Sunday, January 29, 2006

Open thread

Question on your mind? Spit it out.

The question that is, not your mind. Eeew.


An ear wax rant

Time for a few anticipatory answers.

1. No, there's nothing wrong with having dark brown wax. Any shade of brown, all the way down to pale yellow, is fine. It should smell like ear wax, though. (Don't know the smell of your own ear wax? Stick finger in ear. Twirl. Smell it.) If you think you are going to lose your lunch from the aroma, you may have an infection. You need to see your doctor.

Green and pitch black are not acceptable colors, by the way. Green suggests a bacterial infection, black, a fungal infection.

2. No, you do not need to live with an itchy ear. This is soooo treatable it isn't funny. Scratching at them with Q-tips is not the solution (see my January 17 post).

3. No, I can't tell you how to clean your ears. Everyone's wax is different, and different types of wax respond to different cleaning techniques.

The Ear Wax Compendium

A. No wax. This is not abnormal. Most people's ears are self-cleaning. By the way, if your ears are itchy and you "have no wax," the "lack of wax" isn't causing the itchiness. Your incessant cleaning is causing the itchiness. See #2.

B. Dry, scaly wax. This isn't all wax, but flakes of skin combined with wax. This is nearly impossible for you to clean at home, and it's not too easy for me to clean, either. Interesting fact: I see this most often among people of Asian descent.

C. Hair impactions with variable amounts of wax mixed in. This is the absolute worst. It's irritating to the patient, impossible to clean with Q-tips or over-the-counter ear wax remedies, and it's a devil for me to clean, too. TRIM YOUR EAR HAIRS, puhlease.

D. Hard wax. Assuming you have an intact ear drum, it is safe to put oil in your ears to soften the wax: vegetable oil, baby oil, anything but motor oil. Don't waste money on "sweet oil," as this is just overpriced olive oil.

E. Soft wax. This will respond to the use of over-the-counter ear wax kits, assuming you haven't waited to long. Which brings me too . . .

4. Don't wait too long to seek a doctor's help. Once the wax gives you an unremitting hearing loss, it's too late to clean it with Q-tips or over-the-counter wax kits. You'll only make it worse.

It saddens me whenever I have to clean out wax that has been present since the Truman Administration. This is a patient who has had treatable hearing loss for decades. For heaven's sake, practitioners, look in your patient's ears.

5. Irrigation (the most common cleaning technique used by nurses and non-ENTs) probably works about 99% of the time (number pulled from where the sun doesn't shine) but it's that 1% that'll get ya. Yes, I have seen serious injuries due to over-forceful irrigation. For what it's worth, I've never seen any injuries from self-irrigation using a kit. When they're doing it to themselves, folks generally know not to use too much force.

Irrigation is not pleasant, though. If you're doing it to yourself, make sure the solution is at body temperature, or you may get very dizzy.

Important: If you think there is any chance you have a hole in your ear drum, STOP. Do not put anything in your ear canal. Do not irrigate. Do not let the doctor or the nurse irrigate. Repeat, STOP. This is a job for the ENT.

6. When you see your ENT, do not say any of the following things. We've heard each one of these 'jokes' so many times, it makes us want to scream when we hear it again.

A. "Can you see through to the other side?" (No, ma'am. There are two peas rolling around which are obstructing my view.")

B. "Huh?" (Unless you really mean it.)

C. "I was always told you shouldn't stick anything in your ear smaller than your elbow." (I see. You did a damn good job jamming the wax in with your elbow. Or did you use your foot?)

Which brings me to . . .

7. Yes, it is okay to use Q-tips, with several warnings:

A. Make sure you don't forget about the Q-tip and leave it dangling from your ear. This makes cell phone conversations quite hazardous. Yes, I have seen two ear drum perforations (separate patients) by this mechanism.

B. Make sure no one, but no one, is nearby who might bump into you while you are cleaning. This goes double for big dogs.

C. Don't go too deep. If you pinch the stem of the Q-tip behind the cotton, you'll prevent yourself from going too deep.

D. If you wait until you have a hearing loss to use a Q-tip, you have waited too long. You'll only pack it in deeper.

E. If you use Q-tips too frequently, you'll give yourself itchy ears.

F. Once a week is probably often enough. Do it after you shower, since that's when the wax is softest.

G. If you think you might have a hole in your ear drum, see #5 above.

8. Don't even dream of getting your ears candled. If you are a candling practitioner, or if you are a person who loves getting your ears candled, and if you would like to send me hate mail, please do so in the comments. I dearly love reprinting candle fanatics' letters. They are soooo special. And, no, I don't disparage candling "to keep all the money to myself." I disparage candling because it is quackery.

Betcha didn't know someone could wax on about wax, eh?


Friday, January 20, 2006

Weekend Open Thread

Speak up. I can't hear you!


Tuesday, January 17, 2006

Itchy and Scratchy

Q: I have finally found an answer to that smelly stuff in my throat! Thank you so much.

You're welcome. I live for your praise.

Now, I would like to know if you know why my ears are always so itchy way down deep. I clean them with q-tips every day… but still can never relieve that horrible itch. Do you think there may be a correlation to the “tonsil stones?”

Interesting question. No, really, it is, because I can see this going in two different directions.

On the one hand, you're using Q-tips way too often. Every day? Give your ears a break! Wax has a protective effect; it tends to reduce the risk of bacterial and fungal infections in the ear canal. A little wax is a good thing.

You do not need to polish your ear canals.

By doing so, you might have kicked into motion something called the "itch-scratch syndrome." Here's how it works: the more you scratch, the more you itch, and the more you itch, the more you scratch. It's a vicious circle.

When you scratch your skin, mast cells release histamine, a chemical which causes itching (among other signs of inflammation). The more you scratch, the more histamine gets released, and so forth.

Sometimes, the only way to break this circle is to use a steroid cream. If your primary care doctor doesn't know which ones are helpful for itchy ears, she should ask an ENT.


You'll recall, however, that I said this could go in one of two directions. You brought up the point that you're also having tonsil stones (tonsilloliths). Could these be causing that deep-down itch?

YES. Anything causing pain or irritation in the tonsil can be perceived incorrectly as an ear problem. When pain elsewhere in the head or throat causes ear pain, this is called referred otalgia (referred ear pain). A bad enough case of tonsillitis will cause ear pain, and pain in the jaw joint (TMJ, or temporomandibular joint) will usually be blamed on the ear.

Of the two possibilities, itch-scratch syndrome is the easier to treat. If I were your doctor, I'd start there.

Needless to say, share this information with your doc. Good luck!


Saturday, January 14, 2006

Keeping the pipes clean

Kate writes,

Can you address this bit from wikipedia in your boogers blog? Maybe something about how entirely gross and bizarre it and the human body are? "The word frenulum can also refer to the muscular connection that can be felt on the underside of the tongue. The pratice of cutting this is called Kechari Mudra and is a yogic pratice endured mostly in India to allow turning of the tongue itself up into the nasal cavity for spiritual practices."

Kate is referring to this page on Wikipedia, which tells me she has nothing better to do but look up naughty words on the internet. Nevertheless, her question provides a good opportunity to talk about yogic practices of self-cleansing -- the six shatkarmas -- and how at least one of them relates to standard treatment we employ in ENT.

Initially, I thought Kechari Mudra had to be one of the neti shatkarmas. (Doesn't that make it all clear?) In neti shatkarma, the individual douches the nasal cavities with a liquid (milk, clarified butter, or saline) or passes a long soft thread through the nose, draws it out from the mouth, and flosses gently.

My dear, that is not how you blow a Shofar.

This delightful young lady is demonstrating proper use of a neti pot. You don't need a neti pot to irrigate your nose, however, and I can make a good argument against using a neti pot. You can clean it all you like, but you can't see inside of it. I would worry about mold growth in the stem. Here in the States, you can buy a kit which includes a squeeze bottle that can be broken down, washed, and examined in its entirety. If it starts looking grungy, get another kit.

Here's a link to the product I use. No, I don't get anything for this endorsement.

I've never recommended nasal irrigation using milk or butter, but I have advised many patients to irrigate their nose with saline (salt water, buffered with bicarbonate). It can be helpful for a variety of inflammatory nasal and sinus conditions.

This is not for everyone, so make sure you discuss it with your doctor first. In particular, irrigation is a bad idea if you think you might have a sinus infection -- the infection may spread to other sinuses.

Getting back to Kate's question:

It just so happens Kechari Mudra is not a shatkarma. (It's part of kriya yoga.) I suspect Kate envisions the yogi sticking his tongue into his nostril Gene Simmons-fashion, but the reverse is true. In Kechari Mudra, the tongue is moved posteriorly and superiorly, so that the tongue tip ends up in the nasopharynx. Here's a picture, and a description.

This is done not as a self-cleansing practice, but to enhance the flow of psychic energy from the head downward. Got it?

As for the other five shatkarmas, some involve "inhaling" air through the anus, then forcefully expelling it (sthal basti), or using the abdominal muscles to suction up water through the anus, an auto-enema (jala basti). Other shatkarmas cleanse the eyes, the stomach, and the brain.

For my patients, I'll stick to nasal irrigation, thank you very much. But they're your pipes, and this is a free country.


Friday, January 13, 2006


Q: I found your site to be very interesting. I am trying to learn about the uvula, which you do have some information regarding. My question, however, is about possible infections of the uvula, or growth/swelling of the uvula. Is the uvula ever removed for any medical reason?

A: The uvula is that little dangly-downie-thingie (sorry for all the medical jargon) in the back of your throat. It is part of your soft palate. Its only function, as far as I can tell, is to allow you to snort like a pig when reading books to your toddlers, and to pronounce certain Yiddish words (like kopf tukhas) without sounding like a Southern Baptist.

Yes, the uvula can become infected, can develop abnormal growths, and can also harbor cancer. Yes, we sometimes remove it. Let's take this one step at a time.

Quincke's edema is a particular type of swelling of the uvula known as "angioneurotic edema." It can occur as a result of minor injury, food allergy, or even a mild sore throat. The uvula can swell to twice its normal size -- sometimes larger.

The uvula can be infected with papillomavirus (a mucosal wart), yeast (Candidiasis or thrush), or any bacterial or viral infection involving the tonsils or throat.

A warty growth on the uvula can represent a viral papilloma, a squamous papilloma, or even cancer. In most cases, we biopsy these lesions.

Back in training, I saw two cases of uvular thrush in which a beet-red uvula was encased in a white sleeve (the yeast itself). Nasty.

Back in training, I also saw two patients who had burned their uvulas (uvulae?) by sucking to hard on a crack pipe. The red hot screen got pulled through the pipe and smacked 'em in the uvula. Easy diagnosis: nothing else will give you a grid-shaped burn.

We most commonly remove the uvula as part of an operation for obstructive sleep apnea. The operation is called a UPPP, which stands for -- you ready for this? -- uvulopalatopharyngoplasty. The uvula is also removed if it is involved with cancer.

Incidentally, ENT can lay claim to some of the longest words in the English language. My favorite:


30 letters, if I can still count.


Sunday, January 08, 2006

Open thread

Ask away. You have nothing to lose but your boogers.


Aw, crud!

As usual, we'll take this one step at a time.

Q: I am [age deleted - he's under 50] have been coughing phlegm up for the last three years, I am also SOB alot, I also have hard brown crud in my nose sometimes blood encrusted, this is going on three years also. As a kid I had asthma, as a teenager hayfever and rhinitis, as an adult I binge smoked socially at the weekend. I never smoked more than 40 a week and have not smoked in three years.

SOB = short of breath, for you non-medical types.

We all produce about four cups of mucus a day. If it's thin enough, we don't notice this stuff, but if it's thick, we have to cough it up. That's a problem.

The history of smoking and asthma may be relevant. Excessive phlegm can be a sign of rhinitis (nasal inflammation) or sinusitis, but it can also be a sign of lung disease. He's a little young for it, but it's still a possibility. A chest X-ray would be prudent (but he's had better . . . see below).

Nasal crusting can indicate a number of things, from chronic low-level nose bleeds, chronic sinusitis, atrophic rhinitis, or even a bacterial infection (nasal impetigo, an infection with Staphylococcus).

Do you see how impossible it is to narrow this down without examining the patient? There's no substitute for looking up someone's nose and listening to their lungs. Back to our emailer:

At the start of this trouble I had tinnitus, eye pain, dizziness and earache for many months, this also went undiagnosed despite repeated visits to the local Eye and Ear hospital. I ended up with suspected blocked eustacian tube, anyway this eye, ear and sinus trouble cleared up two years ago and hasn't returned.

Tinnitus can be a symptom of Eustachian tube dysfunction, but can indicate many other conditions, too; similarly, eye pain, dizziness, and earache could all be related to his nasal/sinus condition. Impossible to say now, since the symptoms have passed, but a workup at the time might have bolstered this hypothesis, or pointed the doctor elsewhere.

He goes on to say that he's had a number of normal tests, including a high resolution chest CT scan and normal pulmonary function tests. To the best of my knowledge of pulmonary medicine, this should exclude most primary lung conditions. He mentions that he has sinus polyps (yes, this might be relevant) and then proceeds to his question:

I have self-diagnosed myself as having some sort of chronic bronchitis.

My question to you is what is the connection between crud in the nasal cavity and chronic bronchitis. Are they related, ie one airway, similar symptoms. I had a bronchoscopy and biopsy and they maintained that the mucosal layer was normal. ~ No Bronchitis.

The normal bronchoscopy sounds convincing to me, but he'd have to ask his pulmonologist. In any case, one need not invoke chronic bronchitis to explain the phlegm production or the nasal crusting. The nose and sinuses are quite capable of producing this problem all by themselves. Given the normal pulmonary workup, the nose/sinuses sure sound like the leading suspect.

Is it worthwhile looking into PCD / ICS as a cause for these symptoms, I feel my doctors have either given up or want to concentrate on people with life threatening conditions rather than uncomfortable ones!

It is worthwhile for me getting an alternative opinion from across the pond.

I sure wish I knew what PCD and ICS were. Amazing how we all speak English, yet we use different acronyms!

Anyway, I think this fellow should go back to his ear, nose, and throat doctor and ask for a few things. I suspect he's had a sinus CT scan (since he mentions sinus polyps), but if not, this would be helpful. If he hasn't had an endoscopic exam of the nose, this might prove helpful, too. There are many, many things we can do to help nasal crusting and excessive phlegm. True, it might not be life threatening, but it is quality-of-life threatening.

I can't make treatment recommendations when I'm so much in the dark as regards this patient's disease process. First thing I would do would be to satisfy myself that the problem resides in the nose or sinuses, and I'd try to figure out if it came from either (or both). My next step would be to figure out if infection was present or absent, and if allergy was present or absent. That would help me determine which medications to use. I would also be thinking about adjunctive measures, such as having the patient improve his hydration, and possibly begin a plan of nasal irrigations.

And you all thought snot was easy.


Monday, January 02, 2006

Some people.

This speaks for itself. I really can't add anything . . .

I happened upon your site as I was browsing the net and find your comments about ear candling very prejudicial and very uninformed. As a practitioner of Alternative Medicine and a person who is Experienced in the Ancient Art of Ear Candling, I would like to let you know that I do not LEAD people to believe that the ear wax has been removed. I Actually cut the candle open so they can SEE what has come out of their ears. Since I have been offering this NON-INVASIVE form of treatment I have been told, time and time again, that the amount of wax they had removed from their ears with the ear candling method FAR exceeded the amount which was removed using your recommended method. Have you ever tried it??? Maybe you shouldn't condemn something before actually testing it. I advise you to stop mis-informing people of things you know nothing about.

. . . except to point you all to this excellent article on Quackwatch or this article at The Skeptic's Dictionary.

'Nuff said about candling, hmm?