Saturday, December 31, 2005

Stones where?

I am currently doing a project for my anatomy class on tonsilloliths and I was wondering if i could ask you some questions about it. If you are able to answer these questions, it would be greatly appreciated since I need an expert contact. My questions are listed below. Thank you very much and I hope to hear from you soon.

Q: What are some symptoms of tonsilloliths?

Just so everyone is on the same page, tonsilloliths are also known as TONSIL STONES. Symptoms include:

A recurring foreign body sensation in the throat which is relieved when the stone is expressed (removed, that is).

Bad breath.

Sore throat.


The stone itself is the most common symptom. Folks with this problem have figured out ways to pick out the stone. It's not a stone, by the way; it's a ball of dead squamous epithelial cells, combined with bacteria and bacterial waste products -- hence the foul smell.

Q: What is a possible cause?

We see this most commonly as a symptom of chronic tonsillitis. Chronic tonsillitis is a condition in which the tonsils stay inflamed despite recurrent treatment with oral antibiotics. The sore throat is typically not as severe as it is in acute tonsillitis, but it is (as the name would suggest) far more stubborn.

On a more mechanistic level, you may be asking how these things are formed. Do a bit of reading on tonsil anatomy, and you'll learn about tonsillar crypts (yes, as in 'where dead things are buried'). These are epithelium-lined invaginations which seem to be a good deal deeper in patients with chronic tonsillitis. As you know, epithelium is in a constant state of turnover: we make new skin, oral lining, and digestive tract lining on a continuous basis.

My hunch: when the crypts become too deep, the sloughed epithelium has a hard time getting out. It builds up until it becomes macroscopic and so bothersome that the host pushes it out by one means or another.

Q: Is there any way to prevent the formation of tonsil stones?

I have had limited success -- very limited success -- treating this condition with antibiotics. Some folks use a specially designed water pik device to blast out the stones, but that's not a preventive treatment.

I have seen a few of these get better without any treatment except TOT: tincture of time.

Most folks either learn to live with it, or decide to have the tonsils removed.

For more information on tonsil stones, follow this link.


Thursday, December 29, 2005

Swelling behind the ears

Let's take this one apart bit by bit.

Q: My 12 year old child at board school came back with swelling at the back of both ears.

Two things come to mind: lymphadenitis (swollen lymph nodes) and mastoiditis (infection of the bone behind the ears). Lymphadenitis is the more common of the two, and by far the less serious possibility, but both require a visit to the doctor.

While at school we got report that he was in and out of hospital on about three occasions.

Why was he in and out of the hospital? This is important information.

As he came back by weekend, my wife gave him Augmentin. Two days later we took him to a Doctor who said the swelling was "normal". He examined the ear and said it was dirty and needed flushing. This flushing was done and no other medication was prescribed.

Ear, nose, and throat doctors are not big fans of flushing. Flushing can cause more problems than it solves. It can aggravate an existing infection, cause a different kind of infection (the notorious swimmer's ear), or, if done too forcefully, cause trauma to the ear drum.

I'm also wondering about the "swelling was normal" comment. Did he disagree, and think there wasn't any swelling? If he agreed there was swelling, well . . . this is never normal.

As for your wife giving your son Augmentin, if she did not have a full therapeutic course to give, this is a mistake. Even if she did have a full therapeutic course to give, it's risky to do this without a doctor's advice (for example, how does she know she's giving the correct dosage, or if this is even a proper antibiotic to use?) I encourage you to ask the doctor about this, in the future.

Last night, the child ran high temperature throughout and was complaining of some pains in the right ear which has a bigger swelling.

This reinforces what I said earlier: swelling is never "normal." The two conditions mentioned earlier (lymphadenitis, mastoiditis) are still the most likely possibilities.

We are very worried as we believe that this is not normal. We intend to see another Doctor using the information you may provide to us for discussion.

The doctor needs to determine if this is lymphadenitis or mastoiditis. Physical examination (including a good examination of the ear drums) may give the answer, but X-rays may be necessary. The distinction is important. Acute mastoiditis is a severe infection which may spread to the brain, leading to significant disability, even death. While lymphadenitis will usually respond to oral antibiotics, acute mastoiditis may require surgical intervention.


Friday, December 23, 2005

Ear pain

Edited a bit for length, etc.

Q: [I have] been experiencing symptoms of a clogged ear, hearing difficulties, and jaw pain that was diagnosed as fluid in my Eustachian Tube by my doctor. All symptoms occurred on my left side. The symptoms were diagnosed as allergies but no allergy treatment worked.

Last April the problem progressed to similar but more painful symptoms in my left jaw, cheek, and ear. My new problems were no longer accompanied by hearing difficulties which caused my ENT to automatically conclude that my pain was not Eustacian Tube related. He ordered a CAT scan of the sinuses which was negative, and now believes that my problems are caused by either headaches or atypical facial pain.

I have become desperate to relieve the pain, and have begun to treat myself by holding my nose and blowing air into my Eustacian Tubes which pop and crackle when I do so. It tends to relieve the pain for a few hours. Am I harming myself by doing this? Also, what type of examination should I request at the doctor's office to totally rule out Eustacian Tube Dysfunction? The pain has become a regular part of my life now, and still resembles the pain I felt when my Eustacian tubes were full. Do you have any idea what could possibly be wrong?

A: I trust you've read the disclaimer?

First, let me answer your questions.

Are you harming yourself by auto-insufflating (that's what it's called)? Probably not, but I remember doing this after getting off an airplane, and next thing I knew I was sitting on the airport's bathroom floor, the toilets and latrines spinning around my head . . . Point is, I can't do this safely, but apparently, you can. I don't recommend people do this, because if any doctor had told ME to do this, I'd cut him a new one.

What test do you need to rule out Eustachian tube dysfunction? A tympanogram. It's quick, easy, painless (usually), and I'd be surprised and more than a little disturbed if you haven't had one already.

For a full run-down on the differential diagnosis of ear pain, see this page. To the list on that page, I would add migraine, atypical facial pain, giant cell arteritis, trigeminal neuralgia . . . and there are undoubtedly other conditions slipping my mind at the moment.

The main point: ear pain is a thorny, complex problem, and the only hope we have of figuring these out is to (A) take a thorough history, (B) examine the patient, sometimes with additional tests such as tympanometry, fiberoptic laryngoscopy, or binocular microscopy, and (C) be prepared to re-evaluate the patient if our initial diagnosis doesn't pan out.

Have I managed to figure out all of my ear pain patients? Not by a long shot. This is a toughie. Good luck to you.


Thursday, December 22, 2005

Doc Otter is back!

Some of you might remember Doc Otter from his live posts from the New Orleans relief efforts. I gather he ran into trouble at work, thanks to his outspokenness, but now he's back in the blogosphere. Go give him your best wishes.


Wet nose, warm heart

My sister wants to know why her nose drips when she eats.

This is a common complaint: a nose that drips in response to inappropriate stimuli. Believe it or not, you want a runny nose in certain circumstances. Get a big snootful of dust, or step outside into dry, frigid air, and a runny nose is your best friend. You really don't want that dust in your lungs, nor do you want to inhale cold, dry air. Either one could touch off bronchospasm -- an asthma attack.

Unfortunately, some people get a drippy nose at the worst times. Eating is the most common trigger, but sunlight, wind, and emotional upset are other common triggers.

Vasomotor rhinitis is the name of this condition. Aside from a runny nose, other symptoms include stuffiness, postnasal drip, or sneezing. It is not an allergic condition and will not respond to allergy medications.

What is it? First, a quick introduction to your nose. The nose is a sense organ, of course, important both for smell and taste, but the nose also humidifies, filters, and warms the air that you breathe. Air reaching the lungs should be moist, clean, and warm. If it isn't, you might develop reactive airways (asthma) or other problems.

Thanks to its internal nervous system, the nose can alter its state, becoming more stuffy or less stuffy, wetter or drier, in response to environmental triggers. Vasomotor rhinitis is a disorder of this nervous system. I like to call it a twitchy nose.

Avoidance is the best treatment, but easier said than done. If your triggers are food or sunlight, what are you going to do? Most folks stuff their pockets with handkerchiefs.

Nasal steroid sprays, antihistamines, and decongestants don't work well for vasomotor rhinitis, but if you go to your primary care doctor, that's probably what you're going to get. Certain other nasal sprays work very well for this condition, but they're not for everyone.

Not all drippy noses are vasomotor rhinitis, of course. Allergic rhinitis is way up on the list, too, and the treatment for that condition is much different. Occasionally, a drippy nose can be a sign of other, more serious, nasal problems. That's where your doctor comes in.

My recommendation: educate yourself on rhinitis conditions (vasomotor and allergic), and go to your primary care doc armed with this knowledge. If your doc doesn't know the appropriate medications, hopefully she'll send you to an ENT (or at least call on for advice!)


Tuesday, December 20, 2005

Weekend Open Thread

Cough it up and spit it out.


  • if you don't want your medical business broadcast all over the internet, post your questions anonymously.
  • as stated in the disclaimer (which you should have read by now!) I have no intention of answering every question. If I haven't answered you within a day or two, I'm probably not going to do so. Sorry!

I'm telling you, they swoon for me

Anduin asks:

I've been getting dizzy. It feels like I'm swooning and it comes on suddenly, sometimes lasting all day. Could this be vertigo? I've also read it could be an ear infection. How would I know?

A: One of the first things we ENTs are taught is to get away from the term "dizzy." Trouble is, it means different things to different people. The question we ask is, "Can you describe what you feel without using the word dizzy?"

You've used the word "swooning," which suggests you feel as though you might faint. Some folks would call this "lightheadedness." Many things may cause this sensation; the most common causes are probably low blood pressure, low blood sugar, and heart rhythm problems. Other possibilities include drug side effect, allergy, or hormonal problems.

Vertigo is a symptom in which the patient feels as though she is moving when she isn't. Most commonly, vertigo refers to a spinning sensation, but some folks use it to refer to a sense of falling, too. A seasick feeling (mal debarquement) is something else entirely.

Vertigo most commonly indicates an ear problem, but not always. Certain central nervous system conditions can cause vertigo, so it is important to keep that in mind when evaluating the patient.

How can you tell if it's an ear problem? There's no easy answer to that. If other ear symptoms (pain, ringing, hearing loss, pressure) are present, it might be an ear problem. Many common problems (such as benign positional vertigo) do not have other ear symptoms, however.

If you look back at the laundry list of possibilities in that second paragraph, I think you'll be able to predict what comes next. You need to run this by your doctor, since some of these conditions (heart rhythm problems, for example) are potentially serious.


Head-banger's Ball

Q: Hi, I have a question regarding possible trauma that could cause bleeding to the ear. Is it possible that if one bangs on their head (say, out of frustration), that if they bang hard enough, they could cause their brain to start bleeding and that blood could come draining out of one of their ears? Thanks, just wondering.

A: The answer is yes, but you would have to bang it pretty hard. I think this is unlikely. However, under the influence of alcohol or drugs, anything is possible.

We see trauma-related bleeding more commonly in severe accidents -- car vs. car, car vs. pedestrian, assault, gunshot wounds. It takes a good deal of force to fracture the temporal bone. These are serious, sometimes life-threatening injuries, often associated with other problems (including concussion, change in hearing, dizziness, and other neurological problems).

In the absence of significant trauma, the most common causes of bleeding from the ear canal would be infection and minor trauma (from a person trying to clean his ears with inappropriate instruments).

Hope this helps.


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Wax, Boogers, and Phlegm
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All of that is important, but I can't stress the last point enough. Like any doctor, I'm fallible, and my knowledge base is far from exhaustive.

Lastly, I have no intention of answering every question. I never have and I never will. I tend to answer questions that are (1) short, (2) interesting, and (3) instructive for other people. If you're upset because I haven't answered your question, I'm sorry.


Welcome to Wax, Boogers, and Phlegm

Hi, folks. I've had The Medical Consumer Advocate on the web since 1998, but thanks to work, family, and my other blog, I haven't had much time to update it. I'm hoping that Wax, Boogers, and Phlegm will motivate me to answer more of your questions. With any luck, this blog will become The Medical Consumer Advocate's high-activity corner.

I have been a private practice ENT since 1998. I trained at Los Angeles County Hospital from '90 to '95, slaved in academics until '98, and I've been practicing in Crescent City, California since then. For more information on me, check here. (Good heavens, what a young picture!)