How To Take Levothyroxine

Levothyroxine controls hypothyroidism but does not cure it. It may take several weeks before you notice a change in your symptoms. Continue to take levothyroxine even if you feel well. Do not stop taking levothyroxine without talking to your doctor. Your doctor will probably start you on a low dose of levothyroxine and gradually increase your dose. Levothyroxine comes as a tablet to take by mouth. Levothyroxine is best absorbed when it is taken: On an empty stomach or With water only or One hour before or two hours after eating or One hour before taking any medications vitamins or supplements or Two hours before taking iron or calcium or Twelve hours before taking Questran® or Colestid® If you take an antacid calcium carbonate (Tums) cholestyramine (Questran) colestipol (Colestid) iron orlistat (alli Xenical) simethicone (Phazyme Gas X) sodium polystrene sulfonate (Kayexalate) or sucralfate (Carafate) take it at least 4 hours before or 4 hours after you take levothyroxine. Take the missed dose as soon as you remember it. However if it is almost time for the next dose skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one. The tablets may get stuck in your throat or cause choking or gagging; therefore the tablet should be taken with a full glass of water. If you are giving levothyroxine to an infant or child who cannot swallow the tablet crush the tablet and mix it in 1 to 2 teaspoons of plain water. Give this mixture by spoon or dropper right away. Do not store this mixture. Only mix the crushed tablets with water. Do not mix with food or soybean infant formula.

HMO Referrals

Many managed care plans require that patients obtain referrals from their primary care physician prior to their appointment with a consulting specialist. It is the patient's responsibility to obtain a valid referral prior to seeing the specialist. If a valid referral is not obtained you will be responsible for all charges. Authorization is usually required by managed care plans prior to surgical procedures.


Insight into voice changes

  • What causes hoarseness?
  • What can you do to treat it?
  • When should you see an ENT?
  • and more…

Abnormal changes in the voice are called “hoarseness.” When hoarse the voice may sound breathy raspy strained or show changes in volume or pitch (depending on how high or low the voice is). Voice changes are related to disorders in the sound-producing parts (vocal folds) of the voice box (larynx). While breathing the vocal folds remain apart. When speaking or singing they come together and as air leaves the lungs they vibrate producing sound. Swelling or lumps on the vocal folds hinder vibration altering voice quality volume and pitch.

What are the causes of hoarseness?

Acute Laryngitis: The most common cause is acute laryngitis—swelling of the vocal folds that occurs during a common cold upper respiratory tract viral infection or from voice strain. Serious injury to the vocal folds can result from strenuous voice use during an episode of acute laryngitis.

Voice Misuse:

  • Speaking in noisy situations
  • Excessive use
  • Telephone use with the handset cradled to the shoulder
  • Using inappropriate pitch (too high or too low) when speaking
  • Not using amplification when public speaking

Benign Vocal Cord Lesions: Prolonged hoarseness can occur when you use your voice too much or too loudly for extended periods of time. These habits can lead to nodules polyps and cysts. Vocal nodules (singers’ nodes) are callus-like growths of the vocal folds. Vocal fold polyps and cysts also occur in those who misuse their voice but can also occur in those who do not.

Vocal Hemorrhage: If you experience a sudden loss of voice following a yell or other strenuous vocal use you may have developed a vocal fold hemorrhage. Vocal fold hemorrhage occurs when one of the blood vessels on the surface of the vocal folds ruptures and the soft tissues fill with blood. It is considered a vocal emergency and should be treated with absolute voice rest and examination by an otolaryngologist (ear nose and throat doctor).

Gastroesophageal Reflux (GERD): A possible cause of hoarseness is gastro-esophageal reflux when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal folds. Other typical symptoms of GERD include heartburn and regurgitation. Usually the voice is worse in the morning and improves during the day. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it.

Laryngopharyngeal Reflux (LPRD): If the reflux makes it all the way up through the upper sphincter and into the back of the throat it is called LPRD rather than GERD. The structures in the throat (pharynx larynx and lungs) are much more sensitive to stomach acid and digestive enzymes so smaller amounts of the reflux into this area can result in more damage.  Many patients with LPRD do not have hearburn or other classic symptoms of GERD.

Smoking: Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer if smokers become hoarse they should see an otolaryngologist.

Neurological Diseases or Disorders: Hoarseness can also appear in those who have neurological diseases such as Parkinson’s or a stroke or may be a symptom of spasmodic dysphonia a rare neurological disorder that usually affects only the voice but sometimes affects breathing. A paralyzed vocal fold may be the cause of a weak breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out a neurologist may be helpful for diagnosis.

Other Causes: These include allergies thyroid problems trauma to the voice box and occasionally menstruation. Very serious conditions such as laryngeal cancer can also cause hoarseness which is why it is important to have chronic hoarseness evaluated promptly by an otolaryngologist

How is hoarseness treated?

Hoarseness caused by a cold or flu may be evaluated by family physicians pediatricians and internists who have learned how to examine the larynx. Problems with the voice are often best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologists speech/language pathologists and teachers of singing acting and public speaking. Vocal nodules polyps and cysts are typically treated with a combination of microsurgery and voice therapy.

How is hoarseness evaluated?

Otolaryngologists will obtain a thorough history of a patient’s hoarseness and general health. They will then evaluate the voice and do a complete ear nose and throat exam. This includes examination of the vocal folds by laryngoscopy.  Laryngoscopy may be suggested by the otolaryngologist at any time during an evaluation for hoarseness but if it persists beyond three weeks it should be evaluated and that evaluation should occur within a maximum of 3 months. The evaluation should be immediate if there is concern about a serious underlying cause is suspected.

Doctors usually look at the vocal folds either with a mirror placed in the back of the throat or with a very small lighted flexible tube (fiberoptic scope) that is passed through the nose to view the vocal folds. Videotaping or stroboscopy (slow-motion assessment) may also help with the analysis. These procedures are well tolerated by most patients. In some cases special tests designed to evaluate the voice may be recommended. These measure voice irregularities how the voice sounds airflow and other characteristics that are helpful in diagnosing and guiding treatment.

When should I see an otolaryngologist?

  • If hoarseness lasts longer than three weeks especially if you smoke
  • If you do not have a cold or flu
  • If you are coughing up blood
  • If you have difficulty swallowing
  • If you feel a lump in the neck
  • If you observe loss or severe changes in voice lasting longer than a few days
  • If you experience pain when speaking or swallowing
  • If difficulty breathing accompanies your voice change
  • If your hoarseness interferes with your livelihood
  • If you are a vocal performer and unable to perform

How are vocal disorders treated?

The treatment of hoarseness depends on the cause. Many common causes of hoarseness can be treated simply by resting the voice or modifying how it is used. An otolaryngologist may make some recommendations about voice use behavior refer the patient to other voice team members and in some instances recommend surgery if a lesion such as a polyp is identified. Not smoking and avoiding secondhand smoke is recommended to all patients. Drinking fluids and taking medications to thin out the mucus may help.

How to prevent hoarseness

Specialists in speech/language pathology (voice therapists) are trained to assist patients in behavior modification to help eliminate some voice disorders. Patients who have developed bad habits such as smoking or overusing their voice by yelling and screaming benefit most from this conservative approach. The speech/language pathologist may teach patients to alter their methods of speech production to improve the sound of the voice and to resolve problems such as vocal nodules. When a patient’s problem is specifically related to singing a singing teacher may help to improve the patients’ singing techniques.

Prevention tips:

  • If you smoke quit.
  • Avoid agents that dehydrate the body such as alcohol and caffeine.
  • Avoid secondhand smoke.
  • Stay hydrated—drink plenty of water.
  • Humidify your home.
  • Watch your diet—avoid spicy foods.
  • Try not to use your voice too long or too loudly.
  • Use a microphone if possible in situations where you need to project your voice.
  • Seek professional voice training.
  • Avoid speaking or singing when your voice is injured or hoarse.

Reference: American Academy of Otolaryngology. Head and Neck Surgery.

Hearing Loss

You may have hearing loss and not even be aware of it. People of all ages experience gradual hearing loss often due to the natural aging process or long exposure to loud noise. Other causes of hearing loss include viruses or bacteria heart conditions or stroke head injuries tumors and certain medications. Treatment for hearing loss will depend on your diagnosis.

How does the hearing sense work?

Hearing is a complex and intricate process. The ear is made up of three sections: the outer ear the middle ear and the inner ear. These parts work together so you can hear and process sounds. The outer ear or pinna (the part you can see) picks up sound waves and directs them into the outer ear canal.

These sound waves travel down the ear canal and hit the eardrum which causes the eardrum to vibrate. When the eardrum vibrates it moves three tiny bones in your middle ear.  The middle ear is a small air-filled space between the eardrum and the inner ear. These bones form a chain and are called the hammer (or malleus) anvil (or incus) and stirrup (or stapes). The movement of these bones transmits and amplifies the sound waves toward the inner ear.

The third bone in the chain the stapes interfaces with fluid which fills the hearing portion of the inner ear — the cochlea. The cochlea is lined with cells that have thousands of tiny hairs on their surfaces. As the fluid wave travels through the cochlea it causes the tiny hairs to move. The hairs change the mechanical wave into nerve signals. The nerve signals are then transmitted to your brain which interprets the sound.

Test your hearing

To get an idea of how well you hear answer the following questions and then calculate your score. To calculate your score give yourself 3 points for every “Almost always” answer 2 points for every “Half the time” answer 1 point for every “Occasionally” answer and 0 for every “Never.” Please note: If hearing loss runs in your family add an additional 3 points to your overall score.

The American Academy of Otolaryngology—Head and Neck Surgery recommends the following:

0-5 points­—Your hearing is fine. No action is required.

6-9 points—Suggest you see an ear nose and throat (ENT) specialist.

10+ points—Strongly recommend you see an ear nose and throat (ENT) specialist.

I have a problem hearing over the telephone.
Almost always
Half the time

I have trouble following the conversation when two or more people are talking at the same time.
Almost always
Half the time

People complain that I turn the TV volume too high.
Almost always
Half the time

I have to strain to understand conversations.
Almost always
Half the time

I miss hearing some common sounds like the phone or doorbell ring.
Almost always
Half the time

I have trouble hearing conversations in a noisy background such as a party.
Almost always
Half the time

I get confused about where sounds come from.
Almost always
Half the time

I misunderstand some words in a sentence and need to ask people to repeat themselves.
Almost always
Half the time

I especially have trouble understanding the speech of women and children.
Almost always
Half the time

I have worked in noisy environments (such as assembly lines contstruction sites or near jet engines).
Almost always
Half the time

Many people I talk to seem to mumble or don’t speak clearly.
Almost always
Half the time

People get annoyed because I misunderstand what they say.
Almost always
Half the time

I misunderstand what others are saying and make inappropriate responses.
Almost always
Half the time

I avoid social activities because I cannot hear well and fear I’ll make improper replies.
Almost always
Half the time

Ask a family member or friend to answer this question: Do you think this person has a hearing loss?
Almost always
Half the time

What can I do to improve my hearing?

  • Eliminate or lower unnecessary noises around you.
  • Let friends and family know about your hearing loss and ask them to speak slowly and more clearly.
  • Ask people to face you when they are speaking to you so you can watch their faces and see their expressions.
  • Utilize sound amplifying devices on phones.
  • Use personal listening systems to reduce background noise.

Tips to maintain hearing health

  • If you work in noisy places or commute to work in noisy traffic or construction choose quiet leisure activities instead of noisy ones.
  • Develop the habit of wearing earplugs when you know you will be exposed to noise for a long time.
  • Earplugs can reduce the volume of sound reaching the ear to a safer level.
  • Try not to use several noisy machines at the
    same time.
  • Try to keep television sets stereos and headsets low in volume.


Reference: American Academy of Otolaryngology. Head and Neck Surgery.

Headache Diet

Certain foods are believed to be responsible for up to 30 percent of all headaches.

Tyramine content may vary among brand names available on the market because if preparation processing or storage. It is best to eat only freshly prepared foods and to avoid eating those that may have aged fermented pickled or marinated. Tenderizers monosodium glutamate nitrates of nitrate compounds are likely to be provoking agents. It is important to read the labels carefully when shopping and asking questions when eating out.



  • Decaffeinated coffee and colas. Caffeine sources to be limited to two (2) cups per day which includes coffee tea and colas
  • Milk – Homogenized skim (2%)


  • Cottage cheese cream cheese American and Velveeta Cheese or any synthetic cheese
  • Yogurt in ½ cup portions or less


  • Freshly prepared meats eggs.


  • All except those on avoid list. Commercial breads.



  • Alcoholic beverages wine beer
  • Milk – chocolate buttermilk


  • Aged and processed cheese including cheddar swiss mozzarella parmesan Romano brick Brie camembert gruyere gouda stilton provolone Roquefort blue and foods containing cheese (pizza macaroni and cheese)
  • Yogurt and sour cream


  • Aged canned cured or processed meats and those containing nitrites or commercial meats extracts. Pickled or dried herring chicken livers sausage salami bologna pepperoni frankfurters pates peanuts and peanut butter marinated meats. Any meat prepared with tenderizers soy sauce or yeast extracts.


  • Homemade yeast breads fresh cake doughnuts yeast and yeast extracts sourdough breads.
  • Breads or crackers containing cheese chocolate or nuts.



  • Seven in 10 people have at least one headache a year
  • The majority of headaches last for only a few hours but some can persist for weeks
  • Forty-five million Americans suffer from chronic headaches
  • Headaches cost billions of dollars in lost productivity every year

With a headache pain may occur in only one part of the head such as above the eyes or it may involve the entire head. The type of pain experienced varies; it may be constant and dull or sudden and sharp. And sometimes other symptoms such as nausea occur at the same time depending on the type of headache.

Three main types of headaches

Tension headaches  typically feel like a tightening on both sides of the head. They can last for minutes or days and can happen frequently. Tension headaches are often the result of stress or bad posture which causes tightening of the muscles in the neck and the scalp. Tension headaches often worsen with noise and hot stuffy environments. This type of headache occurs mostly in women over age 20.

Migraine headaches  are intense and throbbing often involve one side of the head and can make you sensitive to light or noise. Migraines last from hours up to three days and are more common in women. Some sufferers have an “aura” (a group of visual symptoms) just before an attack. In the U.S. each year about 25 million people experience a migraine. Migraine sufferers usually have their first attack before age 30 but they can also occur in children as young as age three. Migraines recur at intervals of varying length. Some people have attacks several times a month; others have less than one a year. Most people find that migraine attacks occur less frequently and become less severe as they get older. There are two types of migraine: migraine with an aura and migraine without aura. An aura is a group of symptoms that develop before the onset of the main headache.

Cluster headaches  are non-throbbing and usually are felt on one side of the head behind an eye. Cluster headaches affect about 1 million people in the United States. More common in men they can happen over several days and usually last 30 to 45 minutes. They generally occur between one and four times a day. Like migraines cluster headaches are likely to be related to an increased blood flow as a result of the blood vessels in the brain widening.

What are the causes?

There are many possible causes of headache that determine the site and nature of the pain. About three in four of all headaches are caused by tension in the scalp and neck muscles. Very few headaches have serious underlying causes but those that do require urgent medical attention. For example a severe headache may be a sign of meningitis. In elderly people a headache with tenderness of the scalp or temple may be due to temporal ateritis in which blood vessels in the head become inflamed.

If you have a headache that lasts more than 24 hours and is severe or accompanied by other symptoms such as problems with vision or vomiting medical help should be sought immediately.

What might your doctor do?

Your doctor may do a physical examination if he/she suspects an underlying disorder causing your headache. You may require tests such as a CT scan or a MRI of your brain.

Reference: American College of Physicians.

Gastroesophageal Reflux Disease

Troublesome Symptoms:

Symptoms that persist for greater than two weeks and affect quality of life.

  • Asthma
  • Chronic Cough
  • Chronic Hoarseness
  • Nausea and Vomiting
  • Alarm Symptoms

Symptoms that signal complications or alternative diagnosis.

Normally require immediate medical care and should not be treated at the self-care level.
  • Dysphagia
  • Frequent Vomiting
  • GI Bleeding
  • Anemia
  • Choking
  • Unexplained Chest Pain
  • Weight Loss

Lifestyle changes

  • Dietary changes
  • Medication changes
  • Elevate the head of bed
  • Weight reduction
  • Smoking cessation
  • Avoid alcohol
  • Avoid tight fitting clothing
  • Avoid foods that decrease lower esophageal pressure (fats chocolate alcohol peppermint)
  • Avoid direct irritant foods (spicy foods acidic juices coffee)
  • Include protein-rich meals in diet (augments lower esophageal pressure)
  • Eat small meals and avoid eating prior to sleeping
  • Discontinue if possible medications that promote reflux (calcium channel blockers beta-blockers nitrates theophylline)
  • Take direct irritant drugs with water if they cannot be avoided (tetracyclines quinidine potassium iron aspirin NSAIDs

Eustachian Tube Dysfunction

Eustachian tube dysfunction (ETD) can cause dulled hearing. It is usually a temporary problem that lasts a week or so and most commonly occurs during and after a cold. There are various other causes and sometimes it lasts longer. Often no treatment is needed but decongestants antihistamines or a steroid nasal spray sometimes help.

What is the Eustachian tube and what does it do?

The Eustachian tube is a narrow tube that connects the middle ear with the back of the nose. In adults it is about 3-4 cm long. The middle ear space behind the eardrum is normally filled with air. The air in the middle ear is constantly being absorbed by the cells that line the middle ear. So fresh supplies of air are needed to get to the middle ear from time to time.

The Eustachian tube is normally closed but opens from time to time when we swallow yawn or chew. This allows air to flow into the middle ear and any mucus to flow out. This keeps the air pressure equal either side of the eardrum. Having equal air pressure on each side of the eardrum and the middle ear free of mucus enables the eardrum to work and vibrate properly which is needed to hear properly.


How do we hear?

Sound waves hit the eardrum. Vibrations of the eardrum pass on to tiny bones (the ossicles) in the middle ear. These bones transmit the vibrations to the cochlea in the inner ear. Sound signals are sent from the cochlea to the ear nerve and then on to the brain.

What is Eustachian tube dysfunction?

Eustachian tube dysfunction (ETD) means that the Eustachian tube is blocked or does not open properly. Air cannot then get into the middle ear. Therefore the air pressure on the outer side of the eardrum becomes greater than the air pressure in the middle ear. This pushes the eardrum inward. The eardrum becomes tense and does not vibrate so well when hit by sound waves.

What are the symptoms of Eustachian tube dysfunction?

The main symptom is muffled or dulled hearing. You may also have ear pain because the eardrum is tensed and stretched. Other symptoms that may also develop include: a feeling of fullness in the ear; tinnitus (ringing or buzzing in the ear); dizziness. One or both ears may be affected.

Symptoms can last from a few hours to several weeks or more. It depends on the cause. In most cases due to a cold (the common cause) the symptoms are likely to go within a week or so. As symptoms are easing you may get popping sensations or noises in the ear. Also the dulled hearing may come and go for a short time before getting fully back to normal.

What are the causes of Eustachian tube dysfunction?

ETD occurs if the Eustachian tube becomes blocked or if the lining of the tube becomes swollen or if the tube does not open as it should to allow air to travel to the middle ear.

Colds and other nose sinus ear or throat infections

This is the common cause of ETD. The blocked nose or thick mucus that develops during a cold or other infections may block the Eustachian tube. An infection may also cause the lining of the Eustachian tube to become inflamed and swollen. Most people will have had one or more episodes in their life when they have had a cold and find that they cannot hear so well due to ETD. The symptoms of ETD may persist for up to a week or so (sometimes longer) after the other symptoms of the infection have gone. This is because the trapped mucus and swelling may take a while to clear even when the infecting germ has long gone.

Sometimes the infection is very mild. Perhaps a mild cold with a mild bunged up nose. However ETD may still develop in some people for a while.

Glue ear

Glue ear is a condition where the middle ear fills with glue-like fluid. The Eustachian tube becomes congested and prevents the free flow of air into the middle ear causing the difference in air pressure mentioned above. The eardrum becomes tight reducing its ability to vibrate resulting in dulled hearing. The situation is made worse by the glue-like fluid damping down the vibrations of the drum even further. It is a common condition in children. It clears by itself in most cases but some children need an operation to solve the problem.


Allergies that affect the nose such as perennial rhinitis and hay fever can cause extra mucus and inflammation in and around the Eustachian tube and lead to ETD.


Anything that causes a blockage to the Eustachian tube can cause ETD. For example enlarged adenoids. Rarely ETD can be a symptom of rare tumours that sometimes develop at the back of the nose. These will usually cause other symptoms in addition to ETD.

Air travel and the Eustachian tube

Some people develop ear pain when descending to land during a plane journey. It is caused by unequal pressures that develop on either side of the eardrum as the plane descends. As a plane descends the air pressure becomes higher nearer the ground. This pushes the eardrum inwards which can be painful. In most people just normal swallowing and chewing quickly cause air to travel up the Eustachian tube to equalise the pressure.

Some airlines offer sweets to suck and eat when the plane is descending to encourage you to chew and swallow. However if you have a narrow Eustachian tube a cold or anything else that can cause blockage to the Eustachian tube then the pressure does not equalise very easily when the plane descends. This can cause severe ear pain.

What is the treatment for Eustachian tube dysfunction?

Treatment options depend on the cause and severity of the condition.

Often no treatment is needed

In many cases the ETD is mild and does not last longer than a few days or a week or so. For example this is common following a cold. No particular treatment is needed and the symptoms often soon go.

Try to get air to flow into the Eustachian tube

Air is more likely to flow in and out of the Eustachian tube if you swallow yawn or chew. Also try doing the following. Take a breath in. Then try to breathe out gently with your mouth closed and pinching your nose (the Valsalva manoeuvre). In this way no air is blown out but you are gently pushing air into the Eustachian tube. If you do this you may feel your ears go 'pop' as air is forced into the middle ear. This sometimes eases the problem. This is a particularly good thing to try if you get ear pain when descending to land in a plane.

Decongestant nasal sprays or drops

These may be advised by your doctor if you have a cold or other cause of nasal congestion. You can buy these from pharmacies. They may briefly relieve a blocked nose. However you should not use a decongestant spray or drops for more than 5-7 days at a time. If they are used longer than this they may cause a worse rebound congestion in the nose.

Antihistamine tablets or nasal sprays

These may be advised by your doctor if you have an allergy such as hay fever. In this situation they will help to ease nasal congestion and inflammation.

Steroid nasal spray

A steroid nasal spray may be advised if an allergy or other cause of persistent inflammation in the nose is suspected. It works by reducing inflammation in the nose. It takes several days for a steroid spray to build up to its full effect. Therefore you will not have an immediate relief of symptoms when you first start it. However if any inflammation is reduced in the back of the nose then the Eustachian tube is able to work better.

Referral to a specialist

If symptoms persist or the cause of the ETD is not clear then you may be referred to an ear specialist for assessment. Treatment options depend on any underlying cause that may be found.