Archives: Instructions

SWALLOWING TROUBLE / DYSPHAGIA

Insight into complications and treatment

• What are the symptoms of swallowing disorders?
• How are swallowing disorders diagnosed?
• How are swallowing disorders treated?
• and more…

Difficulty in swallowing (dysphagia) is common among all age groups especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors most of which are temporary and not threatening. Difficulties in swallowing rarely represent a more serious disease such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself in a short period of time you should see an otolaryngologist—head and neck surgeon.

How do we swallow?

People normally swallow hundreds of times a day to eat solids drink liquids and swallow the normal saliva and mucus that the body produces. The process of swallowing has four related stages:

• The first stage is the oral preparation stage where food or liquid is manipulated and chewed in preparation for swallowing.
• The second stage is the oral stage where the tongue propels the food or liquid to the back of the mouth starting the swallowing response.
• The third stage is the pharyngeal stage which begins as food or liquid is quickly passed through the pharynx the region of the throat which connects the mouth with the esophagus then into the esophagus or swallowing tube.
• In the final esophageal stage the food or liquid passes through the esophagus into the stomach.

Although the first and second stages have some voluntary control stages three and four occur involuntarily without conscious input.

What are the symptoms of swallowing disorders?

Symptoms of swallowing disorders may include:

• drooling
• a feeling that food or liquid is sticking in the throat
• discomfort in the throat or chest (when gastro esophageal reflux is present)
• a sensation of a foreign body or “lump” in the throat
• weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing
• coughing or choking caused by bits of food liquid or saliva not passing easily during swallowing and being sucked into the lungs
• voice change

How are swallowing disorders diagnosed?

When dysphagia is persistent and the cause is not apparent the otolaryngologist—head and neck surgeon will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors. Sometimes a small tube (flexible laryngoscope) is placed through the nose and the patient is then given food to eat while the scope is in place in the throat. These procedures provide visualization of the back of the tongue throat and larynx (voice box). These procedures are called FEES (Fiber optic Endoscopic Evaluation of Swallowing) or FEESST (Flexible Endoscopic Evaluation of Swallowing with Sensory Testing). If necessary an examination of the esophagus named TransNasal Esophagoscopy (TNE) may be carried out by the otolaryngologist. If you experience difficulty swallowing it is important to seek treatment to avoid malnutrition and dehydration.

How are swallowing disorders treated?

Many of these disorders can be treated with medication. Drugs that slow stomach acid production muscle relaxants and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.

Gastro esophageal reflux can often be treated by changing eating and living habits in these ways:

• Eat a bland diet with smaller more frequent meals.
• Eliminate tobacco alcohol and caffeine.
• Reduce weight and stress.
• Avoid food within three hours of bedtime.
• Elevate the head of the bed at night.

If these don’t help antacids between meals and at bedtime may provide relief.

Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or stimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully.

Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist or a speech language pathologist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.

Once the cause is determined swallowing disorders may be treated with:

• medication
• swallowing therapy
• surgery

Surgery is used to treat certain problems. If a narrowing exists in the throat or esophagus the area may need to be stretched or dilated. If a muscle is too tight it may need to be dilated or released surgically. This procedure is called a myotomy and is performed by an otolaryngologist—head and neck surgeon.

Many diseases contribute to swallowing disorders. If you have a persistent problem swallowing see an otolaryngologist—head and neck surgeon.

What causes swallowing disorders?

Any interruption in the swallowing process can cause difficulties. Eating slowly and chewing thoroughly can help reduce problems with swallowing. However difficulties may be due to a range of other causes including something as simple as poor teeth ill fitting dentures or a common cold. One of the most common causes of dysphagia is gastro esophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx causing discomfort. Other causes may include: hypertension; diabetes; thyroid disease; stroke; progressive neurologic disorder; the presence of a tracheotomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth throat or esophagus; or surgery in the head neck or esophageal areas.

Swallowing difficulty can also be connected to some medications including:

• Nitrates
• Anticholinergic agents found in certain anti-depressants and allergy medications
• Calcium tablets
• Calcium channel blockers
• Aspirin
• Iron tablets
• Vitamin C
• Antipsychotic
• Tetracycline (used to treat acne)

Reference: American Academy of Otolaryngology. Head and Neck Surgery. http://www.entnet.org/HealthInformation/swallowingTrouble.cfm

Hypercalcemia is a condition marked by elevated levels of calcium in your bloodstream.  A low-calcium diet may help you manage hypercalcemia.

Alkaline food chart by degree

DEVIATED SEPTUM

The shape of your nasal cavity could be the cause of chronic sinusitis. The nasal septum is the wall dividing the nasal cavity into halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this natural partition is a firm but bendable structure made mostly of cartilage and is covered by skin that has a substantial supply of blood vessels. The ideal nasal septum is exactly midline separating the left and right sides of the nose into passageways of equal size.

Estimates are that 80 percent of all nasal septums are off-center a condition that is generally not noticed. A "deviated septum" occurs when the septum is severely shifted away from the midline. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose. The symptoms are usually worse on one side and sometimes actually occur on the side opposite the bend. In some cases the crooked septum can interfere with the drainage of the sinuses resulting in repeated sinus infections.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is not generally performed on minors because the cartilaginous septum grows until around age 18. Septal deviations commonly occur due to nasal trauma.

A deviated septum may cause one or more of the following:

• Blockage of one or both nostrils
• Nasal congestion sometimes one-sided
• Frequent nosebleeds
• Frequent sinus infections
• At times facial pain headaches postnasal drip
• Noisy breathing during sleep (in infants and young children)

In some cases a person with a mildly deviated septum has symptoms only when he or she also has a "cold" (an upper respiratory tract infection). In these individuals the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the "cold" resolves and the nasal inflammation subsides symptoms of a deviated septum often resolve too.

Diagnosis Of A Deviated Septum:

Patients with chronic sinusitis often have nasal congestion and many have nasal septal deviations. However for those with this debilitating condition there may be additional reasons for the nasal airway obstruction. The problem may result from a septal deviation reactive edema (swelling) from the infected areas allergic problems mucosal hypertrophy (increase in size) other anatomic abnormalities or combinations thereof. A trained specialist in diagnosing and treating ear nose and throat disorders can determine the cause of your chronic sinusitis and nasal obstruction.

Your First Visit:

After discussing your symptoms the primary care physician or specialist will inquire if you have ever incurred severe trauma to your nose and if you have had previous nasal surgery. Next an examination of the general appearance of your nose will occur including the position of your nasal septum. This will entail the use of a bright light and a nasal speculum (an instrument that gently spreads open your nostril) to inspect the inside surface of each nostril.

Surgery may be the recommended treatment if the deviated septum is causing troublesome nosebleeds or recurrent sinus infections. Additional testing may be required in some circumstances.

Septoplasty:

Septoplasty is a surgical procedure performed entirely through the nostrils accordingly no bruising or external signs occur. The surgery might be combined with a rhinoplasty in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

The time required for the operation averages about one to one and a half hours depending on the deviation. It can be done with a local or a general anesthetic and is usually done on an outpatient basis. After the surgery nasal packing is inserted to prevent excessive postoperative bleeding. During the surgery badly deviated portions of the septum may be removed entirely or they may be readjusted and reinserted into the nose.

If a deviated nasal septum is the sole cause for your chronic sinusitis relief from this severe disorder will be achieved.

Reference: American Academy of Otolaryngology. Head and Neck Surgery. http://www.entnet.org/HealthInformation/deviatedSeptum.cfm

A cough is your body's way of responding to irritants in your throat and airways. An irritant stimulates nerves there to send a cough impulse to your brain. The brain signals the muscles of your abdomen and chest wall to give a strong push of air to your lungs to try to expel the irritant.

An occasional cough is normal and healthy. A cough that persists for several weeks or one that brings up discolored or bloody mucus may indicate an underlying condition that requires medical attention. A cough rarely requires emergency care.

A coughing attack can be very forceful — the velocity of air from a vigorous cough through the nearly closed vocal cords can approach 500 miles per hour. Prolonged vigorous coughing is exhausting and can cause sleeplessness headaches urinary incontinence and even broken ribs.

CAUSES:

An occasional cough is normal. But a cough that persists may signal an underlying problem. A cough is considered "acute" if it lasts less than three weeks; it's "chronic" if it lasts longer than eight weeks (four weeks in children).

Some causes of coughs include:

Common causes — acute

• Common cold
• Influenza (flu)
• Inhaling an irritant
• Pneumonia
• Whooping cough

Common causes — chronic

• Allergies
• Asthma (most common in children
• Bronchitis
• GERD
• Postnasal drip

Others

• Acute sinusitis
• Bronchiectasis
• Bronchiolitis (especially in young children)
• Choking: First aid (especially in children)
• Chronic sinusitis
• COPD
• Croup (especially in young children)
• Cystic fibrosis
• Emphysema
• Hay fever
• Heart failure (congestive)
• Laryngitis
• Lung cancer
• Medications called angiotensin-converting enzyme (ACE) inhibitors
• Neuromuscular diseases such as parkinsonism which weaken the coordination of upper airway and swallowing muscles
• Respiratory syncytial virus (RSV) (especially in young children)
• Tuberculosis

WHEN TO SEE A DOCTOR:

Call your doctor if your cough doesn't go away after several weeks or if you or your child is:

• Coughing up thick greenish-yellow phlegm
• Wheezing
• Experiencing a fever more than 100 F (38 C)
• Experiencing shortness of breath

Seek emergency care

Seek emergency care if you or your child is:

• Choking
• Having difficulty breathing or swallowing
• Coughing up bloody or pink-tinged phlegm

Self-care measures

To ease your cough try these tips:

• Suck cough drops or hard candies. They may ease a dry cough and soothe an irritated throat. Don't give them to a child under age 3 however because they can cause choking.
• Moisturize the air. Use a vaporizer or take a hot steamy shower.
• Drink fluids. Liquid helps thin the mucus in your throat. Warm liquids such as broth tea or lemon juice and honey in warm water can soothe your throat.

Reference: MayoClinic. http://www.mayoclinic.com/health/cough/MY00108

Benign positional vertigo

Benign positional vertigo is the most common type of vertigo. Vertigo is the feeling that you are spinning or that everything is spinning around you. It may occur when you move your head in a certain position.

Causes

Benign positional vertigo is also called benign paroxysmal positional vertigo (BPPV). It is caused by a problem in the inner ear.

The inner ear has fluid-filled tubes called semicircular canals. When you move the fluid moves inside these tubes. The canals are very sensitive to any movement of the fluid. The sensation of the fluid moving in the tube tells your brain the position of your body. This helps you keep your balance.

BPPV occurs when a small piece of bone-like calcium breaks free and floats inside the tube. This sends confusing messages to your brain about your body's position.

BPPV has no major risk factors. However your risk for developing BPPV may increase if you have:

• Family members with BPPV

• Had a prior head injury (even a slight bump to the head)

• Had an inner ear infection called labyrinthitis

Symptoms

BPPV symptoms include:

• Feeling like you are spinning or moving

• Feeling like the world is spinning around you

• Loss of balance

• Nausea and vomiting

• Hearing loss

• Vision problems such as a feeling that things are jumping or moving

The spinning sensation:

• Is usually triggered by moving your head

• Often starts suddenly

• Lasts a few seconds to minutes

Certain positions can trigger the spinning feeling:

• Rolling over in bed

• Tilting your head up to look at something

Exams and Tests

To diagnose BPPV your health care provider may perform a test called the Dix-Hallpike maneuver.

• Your provider holds your head in a certain position. Then you are asked to lie quickly backward over a table.

• As you do this your provider will look for abnormal eye movements and ask if you feel like you are spinning.

If the Dix-Hallpike test doesn't show a clear result you may be asked to do other tests.

Your provider will do a physical exam and ask about your medical history. You may have brain and nervous system (neurological) tests to rule out other causes. These may include:

• EEG

• Electronystagmography (ENG)

• Head CT

• Head MRI

• Hearing test

• Magnetic resonance angiography of the head

• Warming and cooling the inner ear with water or air to test eye movements. This is called caloric stimulation.

Treatment

Your provider will do a procedure called Epley's maneuver. It can move the small piece of calcium that is floating inside your inner ear. This treatment works best to cure BPPV. Other exercises don't work as well.

Some medicines can help relieve spinning sensations.

• Antihistamines

• Anticholinergics

• Sedative-hypnotics

However these medicines often do not work well for treating vertigo.

To keep your symptoms from getting worse avoid the positions that trigger it.

Outlook (Prognosis)

BPPV is uncomfortable but it can usually be treated with Epley's maneuver. It may come back again without warning.

Possible Complications

People with severe vertigo may get dehydrated due to frequent vomiting.

When to Contact a Medical Professional

Call your health care provider if:

• You develop vertigo

• Treatment for vertigo doesn't work

Get immediate medical help if you also have symptoms such as:

• Weakness

• Slurred speech

• Vision problems

These may be signs of a more serious condition.

Prevention

Avoid head positions that trigger positional vertigo.

Alternative Names

Vertigo – positional; Benign paroxysmal positional vertigo; BPPV: dizziness- positional

CAWTHORNE’S HEAD EXERCISES

• Exercises are to be carried out for 4-5 minutes 10-12 times a day. You can expect dizziness to occur when first beginning the exercises. Please be seated while doing them.

• Eye Exercises Looking up then down – at first slowly then quickly 20 times Looking from one side to the other – at first slowly then quickly 20 times.

• Head Exercises Bend head forward – then backward with eyes open – slowly then quickly 20 times.

• Turn head from one side to the other – slowly then quickly 20 times. As dizziness improves these exercises should be done with eyes closed.

• Sitting While sitting shrug shoulders -20 times.

• Turn shoulders to the right then left – 20 times

• Bend forward and pick up objects from group and sit up -20 times

• Standing Change from sitting to standing and back again -20 times with eyes open

• Repeat with eyes closed.

• Throw a small rubber ball from hand to hand above eye level

• Throw ball from hand to hand under one knee.

• Moving About Walk across the room with eyes open then closed -10 times Walk up and down a slope with eyes open the closed – 20 times Any game involving stooping or turning is good.

Sinusitis and Rhinosinusitis

ALLERGIC RHINITIS SINUSITIS and RHINOSINUSITIS

Inflammation of the nasal mucous membrane is called rhinitis. The symptoms include sneezing and runny and/or itchy nose caused by irritation and congestion in the nose. There are two types: allergic rhinitis and non-allergic rhinitis.

Allergic Rhinitis occurs when the body’s immune system over-responds to specific non-infectious particles such as plant pollen, molds, dust mites, animal hair, industrial chemicals (including tobacco smoke), foods, medicines, and insect venom. During an allergic attack, antibodies primarily immunoglobin E (IgE) attach to mast cells (cells that release histamine) in the lungs skin and mucous membranes. Once IgE connects with the mast cells a number of chemicals are released. One of the chemicals histamine opens the blood vessels and causes skin redness and swollen membranes. When this occurs in the nose sneezing and congestion are the result.

Seasonal allergic rhinitis, or hayfever, occurs in late summer or spring. Hypersensitivity to ragweed not hay is the primary cause of seasonal allergic rhinitis in 75 percent of all Americans who suffer from this seasonal disorder. People with sensitivity to tree pollen have symptoms in late March or early April; an allergic reaction to mold spores occurs in October and November as a consequence of falling leaves.

Perennial allergic rhinitis occurs year-round and can result from sensitivity to pet hair mold on wallpaper houseplants carpeting and upholstery. Some studies suggest that air pollution such as automobile engine emissions can aggravate allergic rhinitis. Although bacteria is not the cause of allergic rhinitis one medical study found a significant number of the bacteria Staphylococcus aureus in the nasal passages of patients with year-round allergic rhinitis concluding that the allergic condition may lead to higher bacterial levels thereby creating a condition that worsens the allergies.

Patients who suffer from recurring bouts of allergic rhinitis should observe their symptoms on a continuous basis. If facial pain or a greenish-yellow nasal discharge occurs a qualified ear nose and throat specialist can provide appropriate sinusitis treatment.

Non-Allergic Rhinitis does not depend on the presence of IgE and is not due to an allergic reaction. The symptoms can be triggered by cigarette smoke and other pollutants as well as strong odors alcoholic beverages and cold. Other causes may include blockages in the nose a deviated septum infections and over-use of medications such as decongestants.

Rhinosinusitis: Clarifying The Relationship Between The Sinuses And Rhinitis

Recent studies by otolaryngologist–head and neck surgeons have better defined the association between rhinitis and sinusitis. They have concluded that sinusitis is often preceded by rhinitis and rarely occurs without concurrent rhinitis. The symptoms nasal obstruction/discharge and loss of smell occur in both disorders. Most importantly computed tomography (CT scan) findings have established that the mucosal linings of the nose and sinuses are simultaneously involved in the common cold (previously thought to affect only the nasal passages). Otolaryngologists acknowledging the inter-relationship between the nasal and sinus passages now refer to sinusitis as rhinosinusitis.

The catalyst relating the two disorders is thought to involve nasal sinus overflow obstruction followed by bacterial colonization and infection leading to acute recurrent or chronic sinusitis. Likewise chronic inflammation due to allergies can lead to obstruction and subsequent sinusitis.

Other medical research has supported the close relationship between allergic rhinitis and sinusitis. In a retrospective study on sinus abnormalities in 1 120 patients (from two to 87 years of age) thickening of the sinus mucosa was more commonly found in sinusitis patients during July August September and December months in which pollen mold and viral epidemics are prominent. A review of patients (four to 83 years of age) who had surgery to treat their chronic sinus conditions revealed that those with seasonal allergy and nasal polyps are more likely to experience a recurrence of their sinusitis.

Reference: American Academy of Otolaryngology. Head and Neck Surgery. http://www.entnet.org/HealthInformation/rhinitis.cfm

Affecting the outer ear swimmer’s ear is a painful condition resulting from inflammation irritation or infection. These symptoms often occur after water gets trapped in your ear with subsequent spread of bacteria or fungal organisms. Because this condition commonly affects swimmers it is known as swimmer’s ear. Swimmer’s ear (also called acute otitis externa) often affects children and teenagers but can also affect those with eczema (a condition that causes the skin to itch) or excess earwax. Your doctor will prescribe treatment to reduce your pain and to treat the infection.

What causes swimmer’s ear?

A common source of the infection is increased moisture trapped in the ear canal from baths showers swimming or moist environments. When water is trapped in the ear canal bacteria that normally inhabit the skin and ear canal multiply causing infection of the ear canal.

Swimmer’s ear needs to be treated to reduce pain and eliminate any effect it may have on your hearing as well as to prevent the spread of infection.Other factors that may contribute to swimmer’s ear include:

• Contact with excessive bacteria that may be present in hot tubs or polluted water.
• Excessive cleaning of the ear canal with cotton swabs or anything else
• Contact with certain chemicals such as hair spray or hair dye (Avoid this by placing cotton balls in your ears when using these products.)
• Damage to the skin of the ear canal following water irrigation to remove wax
• A cut in the skin of the ear canal
• Other skin conditions affecting the ear canal such as eczema or seborrhea

What are the signs and symptoms?

The most common symptoms of swimmer’s ear are itching inside the ear and  pain that gets worse when you tug on the auricle (outer ear). Other signs and symptoms may include any of the following:

• Sensation that the ear is blocked or full
• Drainage
• Fever
• Decreased hearing
• Intense pain that may spread to the neck face or side of the head
• Swollen lymph nodes around the ear or in the  upper neck.
• Redness and swelling of the skin around the ear

If left untreated complications resulting from swimmer’s ear may include:

• Hearing loss. When the infection clears up hearing usually returns to normal.Recurring ear infections (chronic otitis externa). Without treatment infection can continue.
• Bone and cartilage damage (malignant otitis externa). Ear infections when not treated can spread to the base of your skull brain or cranial nerves.
• Diabetics and older adults are at higher risk for such dangerous complications.

To evaluate you for swimmer’s ear your doctor will look for redness and swelling in your ear canal. Your doctor also may take a sample of any abnormal fluid or discharge in your ear to test for the presence of bacteria or fungus (ear culture) if you have recurrent or severe infections.

How is swimmer’s ear treated?

Treatment for the early stages of swimmer’s ear includes careful cleaning of the ear canal and use of ear-drops that inhibit bacterial or fungal growth and reduce inflammation. Mildly acidic solutions containing boric or acetic acid are effective for early infections.

How should ear drops be applied?

• Drops are more easily administered if done by someone other than the patient.
• The patient should lie down with the affected ear facing upwards.
• Drops should be placed in the ear until the ear is full.
• After drops are administered the patient should remain lying down for a few minutes so the drops can be absorbed.

If you do not have a perforated eardrum (an eardrum with a hole in it) or a tympanostomy tube in your eardrum you can make your own ear-drops using rubbing alcohol or a mixture of half alcohol and half vinegar. These ear-drops will evaporate excess water and keep your ears dry. Before using any drops in the ear it is important to be sure you do not have a perforated eardrum. Check with your otolaryngologist if you have ever had a perforated punctured or injured eardrum or if you have had ear surgery.

For more severe infections your doctor may prescribe antibiotics to be applied directly to the ear. If the ear canal is swollen shut a sponge or wick may be placed in the canal so the antibiotic drops will enter the swollen canal more effectively.  Pain medication may also be prescribed. If you have tubes in your eardrum a non oto-toxic (do not affect your hearing) topical treatment should be used. Topical antibiotics are effective for infection limited to the ear canal. Oral antibiotics may also be prescribed if the infection goes beyond the skin of the ear canal. Follow-up appointments are very important to monitor improvement or worsening to clean the ear again and to replace the ear wick as needed. Your otolaryngologist has specialized equipment and expertise to effectively clean the ear canal and treat swimmer’s ear. With proper treatment most infections should clear up in 7-10 days.

Why do ears itch?

An itchy ear may be caused by a fungus or allergy but more often from chronic dermatitis (skin inflammation) of the ear canal. Otolaryngologists also treat allergies and they can often prescribe an ear-drop, cream, or ointment to treat the problem.

Tips for prevention 

• A dry ear is unlikely to become infected so it is important to keep the ears free of moisture during swimming or bathing.
• Use ear plugs when swimming
• Use a dry towel or hair dryer to dry your ears
• Have your ears cleaned periodically by an otolaryngologist if you have itchy, flaky, or scaly ears, or extensive earwax
• Don’t use cotton swabs to remove ear wax. They may pack ear wax and dirt deeper into the ear canal remove the layer of earwax that protects your ear and irritate the thin skin of the ear canal. This creates an ideal environment for infection.