You are here
EAR CONDITIONS
Fluid behind ear drum / glue ear
NOSE CONDITIONS
THROAT CONDITIONS
EAR SURGERY
Otosclerosis surgery / stapedotomy
NOSE SURGERY
Nose job surgery / rhinoplasty
THROAT SURGERY
Swimmers ear (term not used much now) is known medically as otitis externa. This is an infection of the ear canal. It can be an acute attack or a chronic problem with flare ups. It is called swimmers ear because patients get a painful or discharging ear after water exposure. They sometimes also have itching or hearing loss. It usually affects one side unless there is underlying eczema of the ear canals. The constant moisture makes the skin more fragile and susceptible to trauma from eg: finger nails. The natural acidic conditions of the ear canal skin and wax can also be altered by prolonged water exposure, and this makes it more susceptible to a bacterial or fungal infection.
The ENT surgeon performs gentle suction cleansing of the ear canal using a microscope in the ENT clinic. The ear drum itself can then be viewed to confirm that this is only an outer ear infection and not a more deep seated infection involving the ear drum or beyond. It is treated with antibiotic ear drops or anti-fungal ear drops and occasionally supplemented with oral antibiotics and painkillers. It is important to avoid water entry into the ear canal using cotton wool coated with vaseline / petroleum jelly when showering / bathing and to avoid swimming during an acute flare up. It often resolves over a few weeks. Once the acute episode is over patients with chronic itchy ears should practice regular water avoidance measures. Occasionally they may have to give up swimming altogether.
Grommets are Indicated
-If there is a history of recurring pain or discharge over 3 – 6 months in children with a history of middle ear infections. The success rate with grommets insertion in eliminating these recurrent infections is well over 95%, obviating the need for recurrent antibiotic prescriptions.
-If there is persistent hearing loss on both sides for about 3 months or more in children who have confirmed glue ear, also known as middle ear effusion (fluid behind the drum). These children are at risk of significant hearing and speech delay, as well as impaired language acquisition as the commonly affected age group (2 – 8 year olds) is at a critical learning period. The success rate in improving hearing in these cases is well over 95%. Aside from hearing and speech improvements, there is also an improvement in behaviour and attentiveness…
-In children with special needs. They are assessed on a case-by-case basis, eg: grommets insertion is usually performed much earlier in cleft palate children.
An alternative to grommets in older more motivated children is regular autoinflation (popping of the ears with the nostrils closed or blowing a balloon through the nose using an Otovent device), although some may find this uncomfortable. After grommets surgery parents are advised to avoid water entering the ear canals for about 10 days using cotton wool coated with vaseline / petroleum jelly when bathing. Thereafter they can swim without ear protection but ‘if possible’ to prevent their children jumping into the pool or going underwater. Bath water however should never enter the ears when grommets are in place as soap makes water ‘more slippy’ allowing it to pass through the grommet together with any accompanying ‘dirt’. The grommets extrude themselves from the drum over time, and the perforation closes spontaneously about 95 - 98 % of the time. Also most children who undergo grommet surgery don’t need it again. Unfortunately the remainder can require several sets of grommets, or an alternative would then be hearing aids.
Complications
With modern anaesthetics there is virtually no serious anaesthetic problems. Occassionally a child may be nauseous or groggy but this usually settles quickly. Short-term surgical problems are rare and include bleeding, infection / pain / discharge (which usually settles with ear drops and a longer period of water avoidance, but very occasionally necessitates early removal of the grommet). Long-term surgical problems are also rare and include leaving a perforation of the drum (usually less than 5 % risk, which can be reversed surgically when they are older) and scarring of the drum (which alters the drum appearance but usually has no effect on hearing).
As an airplane ascends or descends the accompanying air pressure changes will cause the ear drum to move outwards or inwards respectively. This ear drum movement is reversed by our eustachian tubes. These are the passages connecting the space behind the ear drum (known as the middle ear) to the back of the nose. Their function is to equalise pressure on either side of the drum. However babies and toddlers have more dysfunctional eustachian tubes, and there is decreased ability of the drum to revert to a normal position, with resultant pain known as barotrauma. Adults with a cold may also have more dysfunctional eustachian tubes and prone to barotrauma.
If a patient has a history of ear infections, painful ears with previous flights, or is flying with a cold they could use nasal Oxymetazoline decongestant drops (paediatric dosage 0.025 %, adult dosage 0.05 %) before and after the flight and if long haul also during the flight. However these drops should only be used with medical advice, and should not be used simply every time a child gets a cold, as their nose can actually get more blocked over time. Some patients with repeated infections may already have grommets in, and as long as these are working this will automatically alleviate the problem.
This is better assessed on a case-by-case basis. It would depend on how far into the course of the infection the patient is, how distressed they are, the length of the flight, etc... For example, in the case of a patient with a resolving ear infection, if they are already on antibiotics, and the patient is ‘clinically well’ it may be reasonable to travel on a short-haul flight. Whereas if the patient was very distressed, with a red ear drum and not already started on antibiotics, taking a long-haul flight may not be advisable. The pain will be worsened and the drum will likely rupture / perforate. In this situation the extent of the rupture may result in an increased risk of long term hearing and infection problems.
The eustachian tubes connect the back of your nose to your ear, and are the ones that you use to pop your ears or swallow to equalise middle ear pressure when driving down a hill or landing in an airplane. There is increased ease of airflow in a patulous eustachian tube, with patients characteristically having an abnormally loud perception of their voice and nasal breathing in the affected ear. Other symptoms can include tinnitus (noises in the ear), ear fullness and dizziness. It can be very distressing to some patients. Symptoms may sometimes be affected by the postioning of one's head whether upright or lying down. Swimming in chlorinated pools can sometimes improve symptoms. The ear drum can be seen to move in and out with nasal breathing, which is abnormal:
Alternative causes for the above symptoms can include Middle Ear Effusion (Glue Ear) or Superior Semicircular Canal Dehiscence syndrome.
Snoring is a form of Sleep Disordered Breathing due to an obstruction to airflow in the upper airway. This can be soft and considered ‘mild’, and in the case of children may get better as they grow older. However if it is loud (in children or adults) or associated with thrashing about and restless sleep, this may need treatment. There may also be periods of reduced breathing (known as hypopnoea) or absence of breathing (known as apnoea), which are respiratory pauses lasting more than ten seconds due to repeated narrowing or complete obstruction of the throat during sleep. Frequent episodes of hypopnoea and apnoea with thrashing about is termed Obstructive Sleep Apnoea syndrome (OSA), a severe form of sleep disordered breathing, ie snoring with a problem. The heart rate slows, blood pressure rises, the brain is aroused and sleep is frequently disrupted.
A careful history and full ENT examintion is paramount. Episodes of hypopnoea and / or apnoea which can be measured, can result in reduced blood oxygen levels. A non-invasive test called an called overnight sleep study can be used to measure nasal airflow and blood oxygen levels. This can be done at home or in the hospital. In the case of children, their parents’ history is often clear regarding the severity of their child’s snoring (suggesting the likelihood of OSA or not) thus testing is usually not required. However if there is any doubt or parents want objective evidence of OSA, testing is suggested especially before any surgical treatment.
Lifestyle modification although diffcult is important to address in Obstructive Sleep Apnoea (OSA). Obese patients carry fat deposits around the throat and neck that can narrow the upper airway and their large abdomen causes increased straining during breathing, especially when lying on their back. Weight loss is thus essential. Reduction of alcohol is another factor.
Allergic rhinosinusitis with recurring symptoms of an itchy nose, sneezing, nasal discharge, and nasal blockage / mouth breathing can contribute towards OSA. This often responds to antihistamines and / or a nasal steroid spray. Some patients may need surgery to reduce the size of their inferior turbinates, structures situated within the nose on the side walls that warm and humidify the air we breathe but which can become enlarged in allergic rhinosinusitis. This is a temporary procedure to improve airflow with the mainstay treatment still being medications. Allergy testing is also sometimes done. In children commonly OSA results from large adenoid glands, lymphatic tissue situated at the back of the nose and / or enlarged tonsils, lymphatic tissue situated at the back of the mouth. When there is an upper respiratory tract infection because there is increased swelling in these tissues the snoring worsens. If a child suffers from recurrent tonsillitis or is diagnosed with OSA, an operation to remove the tonsils and / or adenoids can usually improve things.
There are some children with abnormalities involving the lower jaw or tongue such as Pierre Robin sequence or Down’s syndrome respectively, or neuromuscular deficits (such as cerebral palsy). They need more specialised treatments eg: Continuous Positive Airway Pressure (CPAP) or additional surgical procedures. Tracheostomy (a hole in the neck leading to the windpipe) is an exceptional last resort.
In adults removal of enlarged tonsils and / or adenoids may improve the snoring and OSA if symptoms persist after medical treatment. However other causes which are not usually treated surgically in children can be corrected in adults including straightening a deviated nasal septal, trimming the inferior turbinates, sinus surgery and sometimes reducing and stiffening the soft palate.
Patients with severe sleep apnoea (daignosed by an overnight sleep study) may only have partial benefit from medical treatment although it is worth trying as the risks are low. Even surgical treatment may be insufficient, and they may need appliances such as a Mandibular Advancement Prosthesis or CPAP.
In adults the short-term problems are poor sleep, feeling very tired during the daytime, and even falling asleep when driving with risks of a road traffic accident. In the long term there are risks of acquiring High Blood Pressure, Stroke, Heart Attack, Heart Failure and Diabetes Mellitus.
In children the short term problems include bed-wetting, daytime sleepiness, poor concentration, learning difficulties, irritability or even hyperactive behaviour. In the long term there are risks of insufficient growth, obesity, Diabetes Mellitus, heart, lung and blood pressure problems.
However not all patients will suffer these and medical advice should be sought as an accurate diagnosis needs to be made together with appropriate treatment instituted.
Often medical treatment is sufficient as an outpatient. For example in a condition like chronic rhinosinusitis, after a careful history and examination a few months course of medical therapy may suffice in improving the situation, as there is often an interplay between anatomic abnormalities, allergies and infection in the nose and sinuses. Hence surgery alone may be insufficient, or to put it another way medical treatment may be sufficient. However in the event of failed medical therapy if the patient’s quality of life is being affected surgical treatment is an option.
If the symptoms are very distressing or serious (eg: respiratory distress with noisy breathing, an uncontrollable nose bleed, a painful swollen neck lump, a red swollen eye with a history of a cold, or a ear is sticking out with a tender swelling behind it) medical treatment as an inpatient is required. Sometimes even joint consultation with a paediatrician, eye specialist, or neurosurgeon may be required. In these types of serious conditions if the patient does not get better urgent surgery may be required.
The laser is a precise tool and not an operation in itself. Hence it depends on the training of the surgeon, advantages vs disadvantages of using a laser, and the disease. It is particularly useful when dealing with conditions like benign tumours, papillomas (wart-like growths), tonsil remnants, and granulation tissue (proud flesh). If it is a fine fibre-guided laser (as used in my practice) it can reach narrow spaces in the nasal vestibule, nasal cavity, oral cavity or pharynx thus ensuring complete vaporisation of disease tissue and hence less chance of it coming back. Because it removes tissue by vaporisation there is less collateral damage to nearby vital structures compared with traditional dissection methods. This is again better achieved with a fine fibre-guided laser.
