wax, boogers, and phlegm

Eustachian tube dysfunction due to a deviated septum?

2008-05-30T20:10:00.000-07:00

Q:

Hi there,

I'm afraid I have a question for you which doesn't involve ear wax! Can a
deviated septum cause eustachian dysfunction?

A:

Interesting question. I had never thought about it. My knee-jerk reaction
is to say 'no,' because I can't immediately think of any mechanism
whereby septal deviation could cause ETD. But the more I think about it,
the more I can devise scenarios and think of things I can't completely
account for. So I would have to say 'maybe.'

The neat thing about this question is that it's empirically testable by
correlating rhinomanometry data (which measures nasal air flow) with
tympanometry data (which measures middle ear pressures -- a direct
measure of Eustachian tube function). Do this before and after
septoplasty and see if the improved airway results in an improved ET
function.

I just searched PubMed and found a relevant article here
and here. The first study found worsening of ET function soon after septoplasty,
with some improvement much later, but many patients showed no change in
ET function. The second study had a very brief abstract (and the main
paper is in French), so there's no telling what they demonstrated.

I would tend to agree with the conclusion suggested in the abstract of
that first paper: "We suggest that it [nasal surgery] may be useful in
cases with severe nasal pathology or chronic infection of the nose or
the nasopharynx, if this is accompanied by poor tubal function." In
other words, if the ENT doc feels the septal deviation is contributing
to sinus infection (for example), which in turn is contributing to ETD,
then septal surgery is indicated. Otherwise, don't bother.

Hope this helps!

D.

Radiofrequency uvulopalatoplasty for snoring

2008-05-11T22:33:00.000-07:00

Yeah, you read that title right. Sometimes I feel motivated to make a public service announcement. Not often, but sometimes, and tonight's the night. And since the chances are pretty good you (or your spouse) snores, I figure I won't lose too many of you with a relatively serious post.

This first bit is for my malpractice insurance carrier:

I am NOT offering medical advice; I am merely providing information. Read the disclaimer. It has flashy things and animated buttons to keep you entertained.

Another note: my ~~victim~~ patient, Jeannie, has given me permission to use her images in these blog posts. Wasn't that nice?

Look, she's even smiling about it.

Follow me below the fold for a discussion of snoring, obstructive sleep apnea, and the use of radiofrequency uvulopalatoplasty to successfully treat snoring.

While many people with obstructive sleep apnea snore, not everyone who snores has obstructive sleep apnea (OSA). What difference does it make? Pretty big one, actually. OSA can kill you (more on that in a moment), snoring can't (unless your bed partner decides to become fodder for the next season of Law & Order). We treat OSA differently than uncomplicated snoring, so it's important to learn right from the start which diagnosis the patient has.

Insurance companies wish docs could differentiate between these two diagnoses based on the history, physical exam, bed partner interview, or some simple radiologic procedure. They would like that very much because those "tests" are cheap, while the gold standard diagnostic procedure is expensive. But, unfortunately for the insurance companies, as well as folks who are under-insured or uninsured, the gold standard -- a sleep study -- is the only way to nail the diagnosis.

We don't like missing the diagnosis of OSA because of its health consequences. You'll learn from the linked article that OSA increases the risk of car accidents, depression, high blood pressure, heart disease, stroke, and death. Left untreated, OSA of sufficient severity decreases your life expectancy.

But let's say you've had your sleep study and you don't have OSA. You snore. That's it. And that's enough. What do you do now?

The sprays you can buy in the drugstore and pills you can buy online don't work. If my son weren't angling for this computer right now, I'd take the time to dig up the reference, but trust me -- some ENTs took a close look at these over the counter "cures" a few years ago and found them inefficacious. That leaves us with the two most common surgical treatments: LAUP (laser-assisted uvulopalatoplasty) and RAUP (radiofrequency-assisted uvulopalatoplasty).

They work by the same method. The idea is to injure the muscle of the soft palate, thus scarring the muscle. This shortens and stiffens the soft palate. Either method can be used to shrink an enlarged uvula, too. The two methods differ in the type of energy used: laser versus electrical current. Yes, "radiofrequency" is a polite, nonthreatening way of saying "electrocution". Sneaky bastards, aren't we?

The two methods have one other big distinction: pain. In order to injure the muscle of the soft palate, the laser has to burn its way through mucosa. With RAUP, we use an insulated needle electrode to bypass the mucosa and go directly to the muscle. The mucosa sustains much less injury than with LAUP. Since sensory nerves are more prevalent in the mucosa than in the muscle, LAUP hurts. In fact, depending upon whom you talk to, the pain is legendary. LAUP? Not so much. Most of my patients use ibuprofen, or if they use any narcotic at all, they're off it within two or three days.

Which brings us back to Jeannie. Say "AH":

Notice that you can't see Jeannie's uvula. Her soft palate is excessively long, so long that her uvula is hidden by her tongue. Even when she presses down with a tongue depressor, her uvula is still playing shy. Compare that photo to this diagram.

In a RAUP, I zap the uvula and soft palate in six or seven different locations. First, however, I inject local anesthetic into the soft palate. This is the least pleasant part of the whole affair, but honestly, it's not much worse than dental work requiring local anesthesia. Once the soft palate is numb, we begin.

The electrode administers a low current to the tissue. Again, it's only the tip which is uninsulated. The portion of the electrode in contact with mucosa is insulated. The muscle takes the hit, not the mucosa, which is just the way we like it.

Jeannie will return in four weeks for another treatment. In my experience, it takes three or sometimes four treatments (and sometimes more than that) to create a happy bed partner. That's the endpoint of treatment, by the way -- not "no snoring," which is difficult and unrealistic, but "my husband sleeps through the night, now," which is really all that matters.

Does it work? I've been a bad scientist -- I haven't tracked my own results -- but my impression is, at least 75% to 80% of my patients are happy customers. I've been doing this for nine years, and I've had relatively few outright failures. In this study, the success rate was 85%.

Most people complain more about post-op swelling than pain. With successive treatments, swelling becomes less of an issue, pain somewhat more, but it's still manageable with ibuprofen or a few days of a weak opiate. Complications are few: if the electrode is too close to the mucosa, you can get an ulceration, which is a tiny version of what LAUP does on the grand scale. Theoretically, bleeding, infection, and excessive swelling can occur, but in my experience the complications are limited to swelling and pain.

Well, Jake wants this computer, so I'll wrap it up. Any questions?

I'll keep you posted on Jeannie.

Cross-posted at Balls and Walnuts.

A mucusy smorgasbord

2008-03-11T21:13:00.000-07:00

Remember, if you need a question answered, send it to azureus at harborside dot com. And don't forget to see me at the blog and give me some love.

***

Heck, I don't even need to give you the letter on this next one. The answer is self-explanatory.

***

1. Itchy ears: if they're bothering you enough, consider asking your ENT for a prescription for Elocon (mometasone cream). The patient applies a thin layer to the ear canal openings once a day only as needed for itching. Works for most itchy ears. Caveat: some folks, and you may be one of them, have itching of the Eustachian tubes due to postnasal drainage. In that case, the only thing that will help is to treat the underlying nasal/sinus condition.

2. Tinnitus: currently, the only medication that seems to have any benefit is Zoloft, an antidepressant. Seems to help with tinnitus about 50% of the time. Not great odds, but better than nothing. (Be warned, though, that it occasionally makes tinnitus worse.) Masking is the old standby -- having some background noise in the room to distract your brain from its internal noise. But Zoloft is useful for folks who are getting loopy from the noise. I'm not sure how well this would work out with your Wellbutrin, though. Could be a problem.

3. For the mucus problem, the key interventions are (a) hydration (shoot for 64 ounces/day noncaffeinated, nonalcoholic beverages), (b) mucolytics such as guaifenesin (Mucinex, which is available OTC), (c) saline irrigation -- and nothing beats the NeilMed stuff, and (d) treatment of the underlying problem. Mucinex is the least important of those four things, hydration arguably is the most important.

4. Sometimes a person has nasal airway obstruction without any obvious source of obstruction. If that's the case, I check for nasal valve collapse. If this is the problem, lateral traction on the cheek greatly improves the airway. A Q-tip inserted into the nostril to "tent up" the ala ("wing" of the nostril) greatly improves the airway. If this is the case, there are two options: Breathe Right strips and surgery. There are a couple of approaches which bolster the nasal valve from within, essentially accomplishing internally what Breathe Right strips do externally.

5. It's very hard to say if your rhinitis and/or sinusitis has been managed with a sufficient level of aggression. There may be a role for oral antibiotics, antibiotic irrigation, antifungal irrigation, or nasal antihistamine spray (Astelin). Rarely, I use oral steroids (like Prednisone) which occasionally work better than nasal steroid sprays (like Flonase). Aggressive allergy management, either by avoidance or desensitization, may also be indicated. This part of the problem goes way beyond what I could accomplish for you in an email. I only wanted to point out that Flonase is a pretty wimpy first step at treating this problem, and there's a hell of a lot more that someone could do for you.

6. You may be wondering about obtaining a culture from the sinuses to find out what is causing the infection (if there is any infection). Nasal cultures are worthless, so the only way to get a worthwhile culture is by getting a surgical specimen. Since most of us leave surgery as a last resort, culturing the sinuses isn't much of an option. (ENTs can puncture into the sinus on an awake patient to get a valid culture, but it's REALLY unpleasant for the patient.)

This should give you plenty to discuss with your doctor.

D.

I'm back -- with boogers!

2007-09-08T09:16:00.000-07:00

Hi folks. Sorry I haven't been updating this. I've been answering most people's emails -- more than half of them, anyway -- but I just haven't had the energy to post here.

If I'm true to form, I'll probably go a long time before posting again here. You're certainly welcome to email me (azureus at harborside dot com).

On to today's letter, which could be titled: TECHNICOLOR BOOGERS.

A brief history: I had extensive endoscopic sinus surgery done 8 days ago--all four sinus cavities were cleared out, turbinates resectioned, and windows were cut. My head had so many polyps they were either going to start going down my throat or out my nose. My CT Scan was completely grey in color, which concurred with my inability to breathe through my nose or smell. I've been back to the dr once, and he used the "sucker" and got a lot of mucous out of the way, and he is having me do saline sinus rinses multiple times a day now.

My question: What is all the junk coming out of my nose? Why the rainbow of color, size, thickness, and consistency? Today I have had clear, red/bloody, yellow-brown, and brown; sometimes like normal boogers and snot, and other times like really thick snot and mucous that has sat around too long. The one that shocked me that I'm really interested in was somewhat tissue-like...it was 1.5" long x 0.5" wide x 0.25" thick chunk of red, white, clear, and yellow, and it came out when I blew my nose. (Yes, I measured it) It was similar to the consistency of raw chicken fat or something equally gross. Then a few minutes later, I blew my nose again and the same sized and consistency chunk came out of the other nostril. I felt much better and finally felt like my nose was really cleared out after these came out, but I couldn't believe something that big and solid was in there. My doc said he didn't use packing, but I wonder if these two were really something natural or if it was a dissolvable packing type of thing? And is that an abnormal size chunk to come out...could I possibly blow out nasal tissue? What about the turbinate resection...could I have blown out cilia and membranes? Any thoughts? And, lastly, is there a record for having the largest boogers?

What struck me right away is that you had your operation only 8 days ago. Eight days is nothing in this business! Of course you're still producing wild mucus. I would expect it. Don't worry about blood-red, black, brown, or yellow. It's GREEN you need to beware, since that would indicate an infection.

But I'm jumping the gun. I should begin, first, with the usual disclaimer: such questions are always more appropriate for your doctor, rather than some dude who has never examined you and who doesn't know precisely what operation was done. My response is an unreliable guess based on the information you've provided me. An educated guess, perhaps, but still unreliable. You ought to talk to your doc about this, or at least share your concerns with his nurse.

Now, on to my thoughts in the matter:

Your doc might have used dissolvable packing. He's old school (I can tell, since you said he resected your turbinates and created windows -- if that means what I think it means, your doc is probably in his 50s or 60s), so to him, "packing" may mean "strip gauze." If he left any gelfoam in your sinus cavities, this stuff can come out looking like tissue.

Short answer: this early post-op, don't fret about anything except green mucus. Two other things which would prompt a call to the doctor: copious watery drainage, which could indicate a leak of cerebrospinal fluid, or signs of infection (facial pain, redness, fever, severe headache, stiff neck -- any of those).

Otherwise, keep irrigating like crazy and you should do well. Good luck.

D.

PS: the nasal and sinus cavities are HUGE. Much bigger than the nose on your face. There's plenty of room in there for enormous boogers.

That spinning sensation

2006-12-16T09:20:00.000-08:00

Q: I am an aerialist (trapeze performer) and am currently dealing with what might be BPPV, Labyrinthitis, or something similar. I am 41 years old. My first experience with BPPV was about 2 1/2 years ago onset was a few days after I had hit my head. I ignored it for a while (it would improve and worsen randomly over the course of a few weeks) but when my work became dangerous I did se a ENT specialist who didn't suggest anything other than rest and Meclizine. Meclizine only worsened my condition. After a few weeks off the trapeze I returned to my usual activities and was fine.

About three months ago I experienced a slightly milder form of vertigo along with fullness in the ear, ear pain, popping and congestion. I saw my chiropractor who did an adjustment maneuver the day after which I was unable to walk my vision was so distorted. I could only focus if I was perfectly still. After 2 days in bed I felt better and slowly resumed activity. Mild vertigo symptoms came back in about a week, during which time my ear symptoms had worsened and I again saw my GP who prescribed Zythrimycin (sp?) - the medication and 2 days of rest and I was completely fine.

3 weeks ago I caught a cold, which caused severe headache and sinus pain after a week and a half I developed distortion in my vision causing dizziness when jumping. My doctor again prescribed Z-pack and I was improving and the dizziness receded. I curtailed trapeze activity but was able to do some aerial work. I was feeling much better dizziness wise, but still had severe headache and sinus pain. My doctor prescribed amoxiclav and flonase which I started on Tuesday morning. My sinuses began to clear, however I still had sinus pain and some facial swelling on the left. I was able to have one training session without dizziness. Later that day (Wednesday of this week) warming up for a performance I experienced positional vertigo, sweats, intestinal distress, and a metallic taste in my mouth. I got through my show and stopped taking the AmoxiClav. I have been doing the Brandt Daroff exercises and after a day of rest am only dizzy on the first set when I move to the right. I rested all day on Thursday and Friday. By end of Friday I was able to complete the BD exersize without vertigo, as well as fold forward and look up.

I saw my doctor Friday afternoon. He took an x-ray and determined that my right sinuses are still very infected and gave me Cefuroxime. He felt the dizziness was unrelated and that if it did nos subside he would refer me to an ENT. I took my first dose of Cefuroxime with dinner Friday evening. I began feeling itchy within a few hours. This morning Saturday my dizziness has worsened. I will be calling my doctor's office later today.

So, that is my history - now for the questions. Is there a reason why antibiotics would be making my vertigo worse? Is it possible to recover from a sinus infection without the use of antibiotics? Is it detrimental for me to be working out in a gym setting if I keep my head upright? I have 11 shows next week starting on Tuesday under contract, and I believe that I can compensate well if the vertigo doesn't worsen. However, I am not sure how to spend my next few days - resting completely, partial workouts? This set of shows were to be the last shows prior to my retirement (I am 41) - so they mean a lot to me. That said, I don't want to be an idiot.

Thank you so much for your time.

A: Before I address your questions, I think it's important we verify that we're talking about the same things.

BPPV: benign paroxysmal positional vertigo. (See also this link.) This has a number of unique features:

1. There is a true vertigo (sense of spinning) when the patient's head is in a particular position. Most commonly, this is provoked by rolling over in bed to one side or the other.

2. If you stay in that position, the vertigo always passes in under a minute.

3. While you are experiencing the vertigo, an observer would see your irises rotate several degrees, correct, the rotate again. Nystagmus is a repetitive eye movement; with BPPV, the nystagmus is called 'rotatory'. Other forms of vertigo show horizontal or vertical nystagmus depending on the motion of the irises. BPPV, to my knowledge, is the only condition which demonstrates rotatory nystagmus.

4. If you immediately go back into the offending position, the vertigo is either nonexistent or much less severe (so-called "fatiguability" -- the symptom "fatigues" with repetition).

5. When you first go into the offending position, there is often a delay of a second or two, sometimes a few seconds ("latency").

6. BPPV responds promptly to positional maneuvers. My favorite is the Epley maneuver, but there are others. With once daily repetition of the maneuvers, nearly all cases of BPPV will resolve in two to three days, assuming the correct maneuver is used. That's where your ENT comes in.

Fullness in the ear, popping, ear pain, and congestion are not associated with BPPV. These symptoms suggest a different problem -- perhaps Eustachian tube dysfunction, an acute ear infection, or possibly otitis media with effusion (fluid behind the ear drum). These problems sometimes improve with antibiotics or a variety of medications which treat the underlying problem, such as sinusitis, allergies, or other nasal/sinus inflammatory conditions. If medications don't help, the ENT can lance the ear drum or place a ventilation tube.

Labyrinthitis is a much more severe condition than anything we have discussed so far. Most cases are caused by viruses. (Bacterial labyrinthitis is a rare but devastating condition which usually leaves the patient with permanent balance and hearing disabilities.) The patient experiences severe vertigo worsened by any kind of motion, and, unlike BPPV, the vertigo can last for hours or days. Nausea and vomiting are common. Ringing in the ears and hearing loss are common. If there's no ringing or hearing loss, but the other symptoms are as I have described, then vestibular neuronitis should be considered.

Viral labyrinthitis and vestibular neuronitis are "self-limiting conditions", which means they improve spontaneously over the course of several days or weeks without any specific treatment.

BPPV, on the other hand, can persist for months unless the patient uses the correct positional maneuvers.

BPPV not uncommonly follows head trauma, labyrinthitis, vestibular neuronitis, or even an upper respiratory tract infection. Once you have it, you can make it go away with positional maneuvers, but it can return weeks, months, years later without warning. Positional maneuvers will again work, but there's no way to get rid of BPPV permanently.

On to your questions:

Is there a reason why antibiotics could make vertigo worse? Not usually. Only as a side effect of the medication (which is, of course, possible for any med, but I don't commonly see vertigo as a side effect of antibiotics).

Is it possible to recover from a sinus infection without the use of antibiotics? Yes. Untreated, most people will fight off a sinus infection. Antibiotics will shorten the duration of the illness (assuming we're talking about bacterial sinusitis) and will also help to prevent the progression of acute sinusitis into chronic sinusitis. One downside of NOT treating with antibiotics: the infection is more likely to turn chronic.

Is it detrimental for me to be working out in a gym setting if I keep my head upright? Assuming you are being safe in your workouts, I see no harm in this, and in fact, the workouts are probably a good thing. How else will you be able to judge if you are safe for performing?

How should you spend the next few days? Tough to say. If your heart is set on performing, you need to be working out, steadily increasing the intensity so that you can determine if you are safe to perform. Only you can make that judgment, by the way -- I doubt any doc could look you over and give you a 100% guarantee of safety. The thing to do, then, is whatever it takes for YOU to figure out if you're safe to perform.

I'm still not certain what it is that currently bothers you. That's where a visit to the ENT would come in handy, but at this time of year, I suspect getting in to the ENT would be difficult on such short notice. If your current problems are more Eustachian tube dysfunction-related, then medications (or possibly even minor surgical procedures, as I've noted above) could help. On the other hand, if your current trouble is more like BPPV, then positional maneuvers are the way to go. By the way, I can imagine situations where your stunts as an aerialist could undo the benefit of the maneuvers. You would know it right away . . . but I would hope you could find that out during your workouts, and not during a show!

Remember, safety is paramount . . . but I doubt I need to tell you that. You have many years ahead of you and I would hate to see you get injured.

Best of luck to you.

Tubes and adults don't always mix

2006-09-17T08:51:00.000-07:00

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!

D.

Those phantom smells

2006-09-06T19:47:00.000-07:00

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!

D.

When is it more than a cold?

2006-09-01T17:29:00.000-07:00

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.

D.

Tonsils, meth, and wax

2006-07-13T17:05:00.000-07:00

FYI: We've been yapping about tonsils over at Balls and Walnuts. Come see.

It never ceases to amaze me how many different questions I can get on ear wax. Here's another:

Q: I have a friend (and no it is not me that I'm referring to...since most of those statements tend to elude to such...) he is an addict and smokes methamphetamine regularly. For quite some time (at least a year) he has had a lot of ear discharge/wax buildup, etc., and is starting to have hearing probs. He regularly can be seen twisting a q-tip around his ear and is often taking his pinky finger, inserting and wriggling it around/up and down while tilting his head. He's also used peroxide wash and tried candling in the past. Where is he headed with this problem is what I'm wondering as I encourage him to visit my ENT but he has yet to do that. It is concerning me that he'll have permanent damage if he does not have matter looked at. As I know that the smoke inhalation of this drug tends to clog the ear air passage and creates an inverse suction of sorts.

I don't know what to say to facilitate a doc visit and was hoping to have some info to back potential damage he has/may have already incurred from letting it slide this long.

A: As much as I'd like to give you ammunition to get him off meth, I don't think ear wax, ear problems, or hearing loss is where it's at. For the last eight years, I have worked in a BIG methamphetamine area (the Pacific Northwest), and I haven't seen a single ear, nose, or throat patient with complications due to meth. Sorry!

He plainly has ear wax from hell, however, and would benefit from having an ENT clean out his ears. He can try using the over-the-counter wax removal products, but when it gets as bad as you describe, these kits can make matters worse.

D.

That purple stuff

2006-07-11T20:24:00.000-07:00

Q: You're a hoot! Wish my ENT had as much personality. I try to make him laugh! Rarely works.

I am asking you this question as I neglected to ask him tonight. I had down wall Cholesteatoma surgery four years ago. I am scheduled for a mastoidectomy, tympanoplasty and meatoplasty next month. Between the surgery date and my schedule to fly ( short distance, one hour flight ) it is exactly one month. Would you give the okay to fly after only one month of the above procedures?

Also what is the purple stuff he puts in my ear. He said it was an ancient Chinese secret. Okay. He may be a little funny! '-)

Thank you!

A: Some definitions for those folks who haven't heard of these things.

The best definition for cholesteatoma is "skin growing where skin does not belong." Most commonly, we're talking about skin growing in the middle ear space. Skin is stupid; skin doesn't know any better than to make more skin. That's what skin does. And so you get this ever-growing ball of skin in a location where any mass can cause trouble (injury to the sense of hearing, or to the sense of balance, or to the facial nerve, or to the brain).

Mastoidectomy refers to an operation in which the surgeon drills out the mastoid bone (the bone behind/below the ear). In this case, it's done to eradicate the cholesteatoma. A canal wall down mastoidectomy is an operation in which the posterior wall of the ear canal is removed as part of the procedure. As a result, the patient will forever after have a large cavity as part of his ear canal (where before, he had a tube).

Tympanoplasty is an operation to fix the ear drum (and sometimes the middle ear bones); meatoplasty is an operation to enlarge the ear canal opening.

To answer your first question: I would say yes, it's okay to fly, but you really need to ask your ENT. There may be details specific to your situation which might result in a different answer. Also, different surgeons have different philosophies about after-care. Ask his nurse to ask him.

That purple stuff: it's a dye called gentian violet. It has antifungal properties. It also stains EVERYTHING, which is why I don't use it. Nasty, nasty stuff; I prefer to use antifungal foot powders (like Tinactin) or CSF powder (if I remember correctly: chloromycetin, sulfanilamide, and fungizone). If I used gentian violet, all my shirts would be purple. Or mostly purple.

Any more questions?

D.

Y'all can't get enough wax

2006-06-18T09:35:00.000-07:00

I know, I know. It's been forever since I posted. Bad me.

Here's an all-too-common problem:

Q: Hi there. Ok, cracking up after googling "Ear wax medication" and reading your blog...as I just did like 4 ear candles on my poor husbands ear (which seemed to work, collecting a ton of wax & sand each time) but yet didn't remove the wax that we can see when we look in his ear.

Here is our issue - hope you can advise. My husband's ear (either from surfing or whatever) has a lot of hardened ear wax build up that can be seen with the naked eye. I can even send you a picture if you so desire. There is a hole about the size of a typed uppercase letter "O" that he has to hear out of in both ears. Frankly, I am tired of repeating myself! The wax is a very pale yellow and is pretty hard - it itches and all that fun stuff.

Are our only options to see an ENT? OR is there some sort of OTC meds that I can buy that will soften the wax and allow us to remove it with a q-tip? Trying to avoid paid medical intervention here, but we will do what it takes to get the man to hear again.

A: When it gets that packed, the best, safest, most reliable technique is removal by an ENT. If that's not an option (for financial reasons), you could try pre-treating with a few drops of warm oil (olive oil, for example), then, the next day, try using one of the over the counter wax removal kits. Your pharmacist can show you what I'm talking about. Your husband will be trying to flush the ears clear. I have to warn you, though, when it gets as bad as you describe, these do-it-yourself methods can make matters worse. If he fails to get the wax out, the wax will form a sludge which will take his hearing from bad to much worse. Not only that, but the plugged sensation is maddening.

Q-tips are a bad idea in this setting because he WILL push the wax deeper, causing pain and almost certain plugging. Don't do it.

D.

Earache my eye!

2006-05-11T21:52:00.000-07:00

Q: Doug, can I ask an ear question?  I have an earache.  Sharp intermittent pains.  Hurts when I swallow.  (and greenish mucus from the nostril on that side, the side with a polyp ... I'll never be able to look you in the face after this revelation.  Allergies?

A: Bare minimum, you have a sinus infection on that side. That green yuck coming out of your nose? It's flowing down into your throat, too. On the way down, it passes by your Eustachian tube orifice. Any irritation of the ET orifice will be felt as a pain in the ear. The general term for this is "referred otalgia."

Infection can also ascend via the Eustachian tube, causing an outright ear infection. You don't mention hearing loss, so I'm going to guess you don't actually have an ear infection.

Allergies? Maybe, but that's not the whole story. Allergies won't give you green mucus -- but sinus infection will. You're gonna need an Rx.

D.

Warm, Pink, Moist, and Lovely

2006-04-27T21:32:00.000-07:00

Michelle recently asked me,

When Docs stick the thingamabob up your nose, what exactly do they see?

Here's my response:

Magic Schoolbus does your nose and throat

. . . an endoscopic guided tour through the nose and throat. Enjoy!

D.

How they do it in Japan . . . Open Thread

2006-04-22T15:49:00.000-07:00

Sorry, sorry. I know I haven't been around much. Vacation happened, and Balls and Walnuts sucks up most of my free time. Just haven't had it in me to cough up any new wax, boogers, or phlegm.

Hat tip to Falafel Sex's Mark Alread for this post on how the Japanese clean ear wax. Cute story, but really, there's nothing new here. Cleaning wax under direct vision is simply the safest way to do it. I use a binocular microscope, which gives me depth perception, excellent lighting, and as much magnification as I want. I have a variety of tools for the job, including right angle picks, curved picks, straight and angled loop curettes, and alligator forceps. The only time I'm ever defeated is when the wax is hard and impacted, and manipulation of it exceeds my patient's pain tolerance.

I still get at least one letter a week griping about my opposition to ear candling. Most recently, a physician wrote a polite letter telling me I was wrong. You know, I wish all of my wax patients would switch to ear candles, and as long as I'm wishing, I wish the candles would WORK, too. Then I could focus my efforts on more troublesome problems.

But candles don't work, so this is a pipe dream. I'll keep on de-waxing people because it's one of the few things I do which gives rapid relief . . . and I do it well.

Consider this an open thread. Come one, come all: any questions?

D.

Don't get all feministical on me.

2006-03-13T12:00:00.000-08:00

Q: Why do men get so damned noisy sinusistically speaking when they reach middle age? My husband clears his throat and manipulates his snot in the noisiest manner, and he's a deep-voiced, big guy, so it is loud!!! I don't know any women who do this. He manages to keep it at bay when in public. He has had his sinuses done successfully (with that headpiece and software-directed surgery) and does not have any allergies that i know of. Can you suggest any causes or whom to go see for this? I am seriously ready to clock him! Or should I call a lawyer?

A: Sinusistically. As a writer, I love that word, love it to death.

First off, let's dispense with the sexism right away. Women get this too. The fact that they don't hawk and snort only means they don't do that around YOU. As you mentioned, he only does it around you, which is a testimony to how comfortable he is in your presence. The big galoot must really love you.

Good. Now that you're feeling better about the hubs, what are we going to do about the snorting? My hunch -- and this could easily be confirmed by having his ENT scope his nasal passages at an early morning appointment (make sure your hubs doesn't clear everything out before going in!) -- is that this is a mucus problem. Even if he's had sinus surgery, his sinus cavities and nasal cavities will continue to produce lots and lots of mucus. Perhaps this stuff is hanging up in his nasopharynx (the top part of the throat).

If the ENT confirms this and rules out the somewhat more serious possibility of recurrent sinus infection, then your husband has a few good options. The best, in my opinion, would be to adopt a routine of nasal irrigation as part of his morning ritual. Nasal douching does wonders for clingy mucus. The solution may be even simpler than that; some folks improve markedly if they increase their intake of noncaffeinated, nonalcoholic fluids.

In summary, I would go to an ENT first, and hold off on the lawyer.

D.

Intracapsular tonsillectomy

2006-03-01T13:54:00.000-08:00

Q: I [identifying information deleted] have been treated with antibiotics 7 times in the last 12 months for 'strep throat.' It is likely that I will have a tonsillectomy soon.

I am looking for information about intracapsular tonsillectomies for adults. So far, ENTs I have talked to here seem to think it's not a surgery that works in adults. (They may not have any experience doing it which may be the issue as well.) I am writing to you because your website mentions that you have performed these surgeries.

I have looked for research confirming that it can work in adults, but have found nothing especially helpful. I am also looking for information concerning who in New England might be willing to do an adult intracapsular tonsillectomy.

Any information or help that you can provide would be incredibly helpful. I am considering writing a research proposal concerning the topic if I can not find decent research on the topic.

Thank you for your time.

A: You're right. It is difficult finding information on the web regarding adult intracapsular tonsillectomy. Here's something from Bryn Mawr Hospital:

For adults, the new procedure may not be as effective as it is in children because the tonsils will have become scared and rubbery from repeated infections, compared with the fluffy tonsils of a child. "Adult tonsils don't shave out as easily, but we will try the partial tonsillectomy first," he said. "If the procedure becomes difficult, we can convert to a traditional tonsillectomy."

I have been doing adult intracapsular tonsillectomies for the last 12 to 18 months, and I know a lot of my colleagues are doing the same. I would agree with the above author that some adults are poor candidates for this -- those whose tonsils are scarred down. Adults with larger tonsils, more typical of what we see in children, are better candidates. The trouble with scarred tonsils is that it becomes challenging if not impossible to leave behind a thin layer of tonsil tissue, which is the aim of the intracapsular technique.

As you have no doubt heard, adult tonsillectomy can be very painful, and the intracapsular technique is a definite improvement with regard to post-op pain. In my experience, even those adults who end up having a complete tonsillectomy still seem to do better post-operatively. Thus, I agree with the above author who always tries the intracapsular method first.

Hopefully, I can get a few of my colleagues to add their thoughts, too.

Somnoplasty for sleep apnea?

2006-02-28T22:42:00.000-08:00

I am a [age omitted to protect identity] year old woman with sleep apnea. The following conditions were noted in the medical diagnosis: slightly elongated uvula,
deviated septum. [I] was given the CPAP which I have used for the
past 6 years. It is a nuisance, but it DID give restorative sleep for
about 4 of those years.

CPAP = continuous positive airway pressure, the treatment of choice for obstructive sleep apnea. Why is it the treatment of choice? Because (1) it works 100% of the time, and (2) as a nonsurgical treatment, it carries 0% surgical risk. (Funny how that works!)

The main problem with CPAP is compliance. About 50% of the folks who try CPAP ultimately fail to adapt to it. It is a rather unnatural, cumbersome device. Nevertheless, if you were able to use it for four years, that tells me you are in the 50% who can tolerate CPAP.

I lost about 12% of my overweight (52 lbs.) and the CPAP doc agreed that the dental device alone might do the trick. It worked OK for a while and then I had to return to the CPAP. In
the past 2 years I've experienced episodes of waking with a rapid heavy heart beat.

Are you talking about the device that thrusts your lower jaw forward? If this helped, it suggests your obstruction is at the level of the tongue base rather than the soft palate. Some folks are performing radiofrequency ablation of the tongue base, but you might have a hard time finding someone who is familiar with that procedure. A conventional somnoplasty involves radiofrequency ablation of the soft palate, not the tongue base.

I'm wondering about your math, by the way. If 52 lbs = 12% of your "overweight", this suggests you're over 400 pounds overweight.

An ENT can determine where you are obstructing with a reasonable degree of certainty by examining your airway with a flexible fiberoptic scope. This will help the ENT figure out what sorts of surgical procedures are helpful.

I have PAT, controlled well by medication. I also have abundant torae
in lower jaw . . . and one fair-sized one growing toward the back of the
roof of mouth. I realize you would have to SEE the area to evaluate
the amount of narrowing, but do you think it might be helpful to
investigate the effect of a SOMNOPLASTY on encroaching sleep apnea?
Since my stomach will not retain pain meds (even pain shots cause
vomitting), I dread the thought of the knife-blade surgery and weeks of
pain, etc., etc.

As I indicated above, an appropriate physical exam (including a fiberoptic airway exam) is essential to answering this question. Also critical are the numbers on your sleep study. If your obstructive sleep apnea is mild, somnoplasty might be an option. If your OSA is moderate to severe, somnoplasty is simply not aggressive enough to solve anything.

Would appreciate your description of somnoplasty, and your comments on
whether I should pursue that procedure.

I can describe somnoplasty for you, but I can't give you any advice as to whether you should pursue it. That's for you to discuss with your doctor.

"Somnoplasty" is a proprietary term, but it has come to refer to all radiofrequency soft palate ablation techniques. The doctor anesthetizes your soft palate with multiple local anesthetic injections. Next, he uses an insulated electrode to heat (with electrical current) the muscle of the soft palate and uvula in several different sites. Over time, the heated area scars down, shortening and stiffening the soft palate and uvula. To some degree, this decreases the volume of the tissue, too.

It's a good treatment for snoring, not so hot for OSA. It's well tolerated compared to the older technique, LAUP (laser-assisted uvulopalatoplasty), which is legendary in terms of post-procedure pain. Pain after a somnoplasty usually does not require narcotic pain medications -- Motrin usually suffices. Some of my patients need narcotics, however.

Multiple procedures are necessary. With the equipment I use, most folks require 3 or 4 separate treatments, spaced out about 4 to 6 weeks apart. Some of my patients have needed 6 or more treatments. It's less aggressive than a LAUP, and therefore less painful, but the tradeoff is, you need more separate procedures.

Risks include, but are not limited to, ulceration of the soft palate, swelling of the uvula or soft palate, more pain than you were bargaining for, and failure of the procedure to fix the problem. Your doctor would fill you in on all the other risks, too.

I hope this helps you discuss your options with your doctor.

D.

Get those butterflies back in your stomach, Susan!

2006-02-25T15:25:00.000-08:00

Susan writes:

A couple of weeks I started getting something I call "ear flutters." It happens only in the late evening (every night now) except for one afternoon episode. My head/ears feel full, and a sound/sensation starts in my right ear. I can describe it as a rapid irregular beat with a tiny mallet, or a very muffled putt-putt from an old outboard motor.

Onset coincided with increased stress and a slight worsening of tinnitus. I'm guessing either my arteries are involved or a space alien has invaded my eardrum.

This is most likely myoclonus. Myoclonus, by the way, is a two bit medical word meaning "muscle twitch." You have two eensy weensy muscles in your middle ear, the tensor tympani, and the stapedius. Either can develop a twitch. Because of where they are located and what they are attached to, a twitch in either of these muscles produces a fluttering sound, and sometimes also a fluttering sensation.

According to this website, middle ear myoclonus can be a symptom of TMJ, multiple sclerosis, intracranial neoplasm, or cerebrovascular disease. That's news to me. In my experience, middle ear myoclonus tends to be idiopathic (no apparent explanation) and goes away with time and/or conservative treatment (muscle relaxants, for example).

Middle ear myoclonus must be distinguished from vascular tinnitus. Vascular tinnitus is a rhythmic sound which follows the pulse. This is a whole different ballgame, and requires a considerably different diagnostic approach.

Here's an interesting online discussion of middle ear myoclonus. One of the participants insists that cutting the muscle is the only cure. Again, relying upon my experience, surgery is rarely necessary (I have never had to refer anyone for this operation). If I ever met a patient with such persistent, intractable myoclonus, I suppose I would go ahead with the appropriate scans to rule out MS or tumor.

By the way, I agree with what Jambo and JoeM say in their first few posts regarding ENTs: unfortunately, there are a few ENTs who don't know about this condition.

Mind you, I haven't read all of their discussion, so I don't vouch for what they have to say. It will give you the opportunity to hear others' experiences, though.

Needless to say, you should find an ENT familiar with this condition and pursue it with him/her.

D.

Weekend Open Thread

2006-02-11T08:43:00.000-08:00

Cough it up or blow it out. It's time for more questions.

D.

Because I can never write enough about ear wax.

2006-02-06T13:18:00.000-08:00

Q: One of my ears creates a lot of hard crumbly ear wax, and eventually I go deaf and have it suctioned out. (My doctor doesn't recommend syringing or peroxide treatments.)

Smart doctor. It is difficult, if not impossible, to irrigate away this type of wax.

I also occasionally get excruciating itching in that ear, which my doctor treats with GlaxoSmithKline Otomize.

I'm not familiar with that product. For itchy ears, I use a variety of steroid creams (see Itchy and Scratchy, below). Very important to rely upon cream, rather than scratching the itch, since scratching makes it itchier.

When I remember I drop olive oil (virgin of course - only the best!) into my ear to soften the wax. I note you suggest baby oil - would that be better?

I tell my patients: anything but motor oil. Vegetable oil and baby oil are equally acceptable.

But why does it happen - could there be some medical or parasitical cause that my doctor hasn't picked up? Or am I just getting old?

Sometimes I discover an explanation for a change in ear wax, such as ear surgery or radiation to the ear. Far more commonly, such changes remain a mystery. If it makes you feel any better, we see this sort of wax in all age groups, so it has nothing to do with age.

D.

Open thread

2006-01-29T08:44:00.000-08:00

Question on your mind? Spit it out.

The question that is, not your mind. Eeew.

D.

An ear wax rant

2006-01-29T08:07:00.000-08:00

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?

D.

Weekend Open Thread

2006-01-20T22:29:00.000-08:00

Speak up. I can't hear you!

D.

Itchy and Scratchy

2006-01-17T22:08:00.000-08:00

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!

D.

Keeping the pipes clean

2006-01-14T12:58:00.000-08:00

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.

D.

Whovula?

2006-01-13T12:32:00.000-08:00

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:

pseudopseudohypoparathyroidism

30 letters, if I can still count.

D.

Open thread

2006-01-08T21:03:00.000-08:00

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

D.

Aw, crud!

2006-01-08T20:19:00.000-08:00

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.

D.

Some people.

2006-01-02T18:46:00.001-08:00

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?

D.

Stones where?

2005-12-31T14:24:00.000-08:00

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.

Cough.

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.

D.

Swelling behind the ears

2005-12-29T11:22:00.001-08:00

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.

D.

Ear pain

2005-12-23T20:21:00.000-08:00

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.

D.

Doc Otter is back!

2005-12-22T18:12:00.000-08:00

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.

D.

Wet nose, warm heart

2005-12-22T11:04:00.000-08:00

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!)

D.

Weekend Open Thread

2005-12-20T20:14:00.000-08:00

Cough it up and spit it out.

Remember,

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

2005-12-20T19:52:00.000-08:00

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.

D.

Head-banger's Ball

2005-12-20T12:47:00.000-08:00

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.

D.

A big, fat DISCLAIMER!

2005-12-20T12:19:00.000-08:00

Because the lawyers at CMA think it's a good idea, I ask you to read this disclaimer.

If you would rather not read the disclaimer, or if you choose to ignore this disclaimer, you belong at THIS SITE.

Wax, Boogers, and Phlegm does NOT offer medical advice. The material posted on this blog is offered for information purposes only.

Do not act or rely upon information from Wax, Boogers, and Phlegm without seeking professional medical advice.

The transmission of information from Wax, Boogers, and Phlegm to you is NOT intended to create nor does it create a physician-patient relationship between you and Dr. Hoffman.

Even if Dr. Hoffman answers your questions, the information he provides MUST be reviewed with your physician.

Dr. Hoffman does not guarantee the accuracy, completeness, usefulness or adequacy of any resources, information, apparatus, product or process available at or from Wax, Boogers, and Phlegm.

***

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.

D.

Welcome to Wax, Boogers, and Phlegm

2005-12-20T09:51:00.000-08:00

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!)

D.