Sunday, September 17, 2006

Tubes and adults don't always mix

Q: I had a bout of Mono last summer and one side effect was a viral infection in my middle ear . A drainage tube was inserted but results have been mixed. I have recovered my hearing in the affected ear for only about 6 weeks in the past 15 months and am about to have a new drainage tube installed.

I use an ear plug when bathing or swimming but it occasionally leaks. I have just been fitted for a molded plug.

My question is:

Could water seeping into the middle ear be the cause of my drainage tube being ineffective? If not, what could be causing my tube to be blocked?

P.S. I am -- years old and my ENT says that he has not seen my problem(s) other than in kids.

A: I'm intrigued by that PS. That must be an ENT who treats very few kids, since I am constantly seeing this sort of thing in adults.

There are several possibilities, and there's no way for me to know exactly what's happening with you. Here are the things which come to mind:

1. Yes, occasional water seepage into the middle ear could be enough to compromise tube function.

2. Even one episode of tube otorrhea (drainage of middle ear fluids through the tube) could be enough to clog the tube, making it nonfunctional.

3. Sometimes, the problem is neither middle ear fluid nor Eustachian tube dysfunction, but low frequency nerve deafness, which can masquerade as the other problems. This is something readily diagnosible by a hearing test.

4. Some middle ear mucosal diseases persist despite tube placement. In this case, you would continue to produce middle ear fluid and you would notice persistent leakage of fluid from the tube . . . unless the fluid is exceptionally thick. That's something your ENT should be able to notice when he examines your ear under the microscope.

5. Rarely, throat tumors can cause persistent Eustachian tube dysfunction. A fiberoptic examination of the throat is sometimes necessary.

6. Finally, and most troubling, I've found that some adults simply don't respond well to tubes even when all of our tests and exam findings indicate that the tube should work like a charm. They're simply unhappy with the tube and there's no good explanation for it.

Good luck!


Wednesday, September 06, 2006

Those phantom smells


Love your blogs.

Thank you.

Okay, here's my question/situation. I occasionally get a bad smell in my nose - like all the air I'm breathing is tainted with cigarette smoke or burnt coffee. Sometimes I have to force myself to breathe through my nose when it's particularly bad. I start to breathe, then my nose rebels and I have to tell it please breathe. (I am not a mouth breather unless absolutely necessary.) When this happens, it lasts about a week or two, then goes away for months. This has been going on and off for at least several years. More than three, for sure.

I have a history of annual sinus infections - mostly in February, early March - and I'm asthmatic and allergic to everything it seems.

Is this worth a visit RIGHT NOW to a specialist, or should I bring this up at my next visit to my regular internist.

The most likely explanation for these phantom odors is, indeed, sinus infection. You may have a chronic sinus infection which flares periodically, either directly producing the odor or indirectly creating a phantom odor by irritating the olfactory nerves.

The worry with any phantom odor, however, is tumor -- a tumor anywhere near or on the olfactory nerves. These are uncommon (much less common than sinusitis) but, as you might imagine, they're a good deal more serious than sinus infection. These can, in fact, be brain tumors.

Phantom odors from a brain tumor would not tend to come and go, however. Typically, the odors would come and stay, possibly get worse, and the tumor could eventually knock out the sense of smell altogether.

It may sound like I'm trying to reassure you, but the other shoe still has to drop. In medicine, we say, "Never say never." In other words, just because something is (A) rare in the first place, and (B) unlikely to present in the manner you have described, doesn't mean you have zero chance of that worst case scenario.

I hope you'll understand that I can't directly advise you how fast to see a doctor. When I do answer those questions, I always answer them the same way ("See your doctor immediately!") because I have to cover my ass. BUT: it sounds like this is making you miserable, so if I were you, I would take care of it sooner rather than later. A consultation with an ENT, who will most likely order a sinus CT and may also examine your nose with an endoscope, would certainly be worthwhile.

Hope this helps!


Friday, September 01, 2006

When is it more than a cold?

Miss Beff writes:

How long should I be stuffed up before thinking it's maybe not a cold and then going to the doctor? Three days? A week of snot sans relief? What?

She also points out that it has been aaaages since I updated. Sorry. Consider the comment section here to be an open thread -- ask away. And if I don't get back to you promptly, email me at azureus at harborside dot com with your questions.

Back to snot. In general, if it's a cold, you should be getting better within two to three weeks. But nothing is that simple. What's the chance it could be something else?

The most likely alternate possibility is sinus infection, allergy, or other forms of chronic rhinitis. Less likely: nasal polyps, and MUCH less likely, nasal/sinus tumors.

In children, you should also consider the possibility of enlarged adenoids, as this will cause nasal airway obstruction, too.

AND unilateral nasal airway obstruction in a child, typically with unilateral foul-smelling drainage, usually means?

Ding ding ding ding! Give a peanut and a popcorn kernel to the gal in the red blouse who correctly answered, "A nasal foreign body." You're head and shoulders above most primary care docs.

Back to the other possibilities. Let's take them one at a time. Bear in mind that colds are so common (hence common cold) you might have a cold AND one of these, okay?

Acute sinus infection

In addition to nasal congestion, expect to see discolored mucus (yellow, green, or occasionally more delightful colors. Brilliant orange, that was my personal favorite), facial pain, facial pressure, and an overall crappy feeling (malaise). Fever is uncommon in adults.

Chronic sinus infection

All of the above (for acute sinusitis) but the symptoms are usually less intense and more longstanding.

Nasal polyps

Polyps do not arise overnight. Generally, the patient gives a history of gradually increasing nasal congestion (over the course of months or years), recurrent sinusitis, and/or severe problems with nasal allergy. Which brings me to . . .

Allergic rhinitis

All the things you hear about in commercials. Congestion, sneezing, watery nasal drainage, itching of the eyes, nose, and throat, itching or pressure in the ears.

Tumors of the nasal cavities or sinuses

Awful, horrible things, usually. You don't want any part of this. Fortunately, these are rare, but a gradually progressive nasal airway obstruction always raises this possibility. What are the warning signs for nasal or sinus tumors?

  • Change in vision (blurry vision, double vision)
  • A bulge in the cheek, to the side of the nose, or in the brow line, often only apparent on comparison to old photographs
  • Numbness on the cheek, teeth, lips, nose, or brow
  • Loose maxillary teeth
  • Blood-streaked nasal mucus in association with gradually progressive congestion on the same side
  • Facial pain
I hope I'm not forgetting anything.

In the discussion of chronic nasal congestion, I'm skipping certain common things like septal deviation or chronic enlargement of the turbinates. Beth is, I think, more concerned with an acute process which seems to drag on longer than usual. For that, sinusitis and allergy would be my top two concerns.

I hope this helps!


By the way, over at Balls and Walnuts I have awarded my regular readers with a very special photo of ME. Me like you've never seen me before.

You've been warned.