. 

There are other types of aches and pains, like temporal arteritis, trigeminal neuralgia, which will be dealt later. Don't want  readers to get headache after reading   so many types of headaches. 

TENSION TYPE HEADACHE

Tension type headache usually is symmetrical (on both sides of the head). This type will be nonpulsatile unlike migraine and it is felt like tightness or band like across the forehead.

There will be pain on touching the area over the forehead but SHOULD NOT confuse it with sinusitis. 

WHAT ARE THE TRIGGER FACTORS? 

Emotional factors like tension, stress, depression, anxiety may trigger it. Areas in ihe neck and shoulder will be the trigger point. 

WHAT ARE THE REMEDIES? 

Sometimes pain killers WON'T be much beneficial. When it turns into chronic type( long standing) then patient needs  RELAXATION  techniques, STRESS management and COUNSELING. 

Medical management may be needed for a longer period if it is chronic. 

Sometimes there will be overlap of headaches due to various conditions. Careful evaluation helps to find out which type of headache the patient has. 

Next topic will be another type  of headache

NONSINUS CAUSE FOR HEADACHE

HEAD ACHE 

 Headache is a common complaint and patients visit  doctors for that often. We have to know there are different types of head aches. 

Most of the headaches are due to minor problems, some may be harbinger of sinister pathologies like brain tumor. 

Type of head ache  that is detailed here is MIGRAINE. 

MIGRAINE is a type of pulsating or throbbing headache characterised by recurrence ( happening again and again) often one-sided with moderate to severe headache. CLASSICAL and COMMON types of migraine are there depending upon the symptoms. 

CLASSICAL type is characterised by nausea, vomiting, photophobia and phonophobia ( can't stand the light and sound) There will be  disturbances of vision with an aura. Family history will be there. 

WHAT TRIGGERS IT?

Trigger factors are stress, hunger, hormonal changes and certain food stuff. ( My migraine triggered by stress, gastritis ,certain food items and I have flashes of light, and family history). Some times migraine will be presenting with certain nose symptoms, but one shouldn't get confused with sinusitis. 

TREATMENT

Trigger avoidance

Symptoms control

Prevention by certain medication

CAREFUL HISTORY TAKING AND CLINICAL EVALUATION IS NEEDED. 

( Next type is stress or tension type headache) 

HEADACHE AND FACIAL PAIN

We as doctors come across, complaints of headache, very often especially in ENT speciality in the form of facial pain due to sinusitis and  headache due to septal deviation of the nose and jaw joint problems to name a few. 

Sometimes facial pain can be due to fifth cranial nerve  nucleus sensitization. So by proper history and examination, doctors have to differentiate ,aches due to sinus pathology from nonsinus pathology, which warrants lot of patience and experience. 

Sinus facial pain is best expressed as pressure, fullness, throbbing in the sinus area (four  types of sinuses) or at the vertex. Facial pain can be on one side or both sides. There will be diurnal variations and associated symptoms like, nasal congestion, smell disturbances. Doctors have to ask leading questions in order to make a correct diagnosis. 

One has to keep in mind that sometimes, very severe case of sinusitis with pus inside, may NOT be presenting with any pain or head ache also. 

TREATMENT depends on various factors, associated comorbidites like diabetes. 

Medical management  is  opted  first in the definitive and symptomatic treatment and only for resistant cases or chronic cases ,sinus surgery  is opted. 

Details of Sinusitis will be discussed later. Non sinus causes of headache will be explained one by one. 

SWALLOWING DIFFICULTY IN ELDERLY

This topic was selected on my patient's suggestion. As age advances, there are so many problems, be it hearing, sight, swallowing, and the list goes on. Presbyphagia or difficulty in swallowing among elderly people are  not uncommon. 

Degluttition  or swallowing has  four phases or stages, oral preparatory and oral phase, pharyngeal phase and oesophageal phase. All the phases are affected as age advances. 

WHAT HAPPENS ACTUALLY? 

ORAL PHASE

There will be loss of teeth, and connective tissue loss of the tongue, as a result there will be weakening of the action of chewing, also the reflexes that aid in chewing is also weakened. The normal upward movement of the tongue  during swallowing along with the movement of soft palate and uvula is weakened. 

Drying of the mouth( can be due to various medicines taken for  comorbidites) , loosening of dentures, mouth sores can create problems during chewing and swallowing. 

PHARYNGEAL PHASE

Pharynx  is the part between tongue and  esophagus ( food pipe) Normally when bolus of food passes through the pharynx, laryngeal inlet ( part of airway)  is closed  by upward movement of laryngeal structures . Rising up of larynx is affected in old age and the transit time of food through pharynx is  increased. So chance of aspiration ( food spill over) and respiratory infections are more. 

OESOPHAGEAL PHASE

When the upper esophageal sphincter ( valve) relaxes ,food passes through the esophagus ( food pipe), in elderly there is prolongation of upper esophageal  sphincter relaxation time. Peristaltic waves that pushes  the food  contents  through the food pipe also is weakened in old age. Patient will have the feeling that food is stuck. 

WHAT CAN BE DONE? 

Drink water frequently in sips

Take lemon, which will increase saliva

Avoid alcohol, smoking, and coffee

If drying of mouth is severe , artificial saliva is available

Avoid overuse of antihistamines

Swallowing therapy and swallowing rehabilitation also  done

EXAMINATION NEEDED TO RULE OUT ANY PATHOLOGY FIRST. 

BAD BREATH... What To Do?

Bad breath or Halitosis, becomes an awkward or embarrassing situation sometimes. It can also be a warning for certain health problems also.

 WHAT ARE THE CAUSES? 

Usually it's due to DENTAL problems or poor orodental hygiene or type of food we eat. Smoking, alcohol consumption, chewing tobacco, neglection of dental hygiene lead on to dental carries or irritation of gums and buccal mucosa ( lining of the mouth). 

Ulcers of oral cavity ( mouth), any pus collection, gum disease, gingivitis ( gum  infections) dental ( teeth) carries, dental abscess, plaques, coated tongue, fungal infection of tongue ,can cause bad breath. 

Diseases of the TONSILS, like tonsillitis, tonsillar abscess( pus), tonsillolith( stones), tonsil foreign body also contributes. 

INADEQUATE WATER INTAKE, dehydration, decreased saliva production, salivary gland diseases, like inflammation, abscess also causes bad breath. 

Upper respiratory infections, like rhinitis, rhinosinusitis, sinus abscess, chronic  discharge from the back of the nose to the throat, fungal sinusitis, nasal pathologies with post nasal discharge ,lesions of the throat also contribute to bad breath. 

LUNG infections like pneumonia, lung abscess, bronchitis are other causes( to list a few). 

STOMACH problems like, gastritis, gastric reflux ( stomach contents entering into the mouth)

Diabetes, Renal( kidney) disease and  liver disease can also cause bad breath. 

WHAT TO DO? 

Maintain good orodental hygiene

Brush the teeth twice daily

Flossing, Rinse your mouth with water after eating. 

Cut down sugar, coffee, tea

Stop smoking, alcohol consumption

Adequate water intake 

Healthy and balanced diet ( include more fresh fruits  and vegetables) 

Dental examination in case of carries

Treat sinusitis, pharyngitis and other  infections promptly. 

Control Diabetes

Early detection  of any lung, liver or kidney ailments( chronic cough, sputum  or phlegm expectoration, swelling (edema) of face ,legs, bloated stomach, indigestion, jaundice are some of the symptoms of lung, kidney, and liver disease respectively. 

HOPE THIS POST WAS USEFUL. 

THE SENSE OF HEARING

Today ( March 3rd) is WORLD HEARING DAY, so thought of writing about the gift of hearing, which is one of the five senses. 

Hearing loss can be from birth ( congenital) or acquired ( due to various causes) and it is one of the cause of disability. Certain guidelines have been made by WHO on prevention of hearing loss, from drugs that harm the ears (ototoxic), chronic ear infections (COM) and noise induced hearing loss (NIHL) . 

PREVENTION

Primary, Secondary  and Tertiary level of prevention

PRIMARY  level of prevention   is for genetic and infectious conditions. Genetic counselling,  and advice regarding  avoidance of consanguinous marriage ( blood relations) as three - quarters of genetic hearing loss are autosomal recessive ( transmitted through families). 

Infections that can cause hearing loss  which can be prevented by  immunization are measles, mumps, rubella ,pnuemococcal infections etc  . Early diagnosis and treatment, health education, avoidance of certain drugs are  also included. 

Doing hearing screening for newborn especially preterm, or for those with family history of hearing loss, treated in  NICU. 

Traumatic causes, due to physical trauma, barotrauma ( pressure difference) noise exposure. Here  avoidance, early diagnosis and treatment and (  avoidance of ototoxic medications and monitoring while taking medicines). 

Lifestyle improvement  advice given, to prevent other diseases which may contribute to hearing loss. Health education regarding proper hygiene, nutrition ( poor nutrition and poor hygiene can cause frequent upper respiratory infections and ear infections ). 

SECONDARY  prevention by screening, early identification of person with hearing loss and treatment. Public education regarding noise induced hearing loss (NIHL), use of ear protection devices( factory workers,  entertainment (  loud music) , aviation sector) 

TERTIARY prevention by early rehabilitation of hearing loss by giving hearing aids and other aids. 

Those who don't have any hearing problems, please take care of your  precious gift. Don't do anything thing that can harm your  ears👂 like over use of ear phones, loud music, frequent use of  buds or wick. TAKE PROPER  CARE OF YOUR EARS. 

SNORING.. How Can It Harm Your Body?

Snoring is a frequent problem we come across. It occurs due to vibration of structures behind the nose( nasopharynx) 

More commonly seen in men, increases with age, obesity and alcohol consumption and nose block. 

WHAT ARE THE CAUSES? 

Obesity

Blockage of Nasal ( nose) Airways (can be  due to allergy, congestion, septal deviation,or any other pathologies. 

Hypotonicity( poor tone) of throat muscle like tongue,  soft palate( roof of mouth) 

Bulky tissues( uvula, tongue, tonsil  and adenoid hypertrophy) 

WHEN  WILL IT BE WORRISOME? 

When it is associated with, sleep disturbances, sleep apnoea(  temporary cessation of breathing) disharmony in relationship, and social disability, interfering with daytime work, fatigue. 

COMPLICATIONS

Waking up from sleep, light and day time sleep, concentration problems, mood disturbances, affecting your work,   increase in blood pressure( pulmonary hypertension) put strain on heart, especially those who have other comorbidities like Diabetes, obesity and if snoring is associated with obstructive sleep apnea . 

WHAT YOU CAN DO? 

Weight reduction, life style changes, avoid smoking and alcohol consumption( especially before sleep) treat the nasal and throat  problems. Can do investigations like sleep studies and other investigations  in case of sleep apnea. 

IF SNORING IS CAUSING HEALTH PROBLEMS, SEEK HELP