Patient Education

As the parent of a child with newly diagnosed hearing loss, you will have many questions and concerns regarding the nature of this problem, its effects on your child’s future, treatment options, and resources. This brief guide will give you necessary initial information, and provide guidance about the availability of resources, and the respective roles of different care providers.

It is always difficult for parents to receive bad news about any aspect of their child’s health. Reacting with anger, grief, and even guilt are not unusual when finding out that your child is hearing-impaired. These feelings are best managed by discussing them with a family member, close friend, clergy, or mental health professional. At times, the feeling may also result in a degree of denial. Feel free to seek a second opinion, but it is unadvisable to delay further recommended diagnostic evaluations for your child. The best treatment for hearing loss of any degree is appropriate early intervention. Significant delays may result in irreversible harm to your child’s hearing, speech, language, and eventual educational development.

You will come into contact with many healthcare and rehabilitation specialists during the long-term management of your child’s hearing loss. Some of them will be involved early in the journey and again at intervals. Others may step in later on. The following are professionals you will encounter and the role each of them will play in managing your child’s hearing loss.

The Audiologist

The audiologist is likely to be the first professional you encounter, and possibly the one who gives you the initial news regarding your child’s hearing loss. The audiologist will carry out behavioral or objective testing (such as auditory brainstem responses) or a combination of these approaches to determine the degree and type of hearing loss. The audiologist will also eventually recommend appropriate amplification, following a medical consultation. The audiologist will also provide your child with well-fitting ear molds along with the hearing aids, as he or she grows. The audiologist may also be the professional who provides you with information and referral to an early intervention program. Over time, the audiologist will provide periodic follow-ups to chart your child’s progress and to monitor his or her hearing loss.

Otologist, Otolaryngologist, or Pediatric Otolaryngologist (ENT Physician)

Upon diagnosis of hearing loss, your child will be referred to an ear, nose, and throat specialist, (otolaryngologist), or one who specializes in childhood ear and hearing problems. This physician’s initial role is to determine the specific nature of the underlying problem that may be at least partially causing the hearing loss. Additionally, the physician will also determine if the problem is medically or surgically treatable, and if so, provide the necessary medical or surgical treatment. Such treatments could include something relatively simple, like the placement of eardrum ventilation tubes, or more complex surgical procedures. The ENT specialist may also refer your child for additional diagnostic procedures such as imaging studies (X-rays, CT-scans, MRI scans) to further define the type and source of hearing loss. The doctor will also provide clearance for hearing aid fitting, after determining if no other intervention is indicated. If it is determined that your child needs a cochlear implant, the otolaryngologist, along with the audiologist, will carry out further tests and examinations, and will carry out the implant surgery.

Primary Care Physician: Pediatrician or Family Practitioner

Your child’s primary care physician may be either a pediatrician or a family practice doctor. If your child is not diagnosed with a hearing loss in the newborn period but develops hearing loss later in life, it is the responsibility of this doctor to make appropriate referrals to an ear, nose and throat specialist and an audiologist to rule out or diagnose hearing loss. Your child’s primary care doctor may also participate in the treatment of ear infections if they appear, or refer them to an otolaryngologist for treatment. The primary care physician or the otolaryngologist may also provide a referral to a doctor who specializes in medical genetics, to find out if your child’s hearing loss may be hereditary. That may help you determine if a similar hearing loss could occur in your other children.

Early Intervention Specialist

This professional is typically is someone with an education background. He or she can help you find resources in your community, define family members’ roles in early intervention and management of the hearing loss, and can help you deal with questions regarding future educational placement. This specialist will also help you deal with your observations and concerns about your child and give you information and support regarding your child’s educational needs in the future.

Speech/ Language Pathologist (SLP)

This professional will evaluate the impact of your child’s hearing loss on speech/language development, and monitor his/her progress, noting if progress with that development is falling behind. If this happens, the SLP may refer back to the audiologist or otolaryngologist to determine if any changes have occurred in your child’s hearing. The SLP will also help your child to learn proper speech production, including correct articulation of speech sounds. If you choose oral communication for your child, in addition to the speech-language pathologist your child may also be treated by an auditory-verbal therapist, who can help your child acquire the full range of speech sounds and guide the family to additional medical or audiological treatments. The auditory-verbal therapist will also help the child’s family become familiar with appropriate speech/language, auditory, and cognitive developmental milestones you may expect for a child with hearing loss.

Finally, many other people can provide additional assistance for your hard-of-hearing child. Parents of older hard-of-hearing children, and hard-of-hearing adults, can share their experiences with you and may have suggestions for educational and recreational resources in the community.

Insight into ear growths

• What causes a cholesteatoma?
• How is cholesteatoma treated?
• Symptoms and dangers
• and more…

An abnormal skin growth in the middle ear behind the eardrum is called cholesteatoma. Repeated infections and/or and a tear or retraction of the eardrum can cause the skin to toughen and form an expanding sac. Cholesteatomas often develop as cysts or pouches that shed layers of old skin, which build up inside the middle ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear. Hearing loss, dizziness, and facial muscle paralysis are rare but can result from continued cholesteatoma growth.

What causes a cholesteatoma?

A cholesteatoma usually occurs because of poor eustachian tube function as well as infection in the middle ear. The eustachian tube conveys air from the back of the nose into the middle ear to equalize ear pressure (“clear the ears”). When the eustachian tubes work poorly, perhaps due to allergy, a cold, or sinusitis, the air in the middle ear is absorbed by the body, creating a partial vacuum in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas weakened by previous infections. This can develop into a sac and become a cholesteatoma. A rare congenital form of cholesteatoma (one present at birth) can occur in the middle ear and elsewhere, such as in the nearby skull bones. However, the type of cholesteatoma associated with ear infections is most common.

How is cholesteatoma treated?

An examination by an otolaryngologist-head and neck surgeon can confirm the presence of a cholesteatoma. Initial treatment may consist of a careful cleaning of the ear, antibiotics, and ear drops. Therapy aims to stop drainage in the ear by controlling the infection. The growth characteristics of a cholesteatoma must also be evaluated.

A large or complicated cholesteatoma usually requires surgical treatment to protect the patient from serious complications. Hearing and balance tests, x-rays of the mastoid (the skull bone next to the ear), and CAT scans (3-D x-rays) of the mastoid may be necessary. These tests are performed to determine the hearing level in the ear and the extent of destruction the cholesteatoma has caused.

Surgery is performed under general anesthesia in most cases. The primary purpose of surgery is to remove the cholesteatoma so that the ear will dry and the infection will be eliminated. Hearing preservation or restoration is the second goal of surgery. In cases of severe ear destruction, reconstruction may not be possible. Facial nerve repair or procedures to control dizziness are rarely required. Reconstruction of the middle ear is not always possible in one operation; therefore, a second operation may be performed six to 12 months later. The second operation will attempt to restore hearing and, at the same time, allow the surgeon to inspect the middle ear space and mastoid for residual cholesteatoma.

Surgery can often be done on an out-patient basis. For some patients, an overnight stay is necessary. In rare cases of serious infection, prolonged hospitalization for antibiotic treatment may be necessary. Time off from work is typically one to two weeks.

After surgery, follow-up office visits are necessary to evaluate results and to check for recurrence. In cases where an open mastoidectomy cavity has been created, office visits every few months are needed to clean out the mastoid cavity and prevent new infections. Some patients will need lifelong periodic ear examinations.

Cholesteatoma is a serious but treatable ear condition which can be diagnosed only by medical examination. Persistent earache, ear drainage, ear pressure, hearing loss, dizziness, or facial muscle weakness need to be evaluated by an otolaryngologist.

Symptoms and dangers

Initially, the ear may drain fluid with a foul odor. As the cholesteatoma pouch or sac enlarges, it can cause a feeling of fullness or pressure in the ear, along with hearing loss. An ache behind or in the ear, especially at night, may cause significant discomfort.

Dizziness, or muscle weakness on one side of the face (the side of the infected ear) can also occur. Any or all of these symptoms are good reasons to seek medical evaluation.

An ear cholesteatoma can be dangerous and should never be ignored. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain. If untreated, deafness, brain abscess, meningitis, and, rarely, death can occur.

A cochlear implant is an electronic device that restores partial hearing to individuals with severe to profound hearing loss who do not benefit from a conventional hearing aid. It is surgically implanted in the inner ear and activated by a device worn outside the ear. Unlike a hearing aid, it does not make sound louder or clearer. Instead, the device bypasses damaged parts of the auditory system and directly stimulates the nerve of hearing, allowing individuals who are profoundly hearing-impaired to receive sound.

What is normal hearing?

Your ear consists of three parts that play a vital role in hearing—the external ear, middle ear, and inner ear.

Conductive hearing: Sound travels along the ear canal of the external ear, causing the ear drum to vibrate. Three small bones of the middle ear conduct this vibration from the eardrum to the cochlea (auditory chamber) of the inner ear.

Sensorineural hearing: When the three small bones move, they start waves of fluid in the cochlea, and these waves stimulate more than 16,000 delicate hearing cells (hair cells). As these hair cells move, they generate an electrical current in the auditory nerve. The electrical signal travels through inter-connections in the brain to specific areas of the brain that recognize it as sound.

How is hearing impaired?

If you have disease or obstruction in your external or middle ear, your conductive hearing may be impaired. Medical or surgical treatment can probably correct this.

An inner ear problem, however, can result in a sensorineural impairment, or nerve deafness. In most cases, the hair cells are damaged and do not function. Although many auditory nerve fibers may be intact and can transmit electrical impulses to the brain, these nerve fibers are unresponsive because of hair cell damage. Since severe sensorineural hearing loss cannot be corrected with medicine, it can be treated only with a cochlear implant.

How do cochlear implants work?

Cochlear implants bypass damaged hair cells and convert speech and environmental sounds into electrical signals and send these signals to the hearing nerve.

A cochlear implant has two main components:

1. An internal component that consists of a small electronic device, which is surgically implanted under the skin behind the ear, connected to electrodes that are inserted inside the cochlea.
2. An external component, which is usually worn behind the ear, that consists of a speech processor, microphone, and battery compartment.

The microphone captures sound, allowing the speech processor to translate the sound into distinctive electrical signals. These signals or “codes” travel up a thin cable to the headpiece and are transmitted across the skin via radio waves to the implanted electrodes in the cochlea. The electrodes’ signals stimulate the auditory nerve fibers to send information to the brain, where it is interpreted as meaningful sound.

Cochlear implant benefits

Cochlear implants are designed only for individuals who attain almost no benefit from a hearing aid. They must be 12 months of age or older (unless childhood meningitis is responsible for deafness).

Otolaryngologists (ear, nose, and throat specialists) perform implant surgery, although not all of them do this procedure. Your local doctor can refer you to an implant clinic for an evaluation. The implant team (otolaryngologist, audiologist, nurse, and others) will determine your candidacy for a cochlear implant and review the appropriate expectations as a result of the cochlear implant.  The implant team will also conduct a series of tests including:

Ear (otologic) evaluation: The otolaryngologist examines the middle and inner ear to ensure that no active infection or other abnormality precludes the implant surgery.

Hearing (audiologic) evaluation: The audiologist performs extensive hearing tests to find out how much you can hear with and without a hearing aid.

X-ray (radiographic) evaluation: Special X-rays are taken, usually computerized tomography (CT) or magnetic resonance imaging (MRI) scans, to evaluate your inner ear anatomy.

Physical examination: Your otolaryngologist also performs a physical examination to identify any potential problems with the use of general anesthesia needed for the implant procedure.

Cochlear implant surgery

Cochlear implant surgery is usually performed as an outpatient procedure under general anesthesia. An incision is made behind the ear to open the mastoid bone leading to the middle ear space. Once the middle ear space is exposed, an opening is made in the cochlea and the implant electrodes are inserted. The electronic device at the base of the electrode array is then placed behind the ear under the skin.

Is there care and training after the operation?

Several weeks after surgery, your cochlear implant team places the signal processor, microphone, and implant transmitter outside your ear and adjusts them. They teach you how to look after the system and how to listen to sound through the implant. There are many causes of hearing loss and some patients may take longer to fit and require more training, due to individual patient differences. Your team will ask you to come back to the clinic for regular checkups and readjustment of the speech processor as needed.

What can I expect from an implant?

Most adult cochlear implant patients notice an immediate improvement in their communication skills. Children require time to benefit from their cochlear implant as the brain needs to learn to correctly interpret the electrical sound input. While cochlear implants do not restore normal hearing, and benefits vary from one individual to another, most users find that cochlear implants help them communicate better through improved lip-reading. Also, 90 percent of adult cochlear implant patients are able to discriminate speech without the use of visual cues. There are many factors that contribute to the degree of benefit a user receives from a cochlear implant, including:

• How long a person has been deaf;
• The number of surviving auditory nerve fibers; and
• A patient’s motivation to learn to hear.

Your team will explain what you can reasonably expect. Before deciding whether your implant is working well, you need to understand clearly how much time you must commit. It is rare that patients do not benefit from a cochlear implant.

FDA approval for implants

The Food and Drug Administration (FDA) regulates cochlear implant devices for both adults and children and approves them only after thorough clinical investigation.

Be sure to ask your otolaryngologist for written information, including brochures provided by the implant manufacturers. You need to be fully informed about the benefits and risks of cochlear implants, including how much is known about safety, reliability, and effectiveness of a device, how often you must come back to the clinic for checkups, and whether your insurance company pays for the procedure.

Costs of implants

More expensive than a hearing aid, the total cost of a cochlear implant including evaluation, surgery, the device, and rehabilitation can cost as much as $100,000. Fortunately, most insurance companies and Medicare provide benefits that cover the cost.

Protruding and drooping ears or torn earlobes can be surgically corrected. Exceptionally large ears or those that stick out make children vulnerable to teasing. These procedures do not alter the patient’s hearing, but they may improve appearance and self-confidence.

What Is Involved in “Pinning Back” the Ears?

Corrective surgery, called otoplasty, should be considered on ears which stick out more than 4/5 of an inch (2 cm) from the back of the head. It can be performed at any age after the ears have reached full size, usually at five or six years of age. Having the surgery at a young age has two benefits: the cartilage is more pliable, making it easier to reshape, and the child will experience the psychological benefits of cosmetic improvement. However, a patient may have the surgery at any age.

The surgery begins with an incision behind the ear, in the fold where the ear joins the head. The surgeon may remove skin and cartilage or trim and reshape the cartilage. In addition to correcting protrusion, ears may also be reshaped, reduced in size, or made more symmetrical. The cartilage is then secured in the new position with permanent stitches which will anchor the ear while healing occurs.

Typically otoplasty surgery takes about two hours. The soft dressings over the ears will be used for a few weeks as protection, and the patient usually experiences only mild discomfort. Headbands are sometimes recommended to hold the ears in place for a month following surgery or may be prescribed for nighttime wear only.

Can Ear Deformities Be Corrected?

The “fold” of hard, raised cartilage that gives shape to the upper portion of the ear does not form in all people. This is called “lop-ear deformity,” and it is inherited. The absence of the fold can cause the ear to stick out or flop down. To correct this problem, the surgeon places permanent stitches in the upper ear cartilage and ties them in a way that creates a fold and props the ear up. Scar tissue will form later, holding the fold in place.

Some infants are born without an opening in their middle ear. These ears can be surgically opened, and the outer ear reshaped to look like the other ear. This procedure will restore hearing if the inner ear is intact.

Those who are born without an ear, or lose an ear due to injury, can have an artificial ear surgically attached for cosmetic reasons. These are custom formed to match the patient’s other ear. Alternatively, rib cartilage or a biomedical implant, in addition to the patient’s own soft tissue, can be used to construct a new ear.

Can Torn Earlobes Be Corrected?

Many mothers have had their earlobes torn by a baby’s tug on their earrings. Earrings also catch on clothing and other objects, resulting in torn earlobes. These tears can be easily repaired surgically, usually in the doctor’s office. In severe cases, the surgeon may cut a small triangular notch at the bottom of the lobe. A matching flap is then created from tissue on the other side of the tear, and the two wedges are fitted together and stitched.

Earlobes usually heal quickly with minimal scarring. In most cases, the earlobe can be pierced again four to six weeks after surgery to receive light-weight earrings.

Does Insurance Pay for Cosmetic Ear Surgery?

Insurance usually does not cover surgery solely for cosmetic reasons. However, insurance may cover, in whole or in part, surgery to correct a congenital or traumatic defect. Before cosmetic ear surgery, discuss the procedure with your insurance carrier to determine what coverage, if any, you can expect.

Insight into causes and treatment options

• Who needs ear tubes and why?
• What to expect after surgery
• and more…

Painful ear infections are a rite of passage for children-by the age of five, nearly every child has experienced at least one episode. Most ear infections either resolve on their own (viral) or are effectively treated by antibiotics (bacterial). But sometimes, ear infections and/or fluid in the middle ear may become a chronic problem leading to other issues such as hearing loss, behavior, and speech problems. In these cases, insertion of an ear tube by an otolaryngologist (ear, nose, and throat specialist) may be considered.

What are ear tubes?

Ear tubes are tiny cylinders placed through the ear drum (tympanic membrane) to allow air into the middle ear. They also may be called tympanostomy tubes, myringotomy tubes, ventilation tubes, or PE (pressure equalization) tubes.

These tubes can be made out of plastic, metal, or Teflon and may have a coating intended to reduce the possibility of infection. There are two basic types of ear tubes: short-term and long-term. Short- term tubes are smaller and typically stay in place for six months to a year before falling out on their own. Long-term tubes are larger and have flanges that secure them in place for a longer period of time. Long-term tubes may fall out on their own, but removal by an otolaryngologist is often necessary.

Who needs ear tubes and why?

Ear tubes are often recommended when a person experiences repeated middle ear infection (acute otitis media) or has hearing loss caused by the persistent presence of middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, or changes in the structure of the eardrum. Other less common conditions that may warrant the placement of ear tubes are malformation of the eardrum or eustachian tube, Down Syndrome, cleft palate, and barotrauma (injury to the middle ear caused by a reduction of air pressure, usually seen with altitude changes such as flying and scuba diving).

Each year, more than half a million ear tube surgeries are performed on children, making it the most common childhood surgery performed with anesthesia. The average age for ear tube insertion is one to three years old. Inserting ear tubes may:

• Reduce the risk of future ear infection;
• Restore hearing loss caused by middle ear fluid;
• Improve speech problems and balance problems; and
• Improve behavior and sleep problems caused by chronic ear infections.

How are ear tubes inserted in the ear?

Ear tubes are inserted through an outpatient surgical procedure called a myringotomy. A myringotomy refers to an incision (a hole) in the ear drum or tympanic membrane. This is most often done under a surgical microscope with a small scalpel (tiny knife), but it can also be accomplished with a laser. If an ear tube is not inserted, the hole would heal and close within a few days. To prevent this, an ear tube is placed in the hole to keep it open and allow air to reach the middle ear space (ventilation).

What happens during surgery?

A light general anesthetic (laughing gas) is administered for young children. Some older children and adults may be able to tolerate the procedure without anesthetic. A myringotomy is performed and the fluid behind the ear drum (in the middle ear space) is suctioned out. The ear tube is then placed in the hole. Ear drops may be administered after the ear tube is placed and may be necessary for a few days. The procedure usually lasts less than 15 minutes and patients awaken quickly.

Sometimes the otolaryngologist will recommend removal of the adenoid tissue (lymph tissue located in the upper airway behind the nose) when ear tubes are placed. This is often considered when a repeat tube insertion is necessary. Current research indicates that removing adenoid tissue concurrent with placement of ear tubes can reduce the risk of recurrent ear infection and the need for repeat surgery.

What happens after surgery?

After surgery, the patient is monitored in the recovery room and will usually go home within an hour if no complications occur. Patients usually experience little or no postoperative pain but grogginess, irritability, and/or nausea from the anesthesia can occur temporarily.

Hearing loss caused by the presence of middle ear fluid is immediately resolved by surgery. Sometimes children can hear so much better that they complain that normal sounds seem too loud.

The otolaryngologist will provide specific postoperative instructions, including when to seek immediate attention and to set follow-up appointments. He or she may also prescribe antibiotic ear drops for a few days.

To avoid the possibility of bacteria entering the middle ear through the ventilation tube, physicians may recommend keeping ears dry by using ear plugs or other water-tight devices during bathing, swimming, and water activities. However, recent research suggests that protecting the ear may not be necessary, except when diving or engaging in water activities in unclean water such as lakes and rivers. Parents should consult with the treating physician about ear protection after surgery.

Consultation with an otolaryngologist (ear, nose, and throat specialist) may be warranted if you or your child has experienced repeated or severe ear infections, ear infections that are not resolved with antibiotics, hearing loss due to fluid in the middle ear, barotrauma, or have an anatomic abnormality that inhibits drainage of the middle ear.

Possible complications

Myringotomy with insertion of ear tubes is an extremely common and safe procedure with minimal complications. When complications do occur, they may include:

• Perforation-This can happen when a tube comes out or a long-term tube is removed and the hole in the tympanic membrane (ear drum) does not close. The hole can be patched through a minor surgical procedure called a tympanoplasty or myringoplasty.
• Scarring-Any irritation of the ear drum (recurrent ear infections), including repeated insertion of ear tubes, can cause scarring called tympanosclerosis or myringosclerosis. In most cases, this causes no problem with hearing.
• Infection-Ear infections can still occur in the middle ear or around the ear tube. However, these infections are usually less frequent, result in less hearing loss, and are easier to treat-often only with ear drops. Sometimes an oral antibiotic is still needed.
• Ear tubes come out too early or stay in too long-If an ear tube expels from the ear drum too soon (which is unpredictable), fluid may return and repeat surgery may be needed. Ear tubes that remain too long may result in perforation or may require removal by an otolaryngologist.

Insight into otitis media and treatments

• What is otitis media?
• How does the ear work?
• What are the symptoms?

Otitis media means “inflammation of the middle ear,” as a result of a middle ear infection. It can occur in one or both ears. Otitis media is the most frequent diagnosis for children who visit physicians for illness. It is also the most common cause of hearing loss in children. Although otitis media is most common in young children, it occasionally affects adults

Is it serious?

Yes, because of the severe earache and hearing loss it can cause. Hearing loss, especially in children, may impair learning capacity and even delay speech development. However, if it is treated promptly and effectively, hearing can almost always be restored to normal. Otitis media is also serious because the infection can spread to nearby structures in the head, especially the mastoid. (see the symptoms list)  Immediate attention from your doctor is the best action.

How does the ear work?

The outer ear collects sounds. The middle ear is a pea-sized, air-filled cavity separated from the outer ear by the paper-thin eardrum. Inside the middle ear are three tiny ear bones. When sound waves strike the eardrum, it vibrates and sets the bones in motion that transmit to the inner ear. The inner ear converts vibrations to electrical signals and sends these signals to the brain. A healthy middle ear has the same atmospheric pressure as air outside of the ear, allowing free vibration. Air enters the middle ear through the narrow eustachian tube that connects the back of the nose to the ear

What causes otitis media?

Blockage of the eustachian tube during a cold, allergy, or upper respiratory infection, and the presence of bacteria or viruses lead to a build-up of pus and mucus behind the eardrum. This infection is called acute otitis media. The build-up of pressurized pus in the middle ear causes pain, swelling, and redness. Since the eardrum cannot vibrate properly, hearing problems may occur. Sometimes the eardrum ruptures, and pus drains out of the ear. More commonly, however, the pus and mucus remain in the middle ear due to the swollen and inflamed eustachian tube. This is called middle ear effusion or serous otitis media. Often after the acute infection has passed, the effusion remains lasting for weeks, months, or even years. This condition allows frequent recurrences of the acute infection and may cause difficulty in hearing.

What will happen at the doctor’s office?

During an examination, the doctor will use an otoscope to look at and assess the ear. The doctor checks for redness in the ear, and/or fluid behind the eardrum,, and to see if the eardrum moves. These are the signs of an ear infection. Two other tests may also be performed:

• Audiogram—Tests if hearing loss has occurred by presenting tones at various pitches.
• Tympanogram—Measures the air pressure in the middle ear to see how well the eustachian tube is working and how well the eardrum can move.

How should medication be taken?

It is important that all the medications be taken as directed and that you keep any follow-up visits. Often, antibiotics to fight the infection will make the earache go away rapidly, but the infection may need more time to clear up. Other medications that your doctor may prescribe include an antihistamine (for allergies), a decongestant (especially with a cold), or both. Sometimes the doctor may recommend a medication to reduce fever and/or pain. Special ear drops can ease the pain. Call your doctor if you have any questions about yours or your child’s medication, or if symptoms do not clear.

What other treatment may be necessary?

If your child experiences multiple episodes of acute otitis media within a short time, or hearing loss, or chronic otitis media lasts for more than three months, your physician may recommend referral to an otolaryngologist for placement of ventilation tubes, also called pressure-equalization (PE) tubes. This is a short surgical procedure in which a small incision is made in the eardrum, any fluid is suctioned out, and a tube is placed in the eardrum.  This tube eventually will fall out on its own and the eardrum heals. There is usually an improvement in hearing and a decrease in further infections with PE tube placement.

Otitis media may recur as a result of chronically infected adenoids and tonsils. If this becomes a problem, your doctor may recommend removal of one or both. This can be done at the same time as ventilation tubes are inserted.

What are the symptoms?

In infants and toddlers, look for: Pulling or scratching at the ear, especially if accompanied by other symptoms; hearing problems; crying, irritability; fever; ear drainage.

In young children, adolescents, and adults look for: earache; feeling of fullness or pressure; hearing problems; dizziness; loss of balance, nausea, vomiting, ear drainage, and/or fever.

Remember, without proper treatment, damage from an ear infection can cause chronic or permanent hearing loss.

Insight into making air travel more comfortable

• Why do ears pop?
• How can air travel cause hearing problems?
• How to help babies unblock their ears?
• and more…

Ear problems are the most common medical complaint of airplane travelers, and while they are usually simple, minor annoyances, they may result in temporary pain and hearing loss. Make air travel comfortable by learning how to equalize the pressure in the ears instead of suffering from an uncomfortable feeling of fullness or pressure.

Why do ears pop?

Normally, swallowing causes a little click or popping sound in the ear. This occurs because a small bubble of air has entered the middle ear, up from the back of the nose. It passes through the Eustachian tube, a membrane-lined tube about the size of a pencil lead that connects the back of the nose with the middle ear. The air in the middle ear is constantly being absorbed by its membranous lining and re-supplied through the Eustachian tube. In this manner, air pressure on both sides of the eardrum stays about equal. If, and when, the air pressure is not equal the ear feels blocked.

The Eustachian tube can be blocked, or obstructed, for a variety of reasons. When that occurs, the middle ear pressure cannot be equalized. The air already there is absorbed and a vacuum occurs, sucking the eardrum inward and stretching it. Such an eardrum cannot vibrate naturally, so sounds are muffled or blocked, and the stretching can be painful. If the tube remains blocked, fluid (like blood serum) will seep into the area from the membranes in an attempt to overcome the vacuum. This is called “fluid in the ear,” serous otitis or aero-otitis.

The most common cause for a blocked Eustachian tube is the common cold. Sinus infections and nasal allergies are also causes. A stuffy nose leads to stuffy ears because the swollen membranes block the opening of the Eustachian tube.

How can air travel cause hearing problems?

Air travel is sometimes associated with rapid changes in air pressure. To maintain comfort, the Eustachian tube must open frequently and wide enough to equalize the changes in pressure. This is especially true when the airplane is landing, going from low atmospheric pressure down closer to earth where the air pressure is higher.

Actually, any situation in which rapid altitude or pressure changes occur creates the problem. It may be experienced when riding in elevators or when diving to the bottom of a swimming pool. Deep sea divers, as well as pilots, are taught how to equalize their ear pressure. Anybody can learn the trick too.

How to unblock ears?

Swallowing activates the muscles that open the Eustachian tube. Swallowing occurs more often when chewing gum or when sucking on hard candies. These are good air travel practices, especially just before take-off and during descent. Yawning is even better. Avoid sleeping during descent because swallowing may not occur often enough to keep up with the pressure changes.

If yawning and swallowing are not effective, pinch the nostrils shut, take a mouthful of air, and direct the air into the back of the nose as if trying to blow the nose gently. The ears have been successfully unblocked when a pop is heard. This may have to be repeated several times during descent.

Even after landing, continue the pressure equalizing techniques and the use of decongestants and nasal sprays. If the ears fail to open or if pain persists, seek the help of a physician who has experience in the care of ear disorders. The ear specialist may need to release the pressure or fluid with a small incision in the ear drum.

How to help babies unblock their ears?

Babies cannot intentionally pop their ears, but popping may occur if they are sucking on a bottle or pacifier. Feed the baby during the flight, and do not allow him or her to sleep during descent. Children are especially vulnerable to blockages because their Eustachian tubes are narrower than in adults.

Is the use of decongestants and nose sprays recommended?

Many experienced air travelers use a decongestant pill or nasal spray an hour or so before descent. This will shrink the membranes and help the ears pop more easily. Travelers with allergy problems should take their medication at the beginning of the flight for the same reason. However, avoid making a habit of nasal sprays. After a few days, they may cause more congestion than relief.

Decongestant tablets and sprays can be purchased without a prescription. However, they should be avoided by people with heart disease, high blood pressure, irregular heart rhythms, thyroid disease, or excessive nervousness. Such people should consult their physicians before using these medicines. Pregnant women should likewise consult their physicians first.

Tips to prevent discomfort during air travel

• Consult with a surgeon on how soon after ear surgery it is safe to fly.
• Postpone an airplane trip if a cold, sinus infection, or an allergy attack is present.
• Patients in good health can take a decongestant pill or nose spray approximately an hour before descent to help the ears pop more easily.
• Avoid sleeping during descent.
• Chew gum or suck on a hard candy just before take-off and during descent.
• When inflating the ears, do not use force. The proper technique involves only pressure created by the cheek and throat muscles.

Insight into the proper care of the ears

• Why does the body produce earwax?
• What is the recommended method of ear cleaning?
• When should a doctor be consulted?
• and more…

Good intentions to keep ears clean may be risking the ability to hear. The ear is a delicate and intricate area, including the skin of the ear canal and the eardrum. Therefore, special care should be given to this part of the body. Start by discontinuing the use of cotton-tipped applicators and the habit of probing the ears.

Why does the body produce earwax?

Cerumen or earwax is healthy in normal amounts and serves as a self-cleaning agent with protective, lubricating, and antibacterial properties. The absence of earwax may result in dry, itchy ears. Most of the time the ear canals are self-cleaning; that is, there is a slow and orderly migration of earwax and skin cells from the eardrum to the ear opening. Old earwax is constantly being transported, assisted by chewing and jaw motion, from the ear canal to the ear opening where it usually dries, flakes, and falls out.

Earwax is not formed in the deep part of the ear canal near the eardrum, but in the outer one-third of the ear canal. So when a patient has wax blockage against the eardrum, it is often because he has been probing the ear with such things as cotton-tipped applicators, bobby pins, or twisted napkin corners. These objects only push the wax in deeper.

When should the ears be cleaned?

Under ideal circumstances, the ear canals should never have to be cleaned. However, that isn’t always the case. The ears should be cleaned when enough earwax accumulates to cause symptoms or to prevent a needed assessment of the ear by your doctor. This condition is called cerumen impaction, and may cause one or more of the following symptoms:

• Earache, fullness in the ear, or a sensation the ear is plugged
• Partial hearing loss, which may be progressive
• Tinnitus, ringing, or noises in the ear
• Itching, odor, or discharge
• Coughing

What is the recommended method of ear cleaning?

To clean the ears, wash the external ear with a cloth, but do not insert anything into the ear canal.

Most cases of ear wax blockage respond to home treatments used to soften wax. Patients can try placing a few drops of mineral oil, baby oil, glycerin, or commercial drops in the ear. Detergent drops such as hydrogen peroxide or carbamide peroxide may also aid in the removal of wax.

Irrigation or ear syringing is commonly used for cleaning and can be performed by a physician or at home using a commercially available irrigation kit. Common solutions used for syringing include water and saline, which should be warmed to body temperature to prevent dizziness. Ear syringing is most effective when water, saline, or wax dissolving drops are put in the ear canal 15 to 30 minutes before treatment. Caution is advised to avoid having your ears irrigated if you have diabetes, a perforated eardrum, tube in the eardrum, or a weakened immune system.

Manual removal of earwax is also effective. This is most often performed by an otolaryngologist using suction, special miniature instruments, and a microscope to magnify the ear canal. Manual removal is preferred if your ear canal is narrow, the eardrum has a perforation or tube, other methods have failed, or if you have diabetes or a weakened immune system.

Why shouldn’t cotton swabs be used to clean earwax?

Wax blockage is one of the most common causes of hearing loss. This is often caused by attempts to clean the ear with cotton swabs. Most cleaning attempts merely push the wax deeper into the ear canal, causing a blockage.

The outer ear is the funnel-like part of the ear that can be seen on the side of the head, plus the ear canal (the hole which leads down to the eardrum). The ear canal is shaped somewhat like an hourglass-narrowing part way down. The skin of the outer part of the canal has special glands that produce earwax. This wax is supposed to trap dust and dirt particles to keep them from reaching the eardrum. Usually the wax accumulates a bit, dries out, and then comes tumbling out of the ear, carrying dirt and dust with it. Or it may slowly migrate to the outside where it can be wiped off.

Are ear candles an option for removing wax build up?

No, ear candles are not a safe option of wax removal as they may result in serious injury. Since users are instructed to insert the 10″ to 15″-long, cone-shaped, hollow candles, typically made of wax-impregnated cloth, into the ear canal and light the exposed end, some of the most common injuries are burns, obstruction of the ear canal with wax of the candle, or perforation of the membrane that separates the ear canal and the middle ear.

The U.S. Food and Drug Administration (FDA) became concerned about the safety issues with ear candles after receiving reports of patient injury caused by the ear candling procedure. There are no controlled studies or other scientific evidence that support the safety and effectiveness of these devices for any of the purported claims or intended uses as contained in the labeling.

Based on the growing concern associated with the manufacture, marketing, and use of ear candles, the FDA has undertaken several successful regulatory actions, including product seizures and injunctions, since 1996. These actions were based, in part, upon violations of the Food, Drug, and Cosmetic Act that pose an imminent danger to health.

What can I do to prevent excessive earwax?

There are no proven ways to prevent cerumen impaction, but not inserting cotton-tipped swabs or other objects in the ear canal is strongly advised. If you are prone to repeated wax impaction or use hearing aids, consider seeing your doctor every 6 to 12 months for a checkup and routine preventive cleaning.

When should a doctor be consulted?

If the home treatments discussed in this leaflet are not satisfactory or if wax has accumulated so much that it blocks the ear canal (and hearing), a physician may prescribe eardrops designed to soften wax, or he may wash or vacuum it out. Occasionally, an otolaryngologist (ear, nose, and throat specialist) may need to remove the wax using microscopic visualization.

If there is a possibility of a hole (perforation or puncture) in the eardrum, consult a physician prior to trying any over-the-counter remedies. Putting eardrops or other products in the ear with the presence of an eardrum perforation may cause pain or an infection. Certainly, washing water through such a hole could start an infection.

Your child has an earache. After your first visit to a physician you may hear some of the following terms related to the diagnosis and treatment of this common childhood disorder.

Acute otitis media

– the medical term for the common ear infection. Otitis refers to an ear inflammation, and media means middle. Acute otitis media is an infection of the middle ear, which is located behind the eardrum. This diagnosis includes fluid effusion trapped in the middle ear.

Adenoidectomy

– removal of the adenoids, also called pharyngeal tonsils. Some believe their removal helps prevent ear infections.

Amoxicillin

– a semi-synthetic penicillin antibiotic often used as the first-line medical treatment for acute otitis media or otitis media with effusion. A higher dosage may be recommended for a second treatment.

Analgesia

– immediate pain relief. For an earache, it may be provided by acetaminophen, ibuprofen, and auralgan.

Antibiotic

– a soluble substance derived from a mold or bacterium that inhibits the growth of other bacterial micro-organisms.

Antibiotic resistance

– a condition where micro-organisms continue to multiply although exposed to antibiotic agents, often because the bacteria has become immune to the medication. Overuse or inappropriate use of antibiotics leads to antibiotic resistance.

Audiometer

– an electronic device used in measuring hearing for pure tones of frequencies, generally varying from 125-8000 Hz, and speech (recorded in terms of decibels).

Azithromyacin

– an antibiotic prescribed for acute otitis media due to Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Also known by its brand name, Zithromax.

Bacteria

– organisms responsible for about 70 percent of otitis media cases. The most common bacterial offenders are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.

Chronic otitis media

– when infection of the middle ear persists, leading to possible ongoing damage to the middle ear and eardrum.

Decibel

– one tenth of a bel, the unit of measure expressing the relative intensity of a sound. The results of a hearing test are often expressed in decibels.

Effusion

– a collection of fluid generally containing a bacterial culture.

First-line agent

– The first treatment of antibiotics prescribed for an ear infection, often amoxicillin.

Myringotomy

– an incision made into the ear drum.

Otitis media without effusion

– an inflammation of the eardrum without fluid in the middle ear.

Otitis media with effusion

– the presence of fluid in the middle ear without signs or symptoms of ear infection. It is sometimes called serous otitis media. This condition does not usually require antibiotic treatment.

Otitis media with perforation

– a spontaneous rupture or tear in the eardrum as a result of infection. The hole in the ear drum usually repairs itself within several weeks.

OtoLAM”

– a myringotomy performed with computer-driven laser technology (rather than manual incision with a conventional scalpel).

Pneumatic otoscopy

– a test administered for the middle ear consisting of an inspection of the ear with a device capable of varying air pressure against the eardrum. If the tympanic membrane moves during the test, normal middle ear function is indicated. A lack of movement indicates either increased impedance, as with fluid in the middle ear, or perforation of the tympanic membrane.

Recurrent otitis media

– when the patient incurs three infections in three months, four in six months, or six in 12 months. This is often an indicator that a tympanostomy with tubes might be recommended.

Second line treatment

– antibiotics prescribed when the first line of treatment fails to resolve symptoms after 48 hours.

Trimethoprim Sulfamethoxazole

– an alternative first line treatment for children allergic to amoxicillin.

Tympanostomy tubes

– small tubes inserted in the eardrum to allow drainage of infection.

Do not hesitate to seek clarification from your physician if he or she uses a term that you do not fully understand.

What is AIED?

Autoimmune inner ear disease (AIED) is an inflammatory condition of the inner ear. It occurs when the body’s immune system attacks cells in the inner ear that are mistaken for a virus or bacteria. AIED is a rare disease occurring in less than one percent of the 28 million Americans with a hearing loss.

How Does the Healthy Ear Work?

The ear has three main parts: the outer, middle and inner ear. The outer ear (the part you can see) opens into the ear canal. The eardrum separates the ear canal from the middle ear. Small bones in the middle ear help transfer sound to the inner ear. The inner ear contains the auditory (hearing) nerve, which leads to the brain.

Any source of sound sends vibrations or sound waves into the air. These funnel through the ear opening, down the ear, canal, and strike your eardrum, causing it to vibrate. The vibrations are passed to the small bones of the middle ear, which transmit them to the hearing nerve in the inner ear. Here, the vibrations become nerve impulses and go directly to the brain, which interprets the impulses as sound (music, voice, a car horn, etc.).

Symptoms Of AIED

The symptoms of AIED are sudden hearing loss in one ear progressing rapidly to the second ear. The hearing loss can progress over weeks or months. Patients may feel fullness in the ear and experience vertigo. In addition, a ringing, hissing, or roaring sound in the ear may be experienced. Diagnosis of AIED is difficult and is often mistaken for otitis media until the patient develops a loss in the second ear. One diagnostic test that is promising is the Western blot immunoassay.

Treatment For AIED?

Most patients with AIED respond to the initial treatment of steroids, prednisone, and methotrexate, a chemotherapy agent. Some patients may benefit from the use of hearing aids. If patients are unresponsive to drug therapy and hearing loss persists, a cochlear implant maybe considered.

History Of AIED

Until recently it was thought that the inner ear could not be attacked by the immune system. Studies have shown that the perisacular tissue surrounding the endolymphatic sac contains the necessary components for an immunological reaction. The inner ear is also capable of producing an autoimmune response to sensitized cells that can enter the cochlea through the circulatory system.

AIED Research

A multi-institutional clinical study, Otolaryngology Clinical Trial Cooperative Group (OCTCG) co-sponsored by the NIH and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, is being conducted to measure the benefits and risks of treating AIED with two different immunosuppressive drugs: prednisone and methotrexate, a chemotherapy drug.

Many medical conditions, such as those listed below, can affect your hearing health. Treatment of these and other hearing losses can often lead to an improved or restored hearing. If left undiagnosed and untreated, some conditions can lead to irreversible hearing impairment or deafness. If you suspect that you or your loved one has a problem with their hearing, ensure optimal hearing healthcare by seeking a medical diagnosis from a physician.

Otitis Media

The most common cause of hearing loss in children is otitis media, the medical term for a middle ear infection or inflammation of the middle ear. This condition can occur in one or both ears and primarily affects children due to the shape of the young Eustachian tube (and is the most frequent diagnosis for children visiting a physician). When left undiagnosed and untreated, otitis media can lead to infection of the mastoid bone behind the ear, a ruptured ear drum, and hearing loss. If treated appropriately, hearing loss related to otitis media can be alleviated.

Tinnitus

Tinnitus is the medical name indicating “ringing in the ears,” which includes noises ranging from loud roaring to clicking, humming, or buzzing. Most tinnitus comes from damage to the microscopic endings of the hearing nerve in the inner ear. The health of these nerve endings is important for acute hearing, and injury to them brings on hearing loss and often tinnitus. Hearing nerve impairment and tinnitus can also be a natural accompaniment of advancing age. Exposure to loud noise is probably the leading cause of tinnitus damage to hearing in younger people. Medical treatments and assistive hearing devices are often helpful to those with this condition.

Swimmer’s Ear

An infection of the outer ear structures caused when water gets trapped in the ear canal leading to a collection of trapped bacteria is known as swimmer’s ear or otitis externa. In this warm, moist environment, bacteria multiply causing irritation and infection of the ear canal. Although it typically occurs in swimmers, bathing or showering can also contribute to this common infection. In severe cases, the ear canal may swell shut leading to temporary hearing loss and making administration of medications difficult.

Earwax

Earwax (also known as cerumen) is produced by special glands in the outer part of the ear canal and is designed to trap dust and dirt particles keeping them from reaching the eardrum. Usually the wax accumulates, dries, and then falls out of the ear on its own or is wiped away. One of the most common and easily treatable causes of hearing loss is accumulated earwax. Using cotton swabs or other small objects to remove earwax is not recommended as it pushes the earwax deeper into the ear, increasing buildup and affecting hearing. Excessive earwax can be a chronic condition best treated by a physician.

Autoimmune Inner Ear Disease

Autoimmune inner ear disease (AIED) is an inflammatory condition of the inner ear. It occurs when the body’s immune system attacks cells in the inner ear that are mistaken for a virus or bacteria. Prompt medical diagnosis is essential to ensure the most favorable prognosis. Therefore, recognizing the symptoms of AIED is important: sudden hearing loss in one ear progressing rapidly to the second and continued loss of hearing over weeks or months, a feeling of ear fullness, vertigo, and tinnitus. Treatments primarily include medications but hearing aids and cochlear implants are helpful to some.

Cholesteatoma

A cholesteatoma is a skin growth that occurs in the middle ear behind the eardrum. This condition usually results from poor eustachian tube function concurrent with middle ear infection (otitis media), but can also be present at birth. The condition is treatable, but can only be diagnosed by medical examination. Over time, untreated cholesteatoma can lead to bone erosion and spread of the ear infection to localized areas such as the inner ear and brain. If untreated, deafness, brain abscess, meningitis, and death can occur.

Perforated Eardrum

A perforated eardrum is a hole or rupture in the eardrum, a thin membrane that separates the ear canal and the middle ear. A perforated eardrum is often accompanied by decreased hearing and occasional discharge with possible pain. The amount of hearing loss experienced depends on the degree and location of perforation. Sometimes a perforated eardrum will heal spontaneously, other times surgery to repair the hole is necessary. Serious problems can occur if water or bacteria enter the middle ear through the hole. A physician can advise you on protection of the ear from water and bacteria until the hole is repaired.

Why Is Early Childhood Hearing Screening Important for Your Child?

Approximately two to four of every 1,000 children in the United States are born deaf or hard-of-hearing, making hearing loss the most common birth disorder. Many studies have shown that early diagnosis of hearing loss is crucial to the development of speech, language, cognitive, and psychosocial abilities. Treatment is most successful if hearing loss is identified early, preferably within the first few months of life. Still, one in every four children born with serious hearing loss does not receive a diagnosis until 14 months old.

When Should a Child’s Hearing Be Tested?

The first opportunity to test a child’s hearing is in the hospital shortly after birth. If your child’s hearing is not screened before leaving the hospital, it is recommended that screening be done within the first month of life.  If test results indicate a possible hearing loss,get a further evaluation as soon as possible, preferably within the first three to six months of life.

Is Early Hearing Screening Mandatory?

In recent years, health organizations across the country, including the American Academy of Otolaryngology – Head and Neck Surgery, have worked to highlight the importance of screening all newborns for hearing loss. These efforts are working. Recently, many states have passed Early Hearing Detection and Intervention legislation.  A few other states regularly screen the hearing of most newborns, but have no legislation that requires screening.  So, check with your local authority or hospital for screening regulations.

How Is Screening Done?

Two tests are used to screen infants and newborns for hearing loss. They are otoacoustic emissions (OAE), and auditory brain stem response (ABR). Otoacoustic emissions involves placing a sponge earphone in the ear canal to measure whether the ear can respond properly to sound. In normal-hearing children, a measurable “echo” should be produced when sound is emitted through the earphone. If no echo is measured, it could indicate a hearing loss.

Auditory brain stem response is a more complex test. Earphones are placed on the ears and electrodes are placed on the head and ears. Sound is emitted through the earphones while the electrodes measure how your child’s brain responds to the sound.

If either test indicates a potential hearing loss, your physician may suggest a follow-up evaluation by an otolaryngologist.

Signs of Hearing Loss in Children

Hearing loss can also occur later in childhood. In these cases, parents, grandparents, and other caregivers are often the first to notice that something may be wrong with a young child’s hearing. Even if your child’s hearing was tested as a newborn, you should continue to watch for signs of hearing loss, including:

• Not reacting in any way to unexpected loud noises,
• Not being awakened by loud noises,
• Not turning his/her head in the direction of your voice,
• Not being able to follow or understand directions,
• Poor language development, or
• Speaking loudly or not using age-appropriate language skills.

If your child exhibits any of these signs, report them to your doctor.

What Happens If My Child Has a Hearing Loss?

Hearing loss in children can be temporary or permanent. It is important to have hearing loss evaluated by a physician who can rule out medical problems that may be causing the hearing loss, such as otitis media (ear infection), excessive earwax, congenital malformations, or a genetic hearing loss.

If it is determined that your child’s hearing loss is permanent, hearing aids may be recommended to amplify the sound reaching your child’s ear. Ear surgery may be able to restore or significantly improve hearing in some instances. For those with certain types of very severe hearing loss who do not benefit sufficiently from hearing aids, a cochlear implant may be considered. Unlike a hearing aid, the implant bypasses damaged parts of the auditory system and directly stimulates the hearing nerve, allowing the child to hear louder and clearer sound.

Research indicates that if a child’s hearing loss is remedied by age six months, it will prevent subsequent language delays. You will need to decide whether your deaf child will communicate primarily with oral speech and/or sign language, and seek early intervention to prevent language delays. Other communication strategies such as auditory verbal therapy, lip reading, and cued speech may also be used in conjunction with a hearing aid or cochlear implant, or independently.

What you should know

Children with cochlear implants are more likely to get bacterial meningitis than children without them. In addition, some children who are candidates for cochlear implants have inner ear abnormalities that may increase their risk for meningitis.

Because children with cochlear implants are at increased risk for pneumococcal meningitis, the Centers for Disease Control and Prevention (CDC) recommends that they receive pneumococcal vaccination on the same schedule recommended for other groups at increased risk for invasive pneumococcal disease. Recommendations for the timing and type of this vaccination vary with age and vaccination history, and should be discussed with a healthcare provider.

The CDC has issued new pneumococcal vaccination recommendations for individuals with cochlear implants. These can be viewed on the CDC website:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5909a2.htm

• Children who have cochlear implants or are candidates for them, and who have not received any previous doses of PCV7, should receive PCV13. PCV13 is now recommended routinely for all infants and children (see Table 2 in the CDC March 13, 2010 report at the website above for the dosing schedule).
• Older children with cochlear implants (between age 2 and 6) should receive two doses of PCV13 if they have not previously received any PCV7 or PCV13. If they have already completed the four-dose PCV7 series, they should receive one dose of PCV13 (up to age 6).
• Children 6 through 18 with cochlear implants may receive a single dose of PCV13, regardless of whether they’ve previously received PCV7 or the pneumococcal polysaccharide vaccine (PPSV) (Pneumovax®).
• In addition to receiving PCV13, children with cochlear implants should receive one dose of PPSV at age 2 or older, and after completing all recommended doses of PCV13.
• Adult patients (19 and older) who are candidates for a cochlear implant, and those who have received an implant, should receive a single dose of PPSV.
• For both children and adults, the vaccination schedule should be completed two weeks or more before surgery.

Additional facts

• According to the Food and Drug Administration (FDA), as of April 2009, approximately 188,000 people worldwide have received cochlear implants, including roughly 41,500 adults and 25,500 children in the U.S. There are 122 known reports of meningitis in patients in the U.S., who have received cochlear implants, with 64% of these cases in children.
• Meningitis is an infection of the fluid that surrounds the brain and spinal cord. There are two main types of meningitis, viral and bacterial. Bacterial meningitis is the more serious, and the type that has been reported in individuals with cochlear implants. The symptoms, treatment, and outcomes may differ, depending on the cause.
• The vaccines available in the U.S. that protect against most bacteria that cause meningitis are:
  
  • 13-valent pneumococcal conjugate (PCV13) (Prevnar 13®)
  • 23-valent pneumococcal polysaccharide (PPSV) (Pneumovax®)
  • Haemophilus influenzae type b conjugate (Hib)
  • Tetravalent (A, C, Y, W-135) meningococcal conjugate (Menactra® and Menveo®)
  • Tetravalent (A, C, Y, W-135) meningococcal polysaccharide (Menomune®)
• Meningitis in individuals with cochlear implants is most commonly caused by the bacterium Streptococcus pneumoniae (pneumococcus). Children with cochlear implants are more likely to get pneumococcal meningitis than children without them.
• There is no evidence that children with cochlear implants are more likely to get meningococcal meningitisthan other children.
• The Haemophilus influenzae type b (Hib) vaccine is not routinely recommended forthose age 5 or older, since most older children and adults arealready immune to Hib. However, it can be given to older children and adults who have never received it. Children under age 5 should receive the Hib vaccine as a routine protection, according to the CDC guidelines. Most children born after 1990 receive the Hib vaccine as infants.

Healthcare providers (family physicians, pediatricians, and otolaryngologists) and families should review the vaccination records of current and prospective cochlear implant recipients to ensure that all recommended vaccinations are up to date.

Who is in day care?

The 2000 census reported that of among the nation’s 19.6 million preschoolers, grandparents took care of 21 percent, 17 percent were cared for by their father (while their mother was employed or in school); 12 percent were in day care centers; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in nursery schools or preschools. More than one-third of preschoolers (7.2 million) had no regular child-care arrangement and presumably were under maternal care.

Day care establishments are defined as those primarily engaged in care of infants or children, or in providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary function or major element. Some may or may not have substantial educational programs, and some may care for older children when they are not in school.

What are your child’s risks of being exposed to a contagious illness at a day care center?

Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centers do pose some degree of an increased health risk for children, because of the exposure to other children who may be sick.

When your child is in a day care center, the risk is greatest for viral upper respiratory infection (affecting the nose, throat, mouth, voice box) and the common cold, ear infections, and diarrhea. Some studies have tried to link asthma to day care. Other studies suggest that being exposed to all the germs in day care actually IMPROVES your child’s immune system.

Studies suggest that the average child will get eight to ten colds per year, lasting ten – 14 days each, and occurring primarily in the winter months. This means that if a child gets two colds from March to September, and eight colds from September to March, each lasting two weeks, the child will be sick more than over half of the winter.

At the same time, children in a day care environment, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media annually. This is four times the incidence of children staying at home.

When should your child remain at home instead of day care or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

• When your child has a temperature higher than 100 degrees, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
• When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home.
• Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
• If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?

The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:

• Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.
• Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:
  
  • Look for otitis (inflammation) in the ear. This is an indicator of future ear infections.
  • Review with you any allergies your child may have. This will assist in determining if the diet offered at the day care center may be harmful to your child.
  • Examine the child’s tonsils for infection and size. Enlarged tonsils could indicate that your child may not be getting a healthy sleep at night, resulting in a tired condition during the day.

Alert the day care center manager when your child is ill, and include the nature of the illness.

Day care has become a necessity for millions of families. Monitoring the health of your own child is key to preventing unnecessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

Researchers continue to look for help for children and parents of children who suffer from the most common type of ear infection, called middle ear infection or otitis media (OM).

About 62 percent of children in developed countries will have their first episode of OM by the age of one, more than 80 percent by their third birthday, and nearly 100 percent will have at least one episode by age five. In the U.S. alone, this illness accounts for 25 million office visits annually with direct costs for treatment estimated at $3 billion. Health economists add that when lost wages for parents are included, the total cost of estimated treatments mount to $6 billion.

This is a big problem.

Treatments

The usual treatment options for children with middle ear infections include 1) antibiotics; and 2) surgical insertion of pressure equalizing tubes in the ears. While studies have shown that antibiotics can be helpful in certain cases, excessive use can lead to bacterial resistance, making infections more difficult to treat. Tubes sometimes do not equalize pressure enough or may need reinsertion over time.

What about vaccines?

A vaccine is a preparation administered to stimulate the body’s own defense system to combat specific bacteria or viruses. The first vaccine was introduced in the 18th century for the prevention of smallpox. Today, each vaccine is designed to resemble a particular virus or bacteria (or group of viruses and bacteria). When administered, the vaccine triggers the defense system without actually causing illness. This helps the body to develop a defense (antibodies) against the virus or bacteria so that if they enter the body, you will not get sick. Today, vaccines exist to combat a wide range of viruses and some bacteria.

One of the most common and potentially serious bacteria to cause ear and sinus infections and pneumonia and meningitis is the pneumococcus. Recently a vaccine was developed that is effective against several common strains of pneumococcus.

Your child’s physician will advise you on appropriate vaccines for your child. If the pneumococcal vaccine is offered to your child, you may want to know:

The conjugate pneumococcal vaccine: This latest advance in pediatric healthcare prevents diseases caused by seven of the most common types of pneumococcal bacteria. It is safe and effective. It protects against serious forms of the disease up to 97 percent of the time, depending on the person. The vaccine is given by a needle. The side effects, which are usually minor and temporary, include some redness, swelling or tenderness from the injection, and a mild fever. Serious side effects, including allergic reactions, are quite rare. It can be given to infants, and there is no other vaccine to prevent pneumococcal disease in children less than two years of age. In 2002 the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommended the vaccine for infants and toddlers under the age of five.

Conjugate vaccines are effective against otitis media in children under the age of five because they have a polysaccharide component linked to a protein component that an infant’s immature defense system can recognize. Children older than five, whose defense systems have matured, may receive a pneumococcal polysaccharide vaccine without the protein component.

How does this relate to otitis media? Here are issues to consider.

Streptococcus pneumoniae bacteria (commonly known as pneumococcus) are thought to cause 50 to 60 percent of cases of otitis media. Before this vaccine was available, each pneumococcal infection caused:

• about five million ear infections;
• more than 700 cases of meningitis;
• 13,000 blood infections (septicemia); and
• other health problems including pneumonia, deafness, and brain damage.

Haemophilus influenzae (NTHi) and Moraxella catarrhalis vaccine

Two other common bacteria that cause ear and sinus infections are nontypeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis. Recently, the National Institutes of Health has issued a license for the first clinical trials for a nontypeable Haemophilus influenzae (NTHi) vaccine. Vaccines to prevent viral infections like the flu that can eventually lead to ear infections should be considered for children with recurring ear infections. These vaccines are usually administered in the fall.

One of the most common birth defects is hearing loss or deafness (congenital), which can affect as many as three of every 1,000 babies born. Inherited genetic defects play an important role in congenital hearing loss, contributing to about 60 percent of deafness occurring in infants. Although exact data is not available, it is likely that genetics plays an important role in hearing loss in the elderly. Inherited genetic defects are just one factor that can lead to hearing loss and deafness, both of which may occur at any stage of a person’s lifespan. Other factors may include: medical problems, environmental exposure, trauma, and medications.

The most common and useful distinction in hearing impairment is syndromic versus non-syndromic.

Non-syndromic hearing impairment accounts for the vast majority of inherited hearing loss, approximately 70 percent. Autosomal- recessive inheritance is responsible for about 80 percent of cases of non-syndromic hearing impairment, while autosomal-dominant genes cause 20 percent, less than two percent of cases are caused by X-linked and mitochondrial genetic malfunctions.

Syndromic (sin-DRO-mik) means that the hearing impairment is associated with other clinical abnormalities. Among hereditary hearing impairments, 15 to 30 percent are syndromic. Over 400 syndromes are known to include hearing impairment and can be classified as: syndromes due to cyotgenetic or chromosomal anomalies, syndromes transmitted in classical monogenic or Mendelian inheritance, or syndromes due to multi-factorial influences, and finally, syndromes due to a combination of genetic and environmental factors.

Variable expression of different aspects of syndromes is common. Some aspects may be expressed in a range from mild to severe or different combinations of associated symptoms may be expressed in different individuals carrying the same mutation within a single pedigree. An example of variable expressivity is seen in families transmitting autosomal dominant Waardenburg syndrome. Within the same family, some affected members may have dystopia canthorum (an unusually wide nasal bridge due to sideways displacement of the inner angles of the eyes), white forelock, heterochromia irides (two different-colored irises or two colors in the same iris), and hearing loss, while others with the same mutation may only have dystopia canthorum.

How Do Genes Work?

Genes are a road map for the synthesis of proteins, which are the building blocks for everything in the body: hair, eyes, ears, heart, lung, etc. Every child inherits half of its genes from one parent and half from the other parent. If the inherited genes are defective, a health disorder such as hearing loss or deafness can result. Hearing disorders are inherited in one of four ways:

Autosomal Dominant Inheritance: For autosomal dominant disorders, the transmission of a rare allele of a gene by a single heterozygous parent is sufficient to generate an affected child. A heterozygous parent has two types of the same gene (in this case, one mutated and the other normal) and can produce two types of gametes (reproductive cells). One gamete will carry the mutant form of the gene of interest, and the other the normal form. Each of these gametes then has an equal chance of being used to form the offspring. Thus the chance that the offspring of a parent with an autosomal dominant gene will develop the disorder is 50 percent. Autosomal dominant traits usually affect males and females equally.

Autosomal Recessive Inheritance: An autosomal recessive trait is characterized by having parents who are heterozygous carriers for mutant forms of the gene in question but are not affected by the disorder. The problem gene that would cause the disorder is suppressed by the normal gene. These heterozygous parents (A/a) can each generate two types of gametes, one carrying the mutant copy of the gene (a) and the other having a normal copy of the gene (A). There are four possible combinations from each of the parents, A/a, A/A, a/A, and a/a. Only the offspring that inherits both mutant copies (a/a) will exhibit the trait. Overall, offspring of these two parents will face a 25 percent chance of inheriting the disorder.

X-linked Inheritance: A male offspring has an X chromosome and a Y chromosome, while a female has two copies of the X chromosome only. Each female inherits an X chromosome from her mother and her father.   On the other hand, each male inherits an X chromosome from his mother and a Y chromosome from his father. In general, only one of the two X chromosomes carried by a female is active in any one cell while the other is rendered inactive. This is why when a female inherits a defective gene on one X chromosome, the normal gene on the other X chromosome can usually compensate. As males only have one copy of the X chromosome, any defective gene is more likely to manifest into a disorder.

Mitochondrial Inheritance: Mitochondrias, small powerhouses within each cell, also contain their own DNA. Interestingly, the sperm does not have any mitochondria, and consequently, only the mitochondria in the egg from the mother can be passed from one generation to the next. This leads to an interesting inheritance pattern where only affected mothers (and not affected fathers as their sperms do not have mitochondria) can pass on a disease from one generation to the next. Sensitivity to aminoglycoside antibiotics can be inherited through a defect in mitochondrial DNA and is the most common cause of deafness in China!

In the last decade, advances in molecular biology and genetics have contributed substantially to the understanding of development, function, and pathology of the inner ear. Researchers have identified several of the various genes responsible for hereditary deafness or hearing loss, most notably the GJB2 gene mutation. As one of the most common genetic causes of hearing loss, GJB2-related hearing loss is considered a recessive genetic disorder because the mutations only cause deafness in individuals who inherit two copies of the mutated gene, one from each parent. A person with one mutated copy and one normal copy is a carrier but is not deaf. Screening tests for the GJB2 gene are available for at risk individuals to help them determine their risk of having a child with hearing problems.

The ear has three main parts: the outer ear (including the external auditory canal), middle ear, and inner ear. The outer ear (the part you can see) opens into the ear canal. The eardrum (tympanic membrane) separates the ear canal from the middle ear. The middle ear contains three small bones which help amplify and transfer sound to the inner ear. These three bones, or ossicles, are called the malleus, the incus, and the stapes (also referred to as the hammer, the anvil, and the stirrup respectively). The inner ear contains the cochlea which changes sound into neurological signals and the auditory (hearing) nerve, which takes sound to the brain.

Any source of sound sends vibrations or sound waves into the air. These funnel through the ear opening, down the external ear canal, and strike your eardrum, causing it to vibrate. The vibrations are passed to the three small bones of the middle ear, which transmit them to the cochlea. The cochlea contains tubes  filled with fluid.  Inside one of the tubes, tiny hair cells pcik up the vibrations and convert them into nerve impulses. These impulses are delivered  to the brain via the hearing nerve.  The brain interprets the impulses as sound (music, voice, a car horn, etc.).

Sound

Sound is measured in decibels (dB). Each decibel is one tenth of a bel, which is a unit that measures the intensity of sound. For every six decibels, the intensity of the sound doubles. At 90 dB of uninterrupted sound, the limit of safe noise exposure is eight hours. For each six dB increase of uninterrupted sound thereafter, the limit of safe exposure is reduced by half.

It is important to know the approximate intensity of sound around you to protect your hearing.

What Is Otosclerosis?

The term otosclerosis is derived from the Greek words for “hard” (scler-o) and “ear” (oto). It describes a condition of abnormal bone growth around the stapes bone, one of  the tiny bones of the middle ear.  This leads to a fixation of the stapes bone. The stapes bone must move freely for the ear to work properly and hear well.

Hearing is a complex process. In a normal ear, sound vibrations are funneled by the outer ear into the ear canal where they hit the tympanic membrane (ear drum). These vibrations cause movement of the ear drum, which  transfers the vibrations to the three small bones of the middle ear, the malleus (hammer), incus (anvil), and stapes (stirrup). When the stapes bone moves, it sets the inner ear fluids in motion, which, in turn, start the process to stimulate the tiny sensory hair cells in the inner ear, which connect with the auditory (hearing) nerve. The hearing nerve then carries sound information to the brain, resulting in hearing of sound. When any part of this process is compromised, hearing is impaired.

Who Gets Otosclerosis and Why?

It is estimated that ten percent of the adult Caucasian population is affected by otosclerosis. The condition is less common in people of Japanese and South American decent and is rare in African Americans. Overall, Caucasian, middle-aged women are most at risk.

The hallmark symptom of otosclerosis, slowly progressing hearing loss, can begin anytime between the ages of 15 and 45, but it usually starts in the early 20’s. The disease can develop in both women and men, but is particularly troublesome for pregnant women who, for unknown reasons,  can experience a rapid decrease in hearing ability.

Approximately 60 percent of otosclerosis cases have a genetic predisposition. On average, a person who has one parent with otosclerosis has a 25 percent chance of developing the disorder. If both parents have otosclerosis, the risk goes up to 50 percent.

Symptoms of Otosclerosis

Gradual hearing loss is the most frequent symptom of otosclerosis. Often, individuals with otosclerosis will first notice that they cannot hear low-pitched sounds or whispers. Other symptoms of the disorder can include dizziness, balance problems, or a sensation of ringing, roaring, buzzing, or hissing in the ears or head known as tinnitus.

How Is Otosclerosis Diagnosed?

Because many of the symptoms typical of otosclerosis can be caused by other medical conditions, it is important to be examined by an otolaryngologist (ear, nose and throat doctor) to eliminate these other causes. After an examination, the otolaryngologist may order a hearing test. The typical finding on the hearing test is a conductive hearing loss in the low frequency tones.  This means that the loss of hearing is due to an inability of the sound vibrations to get transferred into the inner ear. Based on the results of this test and the exam findings, the diagnosis of otosclerosis can be made. The otolaryngologist will suggest treatment options.

Treatment for Otosclerosis

If the hearing loss is mild, the otolaryngologist may suggest continued observation or  a hearing aid to amplify the sound reaching the ear drum. Sodium fluoride has been found to slow the progression of the disease and  is sometimes prescribed. In some cases of otosclerosis, a surgical procedure called stapedectomy can restore or improve hearing.

What Is a Stapedectomy?

A stapedectomy is an outpatient surgical procedure done under local or general anesthesia. The surgeon performs the surgery through the ear canal with an operating microscope. It involves removing part or all of the immobilized stapes bone and replacing it with a prosthetic device. The prosthetic device allows the bones of the middle ear to resume movement, which stimulates fluid in the inner ear and improves or restores hearing.

Modern-day stapedectomy has been performed since 1956 with a success rate of approximately 90 percent. In rare cases (about one percent of surgeries), the procedure may worsen hearing.

Otosclerosis affects both ears in eight out of ten patients. For these patients, ears are operated on one at a time; the worst hearing ear first. The surgeon usually waits a minimum of six months before performing surgery on the second ear.

What Should I Expect after a Stapedectomy?

Most patients return home the evening after surgery and are told to lie quietly on the un-operated ear. Oral antibiotics may be prescribed by the otolaryngologist. Some patients experience dizziness the first few days after surgery. Taste sensation may also be altered for several weeks or months following surgery, but usually returns to normal.

Following surgery, patients may be asked to refrain from nose blowing, swimming, or other activities that may get water in the operated ear. Normal activities (including air travel) are usually resumed two to four weeks after surgery.

Notify your otolaryngologist immediately if any of the following occurs:

• Sudden hearing loss
• Intense pain
• Prolonged or intense dizziness
• Any new symptom related to the operated ear

Since packing is placed in the ear at the time of surgery, hearing improvement may not be noticed until it is removed about one to three weeks after surgery.  The ear drum will heal quickly, generally reaching the maximum level of improvement within two weeks.

Tinnitus is a condition where the patient hears a ringing or other noise that is not produced by an external source. This disorder can occur in one or both ears, range in pitch from a low roar to a high squeal, and may be continuous or sporadic. This often debilitating condition has been linked to ear injuries, circulatory system problems, noise-induced hearing loss, wax build-up in the ear canal, medications harmful to the ear, ear or sinus infections, misaligned jaw joints, head and neck trauma, Ménière’s disease, or an abnormal growth of bone of the middle ear. In rare cases, slow-growing tumors on auditory, vestibular, or facial nerves can cause tinnitus as well as deafness, facial paralysis, and balance problems. The American Tinnitus Association estimates that more than 50 million Americans have tinnitus problems to some degree, with approximately 12 million people having symptoms severe enough to seek medical care.

Tinnitus is not uncommon in children. Although it is as common as in adults, children generally do not complain of tinnitus. Researchers believe that a child with tinnitus considers the noise in the ear to be normal, as it has usually been present for a long time. A second explanation of the discrepancy is that the child may not distinguish between the psychological impact of tinnitus and its medical significance.

Continuous tinnitus can be annoying and distracting, and in severe cases can cause psychological distress and interfere with your child’s ability to lead a normal life. The good news is that most children with tinnitus seem to eventually outgrow the symptom. It is unusual to see a child carry the problem into adulthood.

If you think your child has tinnitus, first arrange an appointment with your family physician or pediatrician. If the child does not have a specific problem with the ears such as middle ear inflammation with thick discharge, then it may be necessary to have your child referred to an otolaryngologist (ear, nose, and throat specialist).

What treatment may be offered

Most people, including children, who are diagnosed with tinnitus find that there is no specific problem underlying their tinnitus. Consequently, there is no specific medicine or operation to “cure” the problem. However, experts suggest that the following steps be taken with the child diagnosed with tinnitus:

• Reassure the child: Explain that this condition is common and they are not alone. Ask your physician to describe the condition to the child in terms and images that they can understand.
  Depending on the nature of the tinnitus, the doctor may order further testing, such as a hearing test, a CT scan, or MRI.
• Explain that he/she may feel less distressed by their tinnitus in the future: Many children find it helpful to have their tinnitus explained carefully and to know about ways to manage it. This is partly due to a medical concept known as “neural plasticity,” where children’s are more able to change their response to all kinds of stimulation. If carefully managed, childhood tinnitus may not be a serious problem.
• Use sound generators or provide background noise. Sound therapy, which makes tinnitus less noticeable, has been used to treat adults for some time, and can also be used with children. If tinnitus occurs on a regular basis, with sound therapy the child’s nervous system can adapt to the condition. The sound can be environmental, such as a fan or quiet background music.
• Have hearing-impaired children wear hearing aids. A child with tinnitus and hearing loss may find that hearing aids can help improve the tinnitus. Hearing aids can pick up sounds children may not normally hear, which in turn will help their brains filter out their tinnitus. It may also help them by taking the strain out of listening. Straining to hear can make your child’s brain focus on the tinnitus noises.
• Help your child to sleep with debilitating tinnitus. Severe tinnitus may lead to sleep difficulties for the young patient. Ask your otolaryngologist the best strategy to adopt if your child cannot sleep.
• Finally, help your child relax. Some children believe their tinnitus gets worse when they are under stress. Discuss appropriate stress-relieving techniques with your pediatrician or family physician.

To understand earaches you must first know about the Eustachian tube, a narrow channel connecting the inside of the ear to the back of the throat, just above the soft palate. The tube allows drainage — preventing fluid in the middle ear from building up and bursting the thin ear drum. In a healthy ear, the fluid drains down the tube, assisted by tiny hair cells, and is swallowed.

The tube maintains middle ear pressure equal to the air outside the ear, enabling free eardrum movement. Normally, the tube is collapsed most of the time in order to protect the middle ear from the many germs residing in the nose and mouth. Infection occurs when the Eustachian tube fails to do its job. When the tube becomes partially blocked, fluid accumulates in the middle ear, trapping bacteria already present, which then multiply. Additionally, as the air in the middle ear space escapes into the bloodstream, a partial vacuum is formed that absorbs more bacteria from the nose and mouth into the ear.

Why do children have more ear infections than adults?

Children have Eustachian tubes that are shorter, more horizontal, and straighter than those of adults. These factors make the journey for the bacteria quick and relatively easy. A child’s tube is also floppier, with a smaller opening that easily clogs.

Inflammation of the middle ear is known as “otitis media.” When infection occurs, the condition is called “acute otitis media.” Acute otitis media occurs when a cold, allergy or upper respiratory infection, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube.

When fluid forms in the middle ear, the condition is known as “otitis media with effusion,” which can occur with or without infection. This fluid can remain in the ear for weeks to many months. When infected fluid persists or repeatedly returns, this is sometimes called “chronic middle ear infection.” If not treated, chronic ear infections have potentially serious consequences such as temporary or permanent hearing loss.

How are recurrent acute otitis media and otitis media with effusion treated?

Some child care advocates suggest doing nothing or administering antibiotics to treat the infection. More than 30 million prescriptions are written each year for ear infections, accounting for 25 percent of all antibiotics prescribed in the United States. However, antibiotics are not effective against viral ear infections (30 to 50 percent of such disorders), may cause uncomfortable side effects such as upset stomach, and can contribute to antibiotic resistance. Medical researchers believe that 25 percent of all pneumococcus strains, the most common bacterial cause of ear infections, are resistant to penicillin, and ten to 20 percent are resistant to amoxicillin.

Is surgery effective against recurrent otitis media and otitis media with effusion?

In some cases, surgery may be the only effective treatment for chronic ear infections. Some physicians recommend the use of laser myringotomy, using a laser to create a tiny hole in the eardrum. The treatment is done in the doctor’s office using topical anesthesia (ear drops). Laser myringotomy works by providing several weeks of ventilation for the middle ear. Proponents suggest this can reduce the many courses of antibiotic treatment for severe ear infections and eliminates the need for surgical insertion of tubes with general anesthesia.

Before the procedure:

Prior to the procedure, the otolaryngologist will examine the patient for a description of the tympanic membrane (eardrum) and the middle ear space. An audiometry may be performed to assess patient hearing. A tympanometry will be performed that tests compliance of the tympanic membrane at various levels of air pressure. This test provides a measurement of the extent of middle ear effusion, Eustachian tube function, and otitis media.

The procedure: During the procedure, a small incision is made in the ear drum, the fluid is suctioned out, and a tube is placed. In young children, this is usually done under a light, general anesthesia; older patients may have the procedure performed under local anesthesia. There are over 50 different tube designs, all in different shapes, color, and composition. In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time. Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.

After the procedure: Immediately after the procedure, the surgeon will examine the patient for persistent or profuse bleeding or discharge. After one month, the tube placement will be reviewed, and the patient’s hearing may be tested. Later, the physician will assess the tube’s effectiveness in alleviating the ear infection.

What is the most common surgical treatment for ear infections?

The most common surgical procedure administered to children under general anesthesia is myringotomy with insertion of tympanostomy tubes (TT). A tube is inserted in the middle ear to allow continuous drainage of fluid. The procedure is recommended for treatment of: chronic otitis media with effusion (lasting longer than three months), recurrent acute otitis media (more than three episodes in six months or more than four episodes in 12 months), severe acute otitis media, otitis media with effusion and a hearing loss greater than 30 dB, non-responsiveness to antibiotics, and impending mastoiditis or intra-cranial complication due to otitis media.

If the patient is age six or younger, it is recommended that tubes remain in place for up to two years. Most tubes will fall out without assistance. Otherwise, the specialist will determine when the tubes should be removed.

Your ENT physician will recommend the most effective treatment for your child’s ear infection.

If your newborn child

• does not startle, move, cry or react in any way to unexpected loud noises,
• does not awaken to loud noises,
• does not turn his/her head in the direction of your voice,
• does not freely imitate sound, or
• has failed a newborn hearing screening test,

then he or she may have some degree of hearing loss.

More than three million American children have a hearing loss, and an estimated 1.3 million of them are under three years of age. Parents and grandparents are usually the first to discover hearing loss in a baby, because they spend the most time with them. If at any time you suspect your baby has a hearing loss, discuss it with your doctor. He or she may recommend evaluation by an otolaryngologist – head and neck surgeon (ear, nose and throat specialist) and additional hearing tests.

Hearing loss can be temporary, caused by ear wax, middle ear fluid, or infections. Many children with temporary hearing loss can have their hearing restored through medical treatment or minor surgery.

However, some children have sensorineural hearing loss (sometimes called nerve deafness), which is permanent. Most of these children have some usable hearing, and children as young as three months old can be fitted with hearing aids.

Early diagnosis is crucial in the management of pediatric hearing loss.  When diagnosis is delayed, there can be significant impact on speech and language development.  Early fitting of hearing or other prosthetic aids, and an early start on special education programs can help maximize a child’s existing hearing. This means your child will get a head start on speech and language development.

Insight into maintaining auditory health

• Can noise hurt my ears?
• How does the ear work?
• How can I protect myself against noise?
• and more…

One in 10 Americans has a hearing loss that affects his or her ability to understand normal speech. Age-related hearing loss is the most common cause of this condition and is more prevalent than hearing loss caused by excessive noise exposure. However, exposure to excessive noise can damage hearing, and it is important to understand the effects of this kind of noise, particularly because such exposure is avoidable.

What causes hearing loss?

The ear has three main parts: the outer, middle, and inner ear. The outer ear (the part you can see) opens into the ear canal. The eardrum separates the ear canal from the middle ear. Small bones in the middle ear help transfer sound vibrations to the inner ear. Here, the vibrations become nerve impulses, which the brain interprets as music, a slamming door, a voice, and so on.

When noise is too loud, it begins to kill the nerve endings in the inner ear. Prolonged exposure to loud noise destroys nerve endings. As the number of nerve endings decreases, so does your hearing. There is no way to restore life to dead nerve endings; the damage is permanent. The longer you are exposed to a loud noise, the more damaging it may be. Also, the closer you are to the source of intense noise, the more damaging it is.

How can I tell if a noise is dangerous?

People differ in their sensitivity to noise. As a general rule, noise may damage your hearing if you are at arm’s length and have to shout to make yourself heard. If noise is hurting your ears, your ears may ring, or you may have difficulty hearing for several hours after exposure to the noise. Noise is characterized by intensity, measured in decibels; pitch, measured in hertz or kilohertz; and duration.

Can noise affect more than my hearing?

A ringing in the ears, called tinnitus, commonly occurs after noise exposure, and often becomes permanent. Some people react to loud noise with anxiety and irritability, an increase in pulse rate and blood pressure, or an increase in stomach acid. Very loud noise can reduce efficiency in performing difficult tasks by diverting attention from the job.

How can I protect myself against noise?

Wear hearing protectors, especially if you must work in an excessively noisy environment. You should also wear them when using power tools, noisy yard equipment, or firearms, or riding a motorcycle or snowmobile. Hearing protectors come in two forms: earplugs and earmuffs.

Earplugs are small inserts that fit into the outer ear canal. They must be sealed snugly so the entire circumference of the ear canal is blocked. An improperly fitted, dirty, or worn-out plug may not seal properly and can result in irritation of the ear canal. Plugs are available in a variety of shapes and sizes to fit individual ear canals and can be custom-made. For people who have trouble keeping them in their ears, the plugs can be fitted to a headband.

Earmuffs fit over the entire outer ear to form an air seal so the entire circumference of the ear canal is blocked, and they are held in place by an adjustable band. Earmuffs will not seal around eyeglasses or long hair, and the adjustable headband tension must be sufficient to hold earmuffs firmly in place.

Earplugs and earmuffs can be found at most pharmacies.

Will I hear other people and machine problems if I wear hearing protectors?

Just as sunglasses help vision in very bright light, so hearing protectors enhance speech understanding in very noisy places. Even in a quiet setting, a normal-hearing person wearing hearing protectors should be able to understand a regular conversation.

Hearing protectors do slightly reduce the ability of those with damaged hearing or poor comprehension of language to understand normal conversation. However, it is essential that persons with impaired hearing wear earplugs or muffs to prevent further inner ear damage in very noisy places.

It has been argued that hearing protectors might reduce a worker’s ability to hear the noises that signify an improperly functioning machine. However, most workers readily adjust to the quieter sounds and can still detect such problems. If a worker is already hearing impaired, he or she needs expert advice about how to protect against further damage. In some cases hearing aids can and should be used under earmuffs.

How can I tell if my hearing is damaged?

Hearing loss usually develops over a period of several years. Because it is painless and gradual, you might not notice it. What you might notice is a ringing or other sound in your ear (tinnitus), which could be the result of long-term exposure to noise that has damaged hearing nerves. Or you may have trouble understanding what people say; they may seem to be mumbling, especially when you are in a noisy place such as a crowd or a party. This could be the beginning of high-frequency hearing loss; a hearing test will detect it.

If you have any of these symptoms, they may be caused by impacted wax or an ear infection, which are relatively easy to correct. However, you may suffer from noise-related hearing loss. In any case, take no chances with noise—the hearing loss it causes is permanent. If you suspect hearing loss, consult a physician with special training in ear care and hearing disorders (called an otolaryngologist or otologist). This doctor can diagnose your hearing problem and recommend the best way to manage it. For more information on the laws for on-the-job noise exposure, please refer to the information provided at www.entnet.org.

Sound Measurements

Decibels (dB) measure the intensity of sound. The scale runs from the faintest sound the human ear can detect, which is labeled 0 dB, to more than 180 dB, the noise at a rocket pad during launch. Most experts agree that continual exposure to more than 85 decibels is dangerous. Recent studies show an alarming increase in noise-related hearing loss in young people.

Approximate examples of decibel levels:

• Faintest sound heard by human ear – 0 dB
• Whisper, quiet library – 30 dB
• Normal conversation, sewing machine, typewriter – 60 dB
• Lawnmower, shop tools, truck traffic – 90 dB
• Chainsaw, pneumatic drill, snowmobile – 100 dB
• Sandblasting, loud rock concert, auto horn – 115 dB
• Gun muzzle blast, jet engine (such noise can cause pain and even brief exposure injures unprotected ears) – 149 dB
• The Occupational Safety and Health Administration’s limit for noise without hearing protectors – 140 dB

Pitch is the frequency of sound vibrations per second measured in hertz or kilohertz, and duration. A low pitch, such as a deep voice or a tuba, makes fewer vibrations per second than a high voice or violin—the higher the pitch, the higher the frequency. Loss of high-frequency hearing also can make speech sound muffled.

The National Institute on Deafness and Other Communication Disorders reports approximately 28 million Americans have lost some or all of their hearing, including 17 in 1,000 children under age 18. Noise exposure is increasingly common in the age of iPods and other personal music players. Overexposure to noise can cause both temporary and permanent hearing loss.

Loudness of common sounds:

Although 10 million Americans suffer irreversible noise-induced hearing loss, with 30 million more exposed to dangerous noise levels each day, very little has been reported on the risk of such hearing loss in children.

How does noise exposure cause hearing loss?

Very loud sounds damage the inner ear by damaging the hair cells of the cochlea. When loud sounds are exposed to the ear for a short time, one may experience what’s called a temporary threshold shift, or a temporary hearing loss. This hearing loss may be accompanied by tinnitus (a ringing in the ears). One may recover from the temporary loss. But if the ear is exposed to loud sounds over longer periods of time, the hair cells can be permanently damaged, causing permanent sensorineural hearing loss.

Should MP3 player use be limited?

The maximum sound from an iPod Shuffle has been measured at 115 decibels, a level that can cause hearing loss to listeners of all ages. A survey sponsored by the Australian government found that about 25 percent of people using portable stereos had daily noise exposures high enough to cause hearing damage. Further research from the Netherlands reports that 90 percent of adolescents listened to music through earphones on MP3 players, almost half used high-volume settings, and only 7 percent used a noise limiter.

Researchers at Boston Children’s Hospital determined that listening to a portable music player with headphones at 60 percent of their potential volume for one hour a day is relatively safe. The maximum volume limit is adjustable on many current MP3 players.

Why earplugs are important at concerts

Parents should be aware that various medical studies have found sound levels at rock concerts often to be significantly higher than 85 dBA, with some reports suggesting that sound intensity may reach 90 dBA to as high as 122 dBA.

To experience 85 dBA, listen to an electric shaver or a busy urban street. If levels are maintained at values greater than 85 dBA for long periods of time, this may lead to a significant noise exposure. Frequent concertgoers may experience some potentially irreversible hearing loss from their experience.

A research study, “Incidence of spontaneous hearing threshold shifts during modern concert performances” (Opperman, Reifman, Schlauch, Levine; Otol-HNS 2006, 134:4: 667-673), examined sound intensity throughout a well known concert venue, and the effectiveness of earplugs. The findings stated that sound pressure levels appeared equally hazardous in all parts of the concert hall, regardless of the type of music played. Accordingly, you should use earplugs at every type of musical concert, regardless of your distance to the stage.

A good rule of thumb: When a child accompanies a parent to any activity or location with excessive noise, ear protection should be worn by the entire family.

Insight into ear injuries

• What is a perforated eardrum?
• What causes eardrum perforation?
• How is hearing affected by a perforated eardrum?
• and more…

A hole or rupture in the eardrum, a thin membrane that separates the ear canal and the middle ear, is called a perforated eardrum. The medical term for eardrum is tympanic membrane. The middle ear is connected to the nose by the eustachian tube, which equalizes pressure in the middle ear.

A perforated eardrum is often accompanied by decreased hearing and occasional discharge. Pain is usually not persistent.

What causes eardrum perforation?

The causes of a perforated eardrum are usually from trauma or infection. A perforated eardrum from trauma can occur:

• If the ear is struck directly
• With a skull fracture
• After a sudden explosion
• If an object (such as a bobby pin, Q-tip, or stick) is pushed too far into the ear canal
• As a result of acid or hot slag (from welding) entering the ear canal

Middle ear infections may cause pain, hearing loss, and spontaneous rupture (tear) of the eardrum, resulting in a perforation. In this circumstance, there maybe infected or bloody drainage from the ear. In medical terms, this is called otitis media with perforation. Symptoms of acute otitis media include a sense of fullness in the ear, diminished hearing, pain, and fever.

On rare occasions a small hole may remain in the eardrum after a previously placed pressure-equalizing (PE) tube falls out or is removed by the physician.

Most eardrum perforations heal on their own within weeks of rupture, although some may take several months to heal. During the healing process the ear must be protected from water and trauma. Eardrum perforations that do not heal on their own may require surgery.

How is hearing affected by a perforated eardrum?

Usually the size of the perforation determines the level of hearing loss – a larger hole will cause greater hearing loss than a smaller hole. The location of the perforation also affects the degree of hearing loss. If severe trauma (e.g., skull fracture) dislocates the bones in the middle ear which transmit sound, or injures the inner ear structures, hearing loss may be severe.

If the perforated eardrum is caused by a sudden traumatic or explosive event, the loss of hearing can be great and tinnitus (ringing in the ear) may be severe. In this case, hearing usually returns partially, and the ringing diminishes in a few days. Chronic infection as a result of the perforation can cause persistent or progressive hearing loss.

How is a perforated eardrum treated?

Before attempting any correction of the perforation, a hearing test should be performed. The benefits of closing a perforation include prevention of water entering the ear while showering, bathing, or swimming (which could cause ear infection), improved hearing, and diminished tinnitus. It also may prevent the development of cholesteatoma (skin cyst in the middle ear), which can cause chronic infection and destruction of ear structures.

If the perforation is very small, an otolaryngologist may choose to observe the perforation over time to see if it will close spontaneously. He or she might try to patch a patient’s eardrum in the office. Working with a microscope, your doctor may touch the edges of the eardrum with a chemical to stimulate growth and then place a thin paper patch on the eardrum. Usually with closure of the tympanic membrane, hearing is improved. Several applications of a patch (up to three or four) may be required before the perforation closes completely. If your physician feels that a paper patch will not provide prompt or adequate closure of the hole in the eardrum, or if paper patching does not help, surgery may be required.

There are a variety of surgical techniques, but most involve grafting skin tissue across the perforation to allow healing. The name of this procedure is called tympanoplasty. Surgery is typically quite successful in repairing the perforation, restoring or improving hearing, and is often done on an outpatient basis.

Your doctor will advise you regarding the proper management of a perforated eardrum.

Insight into acute otitis externa

• What causes swimmer’s ear?
• What are the signs and symptoms?
• How is swimmer’s ear treated?
• and more…

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
• 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 radiate 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 eardrops 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 eardrops using rubbing alcohol or a mixture of half alcohol and half vinegar. These eardrops 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 eardrop, 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.

Insight into causes and treatments for tinnitus

• What causes tinnitus?
• How is tinnitus treated?
• What can help me cope?
• And more…

Nearly 36 million Americans suffer from tinnitus or head noises. It may be an intermittent sound or an annoying continuous sound in one or both ears. Its pitch can go from a low roar to a high squeal or whine. Prior to any treatment, it is important to undergo a thorough examination and evaluation by your otolaryngologist and audiologist. An essential part of the treatment will be your understanding of tinnitus and its causes.

What causes tinnitus?

Tinnitus is commonly defined as the subjective perception of sound by an individual, in the absence of external sounds. Tinnitus is not a disease in itself but a common symptom, and because it involves the perception of sound or sounds, it is commonly associated with the hearing system. In fact, various parts of the hearing system, including the inner ear, are often responsible for this symptom. At times, it is relatively easy to associate the symptom of tinnitus with specific problems affecting the hearing system; at other times, the connection is less clear.

Most of the time, the tinnitus is subjective—that is, the internal sounds can be heard only by the individual. Occasionally, tinnitus is “objective,” meaning that the examiner can actually listen in with a stethoscope or an ear tube and hear the sounds the patient hears. Tinnitus may be caused by different parts of the hearing system. At times, for instance, it may be caused by excessive ear wax, especially if the wax touches the ear drum, causing pressure and changing how the ear drum vibrates. Other times, loose hair from the ear canal may come in contact with the ear drum and cause tinnitus.

Middle ear problems can also cause tinnitus, such as a middle ear infection or the buildup of new bony tissue around one of the middle ear bones which stiffens the middle ear transmission system (otosclerosis). Another cause of tinnitus from the middle ear may be muscle spasms of one of the two tiny muscles attached to middle ear bones. In this case, the tinnitus can be intermittent and at times, the examiner can also hear the patient’s sounds.

Most subjective tinnitus associated with the hearing system originates in the inner ear. Damage and loss of the tiny sensory hair cells in the inner ear (that can be caused by different factors) may be commonly associated with the presence of tinnitus. It is interesting to note that the pitch of the tinnitus often coincides with the area of the maximal hearing loss.

One of the preventable causes of inner ear tinnitus is excessive noise exposure. In some instances of noise exposure, tinnitus is the first symptom before hearing loss develops, so it should be considered a warning sign and an indication of the need for hearing protection in noisy environments. Certain common medications can also damage inner ear hair cells and cause tinnitus. These include non-prescription medications such as aspirin, one of the most common and best known medications that can cause tinnitus and eventual hearing loss. As we age, the incidence of tinnitus increases. Hearing loss associated with aging (also known as presbycusis) typically involves loss of and damage to the hair cells.

A special category is tinnitus that sounds like one’s heartbeat or pulse, also known as pulsatile tinnitus. At times, the presence of pulsatile tinnitus may signal the presence of a vascular tumor in the general vicinity of the middle and inner ear. When noting this type of tinnitus, it is advisable to consult a physician as soon as possible to rule out the presence of this type of vascular tumor.

Conditions that affect the hearing nerve can also cause tinnitus, the most common being benign tumors, typically originating from one of the balance nerves in close proximity to the hearing nerve. These are commonly referred to as acoustic neuroma or vestibular schwannoma. Tinnitus caused by an acoustic neuroma is usually unilateral and may or may not be accompanied initially by a hearing loss.

Tinnitus may also originate from lesions on or in the vicinity of the hearing portion of the brain, called the auditory cortex. These can be traumatic injuries with or without skull fracture, as well as whiplash-type injuries common in automobile accidents. Benign tumors known as meningiomas that originate from the tissue that protects the brain may also be a cause for tinnitus that originates from the brain.

There are a number of non-auditory conditions that can cause tinnitus, as well as lifestyle factors. Hypertension or high blood pressure, thyroid problems, and chronic brain syndromes can all cause tinnitus without any specific auditory problems. Stress and fatigue may cause tinnitus, or can contribute to an exacerbation of an existing case. Poor diet and lack of exercise that may cause blood vessel and heart problems may also either cause it or exacerbate an existing condition. It is also possible that tinnitus could be caused by food or beverage allergies, but these causes are not well documented and are difficult to sort out.

How is tinnitus treated?

In most cases, there is no specific, tried-and-true treatment for ear and head noise. If an otolaryngologist finds a specific cause for your tinnitus, he or she may be able to offer specific treatment to eliminate the noise. This determination may require extensive testing, including x-rays and other imaging studies, audiological tests, tests of balance function, and other laboratory work. However, most of the time, other than linking the presence of tinnitus to sensory hearing loss, specific causes are very difficult to identify. Although there is no specific medication for tinnitus, occasionally medications may be tried and some may help to reduce the noise.

What are some other tinnitus treatment options?

• Alternative treatments, such as mindful meditation
• Amplification (hearing aids)
• Cochlear implants or electrical stimulation
• Cognitive therapy
• Drug therapy
• Sound therapy/tinnitus retraining therapy (TRT)
• TMJ treatment

Can other people hear the noise in my ears?

Not usually, but sometimes they are able to hear a certain type of tinnitus (typically the pulsatile tinnitus mentioned earlier). This is called “objective tinnitus,” and it is caused either by abnormalities in blood vessels around the outside of the ear, or by muscle spasms, which may sound like clicks or crackling inside the middle ear.

Can children be at risk for tinnitus?

It is relatively rare but not unheard of for patients under 18 years old to have tinnitus as a primary complaint. However, it is possible that tinnitus in children is significantly under-reported, in part because young children may not be able to express this complaint. Also, in children with congenital sensorineural hearing loss that may be accompanied by tinnitus, this symptom may be unnoticed because it is something that is constant in their lives. In fact, they may habituate to it; the brain may learn to ignore this internal sound. In pre-teens and teens, the highest risk for developing tinnitus is associated with exposure to high intensity sounds, specifically listening to music. In particular, virtually all teenagers use personal MP3 devices and nearly all hand-held electronic games are equipped with ear buds. It is difficult for a parent to monitor the level of sound children are exposed to. Therefore, the best and most effective mode of prevention of tinnitus in children is proper education relative to excessive sound exposure, as well as monitoring by parents or other caregivers.

Tips to lessen the severity of tinnitus

• Avoid exposure to loud sounds and noises.
• Get your blood pressure checked. If it is high, get your doctor’s help to control it.
• Decrease your intake of salt. Salt impairs blood circulation.
• Avoid stimulants such as coffee, tea, cola, and tobacco.
• Exercise daily to improve your circulation.
• Get adequate rest and avoid fatigue.
• Stop worrying about the noise. Recognize your head noise as an annoyance and learn to ignore it as much as possible. It is part of you.

What can help me cope?

Concentration and relaxation exercises can help to control muscle groups and circulation throughout the body. The increased relaxation and circulation achieved by these exercises can reduce the intensity of tinnitus in some patients.

Masking a head noise with a competing sound at a constant low level, such as a ticking clock or radio static (white noise), may make it less noticeable. Tinnitus is usually more bothersome in quiet surroundings. Products that generate white noise are available through catalogs and specialty stores.

Hearing aids may reduce head noise while you are wearing them and sometimes cause the noise to go away temporarily. If you have a hearing loss, it is important not to set the hearing aid at excessively loud levels, as this can worsen the tinnitus in some cases. However, a thorough trial before purchase of a hearing aid is advisable if your primary purpose is the relief of tinnitus.

Tinnitus maskers can be combined within hearing aids. They emit a competitive but pleasant sound that can distract you from head noise. Some people find that a tinnitus masker may even suppress the head noise for several hours after it is used, but this is not true for all users.

Insight for hearing-impaired travelers

• What are common problems?
• What arrangements can be made?
• How should hearing aids be handled when traveling?
• and more…

Travel is an important aspect of our lives. Whether for business or vacation, traveling can be as stressful as it is enjoyable. And for more than 20 million people in the U.S. with hearing loss, travel can be especially difficult.

What are common problems?

• Inability to hear or understand airline boarding and in-flight announcements;
• Difficulty making reservations;
• Inability to hear hotel room telephones, someone knocking on the door, or warning signals such as smoke alarms;
• Difficulty using public telephones, hotel phones, cell phones etc.;
• Inability to hear or understand scheduled events such as planned activities, tours, museum lectures, and live performances;
• Lack of oral and/or sign language interpreters;
• Lack of accommodations for hearing dogs.

What arrangements can be made?

• Try to make all travel arrangements in advance. Once transportation arrangements have been made, request written confirmation to ensure that information is correct. Always inform the ticket representative that you are hearing-impaired.
• If possible, meet with a travel agent to allow the opportunity for lip reading, or if necessary, written exchange to help confirm travel plans. Agents can contact airlines, hotels, and attractions to make necessary reservations.
• Travel information and reservation services are also available on the internet. Be sure to print copies of important information such as confirmation numbers, reservations, and maps.
• It is important to arrive early at the airport, bus terminal, or train station. Tell the agent at the boarding gate that you are hearing-impaired and need to be notified in person when it’s time to board.
• Confirm the flight number and destination before boarding.
• Inform the flight attendant that you are hearing-impaired and request that any in-flight announcements be communicated to you in person.

Many major airlines and transportation companies have Telecommunications Device for the Deaf (TDD) services to assist passengers. Hand-held personal communication devices provide the ability to send and receive text messages without the need to access public resources.

Is telephone assistance available?

All public telephones should now have a “blue grommet” attachment to the handset indicating it is compatible with the “T” switch in hearing aids. Some public phones have an amplifying headset. Or you may purchase a pocket amplifier from your audiologist or hearing aid dispenser. Cellular phones have solved many of these problems. All manufacturers have models that are also compatible with your hearing aid. You can search the internet by typing in “HAC phones” (hearing aid compatible) to get more information.

What other devices are helpful?

There are many visual alert systems and listening devices than can be useful while traveling.

• Telephone amplifiers and induction couplers can be attached to public or hotel phones and can help increase the volume of the telephone. Induction couplers also make the telephone compatible with your hearing aid telecoil. Telephone manufacturers produce handsets such as the G6 and G66 which plug easily into any modular telephone. Using your own compatible cellular phone, however, not only eliminates these problems, but is also less expensive.
• There are small portable visual alert systems available that flash light when the telephone rings or fire alarm sounds. These can be transported and easily installed in hotel rooms. In the U.S. they should be provided if you ask.
• FM listening systems can provide direct amplification in large areas using radio frequency. They can help the hearing-impaired traveler listen to lectures, tours, etc., by simply having the speaker use a transmitter microphone, broadcasting the presentation over the air waves to the receiver.
• Another technology is portable infrared systems which can be used with hotel televisions and radios. These transmit sound via invisible infrared light to a listener’s receiver.
• Portable wake-up alarms can be used to flash a light or vibrate a bed or pillow. Cellular phones can also work as a vibrating alarm.
• There are portable TV band radios that can be tuned to compatible TV channels and listened to through an earphone. You can set the volume to suit yourself and watch TV without disturbing others.

How should hearing aids be handled when traveling?

If you wear a hearing aid, be sure to pack extra batteries and tubing. These may be difficult to obtain in some places. It would be wise to take a dehumidifier for drying your hearing aids each night to prevent moisture problems, especially if your destination has a warm, humid climate.

There are many things that hearing-impaired people can do to help make their travels safe, comfortable, and enjoyable. Travel does not have to be avoided because of hearing loss. So plan ahead, inform your fellow travelers, transportation hosts, and hotel clerks that you are hearing-impaired, obtain any necessary devices—and enjoy yourself!

Lodging

• Carry printed copies of lodging reservations, dates, and prices.
• Inform the receptionist at the front desk that you are hearing-impaired. This is very important in case of emergency.
• Certain major hotel chains now provide visual alerting devices to help the hearing-impaired traveler recognize the ring of the telephone, a knock on the door, or a fire/emergency alarm. It may be advisable, however, to contact the hotel in advance to make the necessary arrangements.

Inquire what resources are available for using the internet and e-mail.  Does the hotel provide wireless or wired access to the internet?  Do you need to bring your own laptop?  Is there a business office you can use for these purposes?

What Is Voice?

“Voice” is the sound made by vibration of the vocal cords caused by air passing out through the larynx bringing the cords closer together. Your voice is an extremely valuable resource and is the most commonly used form of communication. Our voice is invaluable for both our social interaction as well as for most people’s occupation. Proper care and use of your voice improves the likelihood of having a healthy voice for your entire lifetime.

How Do I Know If I Have A Voice Problem?

Voice problems occur with a change in the voice, often described as hoarseness, roughness, or a raspy quality. People with voice problems often complain about or notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use. Other voice problems may accompany a change in singing ability that is most notable in the upper singing range. A more serious problem is indicated by spitting up blood or when blood is present in the mucus. These require prompt attention by an otolaryngologist.

What Is The Most Common Cause Of A Change In Your Voice?

Voice changes sometimes follow an upper respiratory infection lasting up to two weeks. Typically the upper respiratory infection or cold causes swelling of the vocal cords and changes their vibration resulting in an abnormal voice. Reduced voice use (voice rest) typically improves the voice after an upper respiratory infection, cold, or bronchitis. If voice does not return to its normal characteristics and capabilities within two to four weeks after a cold, a medical evaluation by an ear, nose, and throat specialist is recommended. A throat examination after a change in the voice lasting longer than one month is especially important for smokers. (Note: A change in voice is one of the first and most important symptoms of throat cancer. Early detection significantly increases the effectiveness of treatment.)

Six Tips To Identify Voice Problems

Ask yourself the following questions to determine if you have an unhealthy voice:

• Has your voice become hoarse or raspy?
• Does your throat often feel raw, achy, or strained?
• Does talking require more effort?
• Do you find yourself repeatedly clearing your throat?
• Do people regularly ask you if you have a cold when in fact you do not?
• Have you lost your ability to hit some high notes when singing?

A wide range of problems can lead to changes in your voice. Seek out a physician’s care when voice problems persist.

Hoarseness or roughness in your voice is often caused by a medical problem. Contact an otolaryngologist-head and neck surgeon if you have any sustained changes to your voice.

It may come as a surprise to you the variety of medical conditions that can lead to voice problems. The most common causes of hoarseness and vocal difficulties are outlined below. If you become hoarse frequently or notice voice change for an extended period of time, please see your Otolaryngologist (Ear, Nose, and Throat doctor) for an evaluation.

Acute Laryngitis

Acute laryngitis is the most common cause of hoarseness and voice loss that starts suddenly. Most cases of acute laryngitis are caused by a viral infection that leads to swelling of the vocal cords. When the vocal cords swell, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to rest or reduce your voice use. Serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis. Since most acute laryngitis is caused by a virus, antibiotics are not effective. Bacterial infections of the larynx are much rarer and often are associated with difficulty breathing. Any problems breathing during an illness warrants emergency evaluation.

Chronic Laryngitis

Chronic laryngitis is a non-specific term and an underlying cause should be identified. Chronic laryngitis can be caused by acid reflux disease, by exposure to irritating substances such as smoke, and by low grade infections such as yeast infections of the vocal cords in people using inhalers for asthma. Chemotherapy patients or others whose immune system is not working well can get these infections too.

Laryngopharyngeal Reflux Disease (LPRD)

Reflux of stomach juice into the throat can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a lump in the throat sensation, or throat pain are common symptoms of stomach acid irritation of the throat. Please be aware that LPRD can occur without any symptoms of frank heartburn and regurgitation that traditionally accompany gastro esophageal reflux disease (GERD).

Voice Misuse and Overuse

Speaking is a physical task that requires coordination of breathing with the use of several muscle groups. It should come as no surprise that, just like in any other physical task, there are efficient and inefficient ways of using your voice. Excessively loud, prolonged, and/or inefficient voice use can lead to vocal difficulties, just like improper lifting can lead to back injuries. Excessive tension in the neck and laryngeal muscles, along with poor breathing technique during speech leads to vocal fatigue, increased vocal effort, and hoarseness. Voice misuse and overuse puts you at risk for developing benign vocal cord lesions (see below) or a vocal cord hemorrhage.

Common situations that are associated with voice misuse:

• Speaking in noisy situations
• Excessive cellular phone use
• Telephone use with the handset cradled to the shoulder
• Using inappropriate pitch (too high or too low) when speaking
• Not using amplification when publicly speaking
• Benign Vocal Cord Lesions

Benign non-cancerous growths on the vocal cords are most often caused by voice misuse or overuse, which causes trauma to the vocal cords. These lesions (or “bumps”) on the vocal cord(s) alter vocal cord vibration and lead to hoarseness. The most common vocal cord lesions are nodules, polyps, and cysts. Vocal nodules (also known as nodes or singer’s nodes) are similar to “calluses” of the vocal cords. They occur on both vocal cords opposite each other at the point of maximal wear and tear, and are usually treated with voice therapy to eliminate the vocal trauma that is causing them. Contrary to common myth, vocal nodules are highly treatable and intervention leads to improvement in most cases. Vocal cord polyps and cysts are the other common benign lesions. These are sometimes related to voice misuse or overuse, but can also occur in people who don’t use their voice improperly. These types of problems typically require microsurgical treatment for cure, with voice therapy employed in a combined treatment approach in some cases.

Vocal Cord Hemorrhage

If you experience sudden loss of voice following yelling, shouting, or other strenuous vocal tasks, you may have developed a vocal cord hemorrhage. Vocal cord hemorrhage results when one of the blood vessels on the surface of the vocal cord ruptures and the soft tissues of the vocal cord fill with blood. It is considered a vocal emergency and is treated with absolute voice rest until the hemorrhage resolves. If you lose your voice after strenuous voice use, see your Otolaryngologist as soon as possible.

Vocal Cord Paralysis and Paresis

Hoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common neurological condition that affects the larynx is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rare and is usually manifested by noisy breathing or difficulty getting enough air while breathing or talking. When one vocal cord is paralyzed or weak, voice is usually the problem rather than breathing. One vocal cord can become paralyzed or weakened (paresis) from a viral infection of the throat, after surgery in the neck or chest, from a tumor or growth along the laryngeal nerves, or for unknown reasons. Vocal cord paralysis typically presents with a soft and breathy voice. Many cases of vocal cord paralysis will recover within several months. In some cases however, the paralysis will be permanent, and may require active treatment to improve the voice. Treatment choice depends on the nature of the vocal cord paralysis, the degree of vocal impairment, and the patient’s vocal needs. While we are not able to make paralyzed vocal cords move again, there are good treatment options for improving the voice. One option includes surgery for unilateral vocal cord paralysis that repositions the vocal cord to improve contact and vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to accomplish this. Voice therapy may be used before or after surgical treatment of the paralyzed vocal cords, or it can also be used as the sole treatment. (For more information, see Vocal Cord Paralysis Fact Sheet.)

Laryngeal Cancer

Throat cancer is a very serious condition requiring immediate medical attention. Chronic hoarseness warrants evaluation by an otolaryngologist to rule out laryngeal cancer. It is important to remember that prompt attention to changes in the voice facilitate early diagnosis. Remember to listen to your voice because it might be telling you something. Laryngeal cancer is highly curable if diagnosed in its early stages. (For more information, see Laryngeal Cancer Fact Sheet.)

Who is in day care?

The 2000 census reported that of among the nation’s 19.6 million preschoolers, grandparents took care of 21 percent, 17 percent were cared for by their father (while their mother was employed or in school); 12 percent were in day care centers; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in nursery schools or preschools. More than one-third of preschoolers (7.2 million) had no regular child-care arrangement and presumably were under maternal care.

Day care establishments are defined as those primarily engaged in care of infants or children, or in providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary function or major element. Some may or may not have substantial educational programs, and some may care for older children when they are not in school.

What are your child’s risks of being exposed to a contagious illness at a day care center?

Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centers do pose some degree of an increased health risk for children, because of the exposure to other children who may be sick.

When your child is in a day care center, the risk is greatest for viral upper respiratory infection (affecting the nose, throat, mouth, voice box) and the common cold, ear infections, and diarrhea. Some studies have tried to link asthma to day care. Other studies suggest that being exposed to all the germs in day care actually IMPROVES your child’s immune system.

Studies suggest that the average child will get eight to ten colds per year, lasting ten – 14 days each, and occurring primarily in the winter months. This means that if a child gets two colds from March to September, and eight colds from September to March, each lasting two weeks, the child will be sick more than over half of the winter.

At the same time, children in a day care environment, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media annually. This is four times the incidence of children staying at home.

When should your child remain at home instead of day care or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

• When your child has a temperature higher than 100 degrees, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
• When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home.
• Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
• If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?

The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:

• Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.
• Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:
• Look for otitis (inflammation) in the ear. This is an indicator of future ear infections.
• Review with you any allergies your child may have. This will assist in determining if the diet offered at the day care center may be harmful to your child.
• Examine the child’s tonsils for infection and size. Enlarged tonsils could indicate that your child may not be getting a healthy sleep at night, resulting in a tired condition during the day.

Alert the day care center manager when your child is ill, and include the nature of the illness.

Day care has become a necessity for millions of families. Monitoring the health of your own child is key to preventing unnecessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

A variety of medications can have a negative effect on the voice. These include prescription medications, over-the-counter medications, and herbal remedies. If you feel that your medication is adversely affecting your voice, consult your physician.

Vocal cords and dryness

Vocal cords function best when they are well lubricated, just like your automobile engine. Dehydrated vocal cords do not vibrate as efficiently as moist ones, leading to vocal difficulties. Many medications can have a drying effect; they include:

• Decongestants and remedies for nose/sinus congestion: Pseudoephedrine is a medication that is present in many over the counter and prescription cold remedies. Minimize the use of these medications as you are able.
• Antihistamines: These are present in many cold and allergy preparations. Some of the newer generation antihistamines tend to be less drying than traditional ones, and a pharmacist can guide you on this.
• Diuretics: Diuretics, commonly used to treat high blood pressure, increase fluid output from the body as urine, and can dry your mucous membranes. Do not discontinue diuretic medications without the advice of your physician.
• Other medications that can be drying: Antidepressants, medications for Parkinson’s disease, and other neurological diseases.

Inflammation and hoarseness of the vocal cords

Commonly prescribed inhaled steroid medications for asthma frequently cause hoarseness. The steroid and/or the carrier substances within the inhaled preparation can be irritating and can lead to a yeast infection on the vocal cords in some cases. If your physician recommends that you take an inhaled steroid medication for your asthma, make sure to follow the manufacturer’s recommendations closely with regards to use. You should rinse your mouth and gargle with water after you use the medication. Use a spacer if recommended. If you notice that you become hoarse while using an inhaled steroid, see your otolaryngologist. Commonly, your symptoms can be treated quite easily. If you have persistent problems with your voice because of your inhaled steroid, see your primary care physician or pulmonologist.

Several medications classes that relax muscles can lead to vocal difficulties by making acid reflux worse. Acid reflux is a common cause of hoarseness and vocal difficulties, and the following medications may make acid reflux worse by relaxing your esophageal sphincter muscles:

• Antihypertensives (medications for high blood pressure): calcium channel blockers, beta blockers
• Muscle relaxants

Other medications and associated conditions that may affect the voice include:

• Angiotensin-converting-enzyme (ACE) inhibitors (blood pressure medication) may induce a cough or excessive throat clearing in as many as 10 percent of patients. Coughing or excessive throat clearing can contribute to vocal cord lesions.
• Oral contraceptives contain estrogen and may cause fluid retention (edema) in the vocal cords.
• Estrogen replacement therapy post-menopause may have a positive or negative effect on the voice.
• Testosterone and other androgen-like hormones: These medications deepen the voice; accordingly, women should consult with their physician carefully before starting this regimen. Permanent voice changes can occur with their use.
• An inadequate level of thyroid replacement medication in patients with hypothyroidism.
• Anticoagulants (blood thinners) may increase chances of vocal cord hemorrhage or polyp formation in response to trauma.
• Herbal medications are not harmless and should be taken with caution. Many have unknown side effects that include voice disturbance.

What is GERD?

Gastroesophageal reflux disease, or GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from “refluxing” or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid to move up the esophagus.

When stomach acid touches the sensitive tissue lining the esophagus, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn.

Occasional heartburn is normal. However, if heartburn becomes chronic, occurring more than twice a week, you may have GERD. Left untreated, GERD can lead to more serious health problems.

Who gets GERD?

Anyone can have GERD. Women, men, infants and children can all experience this disorder. Overweight people and pregnant women are particularly susceptible because of the pressure on their stomachs. Recent studies indicate that GERD may often be overlooked in infants and children. In infants and children, GERD can cause repeated vomiting, coughing, and other respiratory problems such as sore throat and ear infections. Most infants grow out of GERD by the time they are one year old.

Tips to Prevent GERD

• Do not drink alcohol
• Lose weight
• Quit smoking
• Limit problem foods such as:
  
  • Caffeine
  • Carbonated drinks
  • Chocolate
  • Peppermint
  • Tomato and citrus foods
  • Fatty and fried foods
• Wear loose clothing
• Eat small meals and slowly

What are the symptoms of GERD?

The symptoms of GERD may include persistent heartburn, acid regurgitation, and nausea. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be sever enough to mimic the pain of a heart attack, hoarseness in the morning, or trouble swallowing. Some people may also feel like they have food stuck in their throat or like they are choking. GERD can also cause a dry cough and bad breath.

What are the complications of GERD?

GERD can lead to other medical problems such as ulcers and strictures of the esophagus (esophagitis), cough, asthma, throat and laryngeal inflammation, inflammation and infection of the lungs, and collection of fluid in the sinuses and middle ear. GERD can also cause a change in the esophageal lining called Barrett’s esophagus, which is a serious complication that can lead to cancer.

What causes GERD?

Physical causes of GERD can include: a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach.
Lifestyle factors that contribute to GERD include:

• alcohol use
• obesity
• pregnancy
• smoking
• Certain foods can contribute to GERD, such as:
  
  • citrus fruits
  • chocolate
  • caffeinated drinks
  • fatty and fried foods
  • garlic and onions
  • mint flavorings (especially peppermint)
  • spicy foods
  • tomato-based foods, like spaghetti sauce, chili, and pizza

When should I see a doctor?

If you experience heartburn more than twice a week, frequent chest pains after eating, trouble swallowing, persistent nausea, and cough or sore throat unrelated to illness, you may have GERD. For proper diagnosis and treatment, you should be evaluated by a physician.

How can my ENT help?

Otolaryngologists, or ear, nose, and throat doctors, and have extensive experience with the tools that diagnose GERD and they are specialists in the treatment of many of the complications of GERD, including: sinus and ear infections, throat and laryngeal inflammation, Barrett’s esophagus, and ulcerations of the esophagus.

How is GERD diagnosed?

GERD can be diagnosed or evaluated by clinical observation and the patient’s response to a trial of treatment with medication. In some cases other tests may be needed including: an endoscopic examination (a long tube with a camera inserted into the esophagus), biopsy, x-ray, examination of the throat and larynx, 24 hour esophageal acid testing, esophageal motility testing (manometry), emptying studies of the stomach, and esophageal acid perfusion (Bernstein test). Endoscopic examination, biopsy, and x-ray may be performed as an outpatient in a hospital setting. Light sedation may be used for endoscopic examinations.

While most people with GERD respond to a combination of lifestyle changes and medication. Occasionally, surgery is recommended.

Lifestyle changes include: losing weight, quitting smoking, wearing loose clothing around the waist, raising the head of your bed (so gravity can help keep stomach acid in the stomach), eating your last meal of the day three hours before bed, and limiting certain foods such as spicy and high fat foods, caffeine, alcohol.

Medications your doctor may prescribe for GERD include: antacids (such as Tums, Rolaids, etc.), histamine antagonists (H2 blockers such as Tagamet,), proton pump inhibitors (such as Prilosec, Prevacid, Aciphex, Protonix, and Nexium), pro-motility drugs (Reglan), and foam barriers (Gaviscon). Some of these products are now available over-the-counter and do not require a prescription.

Surgical treatment includes: fundoplication, a procedure where a part of the stomach is wrapped around the lower esophagus to tighten the LES, and endoscopy, where hand stitches or a laser is used to make the LES tighter.

Are there long-term health problems associated with GERD?

GERD may damage the lining of the esophagus, thereby causing inflammation (esophagitis), although usually it does not. Barrett’s esophagus is a pre-cancerous condition that requires periodic endoscopic surveillance for the development of cancer.

For more information on GERD or to find an otolaryngologist near you, visit www.entnet.org.

Does your child have allergies? Allergies can cause many ear, nose, and throat symptoms in children, but allergies can be difficult to separate from other causes. Here are some clues that allergy may be affecting your child.

Children with nasal allergies often have a history of other allergic tendencies (or atopy). These may include early food allergies or atopic dermatitis in infancy. Children with nasal allergies are at higher risk for developing asthma.

Nasal allergies can cause sneezing, itching, nasal rubbing, nasal congestion, and nasal drainage. Usually, allergies are not the primary cause of these symptoms in children under four years old. In allergic children, these symptoms are caused by exposure to allergens (mostly pollens, dust, mold, and dander). Observing which time of year or in which environments the symptoms are worse can be important clues to share with your doctor.

Ear infections:

One of children’s most common medical problems is otitis media, or middle ear infection. In most cases, allergies are not the main cause of ear infections in children under two years old. But in older children, allergies may play role in ear infections, fluid behind the eardrum, or problems with uncomfortable ear pressure. Diagnosing and treating allergies may be an important part of healthy ears.

Sore throats:

Allergies may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats, and a husky voice.

Sleep disorders:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis and perennial (year-round) allergic rhinitis. Nasal congestion can contribute to sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Fatigue is one of the most common, and most debilitating, allergic symptoms. Fatigue not only affects children’s quality of life, but has been shown to affect school performance.

Pediatric sinusitis:

Allergies should be considered in children who have persistent or recurrent sinus disease. Depending on the age of your child, their individual history, and an exam, your doctor should be able to help you decide if allergies are likely. Some studies suggest that large adenoids (a tonsil-like tissue in the back of the nose) are more common in allergic children.

There are many different reasons why your voice may sound hoarse or abnormal from time to time, and some of these reasons are things that you can not really control. An example would be catching a common cold virus that causes laryngitis. Sure, you can wash your hands frequently and try to avoid people with colds, but virtually everyone catches a cold with a bit of laryngitis now and again. What you probably did not know is that there are steps you can take to prevent many voice problems. The following steps are helpful for anyone who wants to keep their voice healthy, but are particularly important for people who have an occupation, such as teaching, that is heavily voice-related.

Key Steps for Keeping Your Voice Healthy

• Drink plenty of water. Moisture is good for your voice. Hydration helps to keep thin secretions flowing to lubricate your vocal cords. Drink plenty (up to eight 8-ounce glasses is a good minimum target) of non-caffeinated, non-alcoholic beverages throughout the day.
• Try not to scream or yell. These are abusive practices for your voice, and put great strain on the lining of your vocal cords.
• Warm up your voice before heavy use. Most people know that singers warm up their voices before a performance, yet many don’t realize the need to warm up the speaking voice before heavy use, such as teaching a class, preaching, or giving a speech. Warm-ups can be simple, such as gently gliding from low to high tones on different vowel sounds, doing lip trills (like the motorboat sound that kids make), or tongue trills.
• Don’t smoke. In addition to being a potent risk factor for laryngeal (voice box) cancer, smoking also causes inflammation and polyps of the vocal cords that can make the voice very husky, hoarse, and weak.
• Use good breath support. Breath flow is the power for voice. Take time to fill your lungs before starting to talk, and don’t wait until you are almost out of air before taking another breath to power your voice.
• Use a microphone. When giving a speech or presentation, consider using a microphone to lessen the strain on your voice.
• Listen to your voice. When your voice is complaining to you, listen to it. Know that you need to modify and decrease your voice use if you become hoarse in order to allow your vocal cords to recover. Pushing your voice when it’s already hoarse can lead to significant problems. If your voice is hoarse frequently, or for an extended period of time, you should be evaluated by an Otolaryngologist (Ear, Nose, and Throat physician.)

Laryngeal cancer is not as well known by the general public as some other types of cancer, yet it is not a rare disease. The American Cancer Society estimates that in 2005 almost 10,000 new cases of laryngeal cancer will be diagnosed, and close to 3,800 people will die from laryngeal cancer in the United States. Even for survivors, the consequences of laryngeal cancer can be severe with respect to voice, breathing, or swallowing. It is fundamentally a preventable disease though, since the primary risk factors for laryngeal cancer are associated with modifiable behaviors.

Risk Factors Associated With Laryngeal Cancer

Development of laryngeal cancer is a process that involves many factors, but approximately 90 percent of head and neck cancers occur after exposure to known carcinogens (cancer causing substances). Chief among these factors is tobacco. Over 90 percent of laryngeal cancers are a type of cancer called squamous cell carcinoma (SCCA), and over 95 percent of patients with laryngeal SCCA are smokers. Smoking contributes to cancer development by causing mutations or changes in genes, impairing clearance of carcinogens from the respiratory tract, and decreasing the body’s immune response.

Tobacco use is measured in pack-years, where one pack per day for one year is considered one pack-year. Two pack-years is defined as either one pack per day for two years, or two packs per day for one year (Longer terms of pack years are determined using a similar ratio.) Depending upon the number of pack-years smoked, studies have reported that smokers are about 5 to 35 times more likely to develop laryngeal cancer than non-smokers. It does seem that the duration of tobacco exposure is probably more important overall to cancer causing effect, than the intensity of the exposure.

Alcohol is another important risk factor for laryngeal cancer, and acts as a promoter of the cancer causing process. The major clinical significance of alcohol is that it potentiates the effects of tobacco. Magnitude of this effect is between an additive and a multiplicative one. That is, people who smoke and drink alcohol have a combined risk that is greater than the sum of the individual risks. The American Cancer Society recommends that those who drink alcoholic beverages should limit the amount of alcohol they consume, with one drink per day considered a limited alcohol exposure.

Other risk factors for laryngeal cancer include certain viruses, such as human papilloma virus (HPV), and likely acid reflux. Vitamin A and beta-carotene may play a protective role.

Signs and Symptoms of Laryngeal Cancer

Signs and symptoms of laryngeal cancer include: progressive or persistent hoarseness, difficulty swallowing, persistent sore throat or pain with swallowing, difficulty breathing, pain in the ear, or a lump in the neck. Anyone with these signs or symptoms should be evaluated by an Otolaryngologist (Ear, Nose and Throat Doctor). This is particularly important for people with risk factors for laryngeal cancer.

Treatment of Laryngeal Cancer

The primary treatment options for laryngeal cancer include surgery, radiation therapy, chemotherapy, or a combination of these treatments. Remember that this is a preventable disease in the vast majority of cases, because the main risk factors are associated with modifiable behaviors. Do not smoke and do not abuse alcohol!

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease, or GERD.

Sometimes, acidic stomach contents will reflux all the way up the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES), and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up, and in most infants, it is a normal occurrence that resolves in the first year. Only infants who have associated breathing or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a “lump” or something “stuck” in the throat, which does not go away despite multiple swallowing attempts to clear the “lump.” Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This is known as “laryngospasm.”

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist, such as an otolaryngologist (ear-nose-throat doctor). Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

• Chronic cough
• Hoarseness
• Noisy breathing (stridor)
• Croup
• Reactive airway disease (asthma)
• Sleep-disordered breathing (SDB)
• Spit-up
• Feeding difficulty
• Turning blue (cyanosis)
• Aspiration
• Pauses in breathing (apnea)
• Apparent life-threatening event (ALTE)
• Failure to thrive (a severe deficiency in growth, where an infant or child is less than 5 percentile, compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long-term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction. The latter can cause recurrent ear infections, or persistent middle ear fluid, and even symptoms of sinusitis. The direct relationship between LPR and the latter mentioned problems are currently being researched.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician getting a referral to see an otolaryngologist for evaluation. In the office, he or she may look directly at the voice box and related structures with a flexible scope or order a 24-hour pH monitoring of the esophagus. The otolaryngologist may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box (direct laryngoscopy), trachea and bronchi (bronchoscopy), and esophagus (esophagoscopy). LPR in infants and children remains a diagnosis of clinical judgment, based on history given by the parents, the physical exam, and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment is usually based on successful treatment of GER. In infants and children, basic recommendations may include use of smaller and more frequent feedings, thickening of the food/liquid, and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications, including H2 blockers or proton pump inhibitors, may be necessary. Similar to adults, children with severe symptoms who fail medical treatment or have diagnostic evaluations demonstrating anatomical abnormalities, may require surgical intervention.

The term vocal cord lesion (physicians call them vocal “fold” lesions) refers to a group of noncancerous (benign), abnormal growths (lesions) within or along the covering of the vocal cord. Vocal cord lesions are one of the most common causes of voice problems and are generally seen in three forms; nodules, polyps, and cysts.

Vocal Cord Nodules (also called Singer’s Nodes, Screamer’s Nodes)

Vocal cord nodules are also known as “calluses of the vocal fold.” They appear on both sides of the vocal cords, typically at the midpoint, and directly face each other. Like other calluses, these lesions often diminish or disappear when overuse of the area is stopped.

Vocal Cord Polyp

A vocal cord polyp typically occurs only on one side of the vocal cord and can occur in a variety of shapes and sizes. Depending upon the nature of the polyp, it can cause a wide range of voice disturbances.

Vocal Cord Cyst

A vocal cord cyst is a firm mass of tissue contained within a membrane (sac). The cyst can be located near the surface of the vocal cord or deeper, near the ligament of the vocal cord. As with vocal cord polyps and nodules, the size and location of vocal cord cysts affect the degree of disruption of vocal cord vibration and subsequently the severity of hoarseness or other voice problem. Surgery followed by voice therapy is the most commonly recommended treatment for vocal cord cysts that significantly alter and/or limit voice.

Reactive Vocal Cord Lesion

A reactive vocal cord lesion is a mass located opposite an existing vocal cord lesion, such as a vocal cord cyst or polyp. This type of lesion is thought to develop from trauma or repeated injury caused by the lesion on the opposite vocal cord. A reactive vocal cord lesion will usually decrease or disappear with voice rest and therapy.

What Are The Causes Of Benign Vocal Cord Lesions?

The exact cause or causes of benign vocal cord lesions is not known. Lesions are thought to arise following “heavy” or traumatic use of the voice, including voice misuse such as speaking in an improper pitch, speaking excessively, screaming or yelling, or using the voice excessively while sick.

What Are The Symptoms Of Benign Vocal Cord Lesions?

A change in voice quality and persistent hoarseness are often the first warning signs of a vocal cord lesion. Other symptoms can include:

• Vocal fatigue
• Unreliable voice
• Delayed voice initiation
• Low, gravelly voice
• Low pitch
• Voice breaks in first passages of sentences
• Airy or breathy voice
• Inability to sing in high, soft voice
• Increased effort to speak or sing
• Hoarse and rough voice quality
• Frequent throat clearing
• Extra force needed for voice
• Voice “hard to find”

When a vocal cord lesion is present, symptoms may increase or decrease in degree, but will persist and do not go away on their own.

How Is The Diagnosis Of A Benign Vocal Cord Lesion Made?

Diagnosis begins with a complete history of the voice problem and an evaluation of speaking method. The otolaryngologist will perform a careful examination of the vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through the patient’s mouth that allows the examiner to view the voice box (images are often recorded on video). The stroboscopic light source allows the examiner to assess vocal fold vibration. Sometimes a second exam will follow a trial of voice rest to allow the otolaryngologist an opportunity to assess changes in the vocal cord lesion.

Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication’s side effects, and hormonal imbalances. An evaluation of these conditions is an important diagnostic factor.

How Are Benign Vocal Cord Lesions Treated?

The most common treatment options for benign vocal cord lesions include: voice rest, voice therapy, singing voice therapy, and phonomicrosurgery, a type of surgery involving the use of microsurgical techniques and instruments to treat abnormalities on the vocal cord.

Treatment options can vary according to the degree of voice limitation and the exact voice demands of the patient. For example, if a professional singer develops benign vocal cord lesions and undergoes voice therapy, which improves speaking but not singing voice, then surgery might be considered to restore singing voice. Successful and appropriate treatment is highly individual and includes consideration of the patient’s vocal needs and the clinical judgment of the otolaryngologist.

Today in the United States, studies estimate that 34 percent of U.S. adults are overweight and an additional 31 percent (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13 percent of Americans were obese, and in 1980 15 percent were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15 percent of 6- to 11-year-olds and more than 15 percent of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight?”

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

• Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
• Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
• Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. “Morbid” is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II Diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea, and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem, and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose, and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose, and throat conditions that are common in obese children, such as:

Sleep apnea:

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea-hypopnea is slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea-obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated.” Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections:

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity, and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies:

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose, and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that:

Morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care, and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells, and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

Who is an Occupational or Professional Voice User?

An occupational or professional voice user is anyone whose voice is essential to their job. We are all accustomed to thinking of singers, actors, actresses, and broadcast personalities as professional voice users. Indeed, special or unique qualities of the voice are often the essential feature of their careers. But what about other occupational voice users?

Teachers, clergy, salespeople, courtroom attorneys, telemarketers, and receptionists are also people for whom spoken communication is an essential part of what they do, and there are countless other professions that rely heavily on the voice. In spite of this era of email and Internet communications, we can’t really imagine an effective classroom, pulpit, or courtroom without voice. Can you imagine the difficulties of a physician conveying sensitive or complex information to a patient or colleague, or a business executive conducting a meeting without voice? Once you pause to consider a world without voice communications, you realize that voice is crucial to many professions.

Why is the Voice Important?

Voice is something that is often taken for granted. Many people, including many occupational voice users, don’t pay attention to their voice until they develop a significant problem with it. These voice problems then have an adverse effect upon their ability to do their job. Consider, for example, a school teacher. Arguably, this is the most vocally demanding profession. Teachers are using their voices constantly, often in noisy rooms with poor acoustics. One recent 2004 research article found that 11 percent of teachers participating in the study reported a current voice problem. Non-teachers expressing voice problems comprised only 6.2 percent of the participants.

A similar ratio was evident when participants were asked about ever having a voice disorder in their lifetime. Teachers reported an incidence of 57.7 percent, while non-teachers reported a 28.8 percent incident rate. In another study, about 20 percent of teachers had missed work due to their voice, while only 4 percent of non-teachers had missed a day due a voice related ailment. It is thus very clear from the medical literature that high voice demands in the workplace can have health consequences for the individual, and productivity consequences for the employer. Research is ongoing into strategies to enhance the vocal health of individuals in professions with high voice demands.

What can be done about these issues?

As with many ailments, awareness is key. First, people must be made aware of voice-related occupations. A person may not know that they are in such a profession until a voice problem brings the issue to the forefront.

Secondly, one needs to be aware that high voice demand occupations do place you at greater risk for developing vocal difficulties, and that you have to listen to your own voice in order to recognize when you are developing problems. Do not accept hoarseness as part of the job. Be aware that there are steps you can take to help prevent voice problems. (For more information, see Maintaining a Healthy Voice Fact Sheet.)

Finally, know that proper evaluation and treatment can take care of most voice-related problems, and can set you up to succeed at even the most demanding voice-related occupation. If you listen to your voice and find that it is complaining to you, seek out your local Otolaryngologist (Ear, Nose and Throat Doctor) for an evaluation and treatment recommendations.

Voice problems usually are associated with hoarseness (also known as roughness), instability, or problems with voice endurance. If you are unsure if you have an unhealthy voice, ask yourself the following:

• Has your voice become hoarse or raspy?
• Does your throat often feel raw, achy or strained?
• Has it become an effort to talk?
• Do you repeatedly clear your throat?
• Do people regularly ask you if you have a cold when in fact you do not?
• Have you lost your ability to hit some high notes when singing?

Voice problems arise from a variety of sources including voice overuse or misuse, cancer, infection, or injury. Here are steps that can be taken to prevent voice problems and maintain a healthy voice:

Drink water (stay well hydrated): Keeping your body well hydrated by drinking plenty of water each day (6-8 glasses) is essential to maintaining a healthy voice. The vocal cords vibrate extremely fast even with the most simple sound production; remaining hydrated through water consumption optimizes the throat’s mucous production, aiding vocal cord lubrication. To maintain sufficient hydration avoid or moderate substances that cause dehydration. These include alcohol and caffeinated beverages (coffee, tea, soda). And always increase hydration when exercising.

Do not smoke: It is well known that smoking leads to lung or throat cancer. Primary and secondhand smoke that is breathed in passes by the vocal cords causing significant irritation and swelling of the vocal cords. This will permanently change voice quality, nature, and capabilities.

Do not abuse or misuse your voice: Your voice is not indestructible. In every day communication, be sure to avoid habitual yelling, screaming, or cheering. Try not to talk loudly in locations with significant background noise or noisy environments. Be aware of your background noise—when it becomes noisy, significant increases in voice volume occur naturally, causing harm to your voice. If you feel like your throat is dry, tired, or your voice is becoming hoarse, stop talking.

To reduce or minimize voice abuse or misuse use non-vocal or visual cues to attract attention, especially with children. Obtain a vocal amplification system if you routinely need to use a “loud” voice especially in an outdoor setting. Try not to speak in an unnatural pitch. Adopting an extremely low pitch or high pitch can cause an injury to the vocal cords with subsequent hoarseness and a variety of problems.

Minimize throat clearing: Clearing your throat can be compared to slapping or slamming the vocal cords together. Consequently, excessive throat clearing can cause vocal cord injury and subsequent hoarseness. An alternative to voice clearing is taking a small sip of water or simply swallowing to clear the secretions from the throat and alleviate the need for throat clearing or coughing. The most common reason for excessive throat clearing is an unrecognized medical condition causing one to clear their throat too much. Common causes of chronic throat clearing include gastroesophageal reflux, laryngopharyngeal reflux disease, sinus and/or allergic disease.

Moderate voice use when sick: Reduce your vocal demands as much as possible when your voice is hoarse due to excessive use or an upper respiratory infection (cold). Singers should exhibit extra caution if one’s speaking voice is hoarse because permanent and serious injury to the vocal cords are more likely when the vocal cords are swollen or irritated. It is important to “listen to what your voice is telling you.”

Your voice is an extremely valuable resource and is the most commonly used form of communication. Our voices are invaluable for both our social interaction as well as for most people’s occupation. Proper care and use of your voice will give you the best chance for having a healthy voice for your entire lifetime.

Hoarseness or roughness in your voice is often caused by a medical problem. Contact an otolaryngologist—head and neck surgeon if you have any sustained changes to your voice.

Unfortunately, there may be a time when medical therapy (antibiotics) fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils, causing loud snoring, upper airway obstruction, and other sleep disorders. The best recourse for both these conditions may be removal or reduction of the tonsils and adenoids. The American Academy of Otolaryngology-Head and Neck Surgery recommends that children who have three or more tonsillar infections a year undergo a tonsillectomy; the young patient with a sleep disorder should be a candidate for removal or reduction of the enlarged tonsils.

The tonsillectomy today

The first report of tonsillectomy was made by the Roman surgeon Celsus in 30 AD. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. Today, the scalpel is still the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:

Cold knife (steel) dissection:

Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The procedure requires the young patient to undergo general anesthesia; the tonsils are completely removed with minimal post-operative bleeding.

Electrocautery:

Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400 degrees Celsius) results in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.

Harmonic scalpel:

This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.

Radiofrequency ablation:

Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. The procedure can be performed in an office setting under light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.

Carbon dioxide laser:

Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.

The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in two to five percent of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are adverse to outpatient procedures without sedation.

Microdebrider:

What is a “microdebrider?” The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device.

The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.

Bipolar Radiofrequency Ablation (Coblation):

This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 C°. The advantages of this technique are less pain, faster healing, and less post operative care.

Consult with your specialist regarding the optimum procedure to remove or reduce your child’s tonsils and adenoids.

Tonsillitis refers to inflammation of the pharyngeal tonsils (glands at the back of the throat, visible through the mouth). The inflammation may involve other areas of the back of the throat, including the adenoids and the lingual tonsils (tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent, and chronic tonsillitis, and peritonsillar abscess.

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Due to improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.

Who gets tonsillitis?

Tonsillitis most often occurs in children, but rarely in those younger than two years old. Tonsillitis caused by bacteria (streptococcus species) Streptococcus species typically occurs in children aged 5 to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient’s history often helps identify the type of tonsillitis present (i.e., acute, recurrent, chronic).

What causes tonsillitis?

The herpes simplex virus, Streptococcus pyogenes (GABHS), Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis. (i.e., “strep throat”).

What are the symptoms of tonsillitis?

The type of tonsillitis determines what symptoms will occur.

• Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days, but may last up to two weeks despite therapy.
• Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
• Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical nodes.
• Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).

What happens during the physician visit?

Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history. A physical examination of a young patient with tonsillitis may find:

• Fever and enlarged inflamed tonsils covered by pus.
• Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis (“strep throat”) associated with the presence of palatal petechiae (tiny hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children 5-15 years old.
• Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
• Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
• Signs of dehydration (found by examination of skin and mucosa).
• The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise, and low-grade fever accompany acute tonsillitis.
• A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
• Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.
• Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw, difficulty opening the mouth, and pain referred to the ear may be present in varying severity.

Treatment

Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended. Peritonsillar abscess may need more urgent treatment to drain the abscess.

The tonsils are two clusters of tissue located on both sides of the back of the throat. Adenoids sit high in the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics. The surgery is most often performed on children.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both procedures are often  performed at the same time; hence the surgery is known as a tonsillectomy and adenoidectomy, or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for several hours after surgery for observation. Children with severe obstructive sleep apnea and very young children are usually admitted overnight to the hospital for close monitoring of respiratory status.  An overnight stay may also be required if there are complications such as excessive bleeding, severe vomiting, or low oxygen saturation.

When the tonsillectomy patient comes home

Most children take seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids..Starting immediately after surgery, children may have fluids such as water or apple juice.   Some patients experience nausea and vomiting after the surgery. This usually occurs within the first 24 hours and resolves on its own after the effects of anesthesia wear off. Contact your physician if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).

Eating: Generally, there are no food restrictions after surgery, but some physicians will recommend a soft diet during the recovery period. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed the night of the surgery and for a day or two afterward. Contact your physician if the fever is greater than 102º.

Activity: Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication is no longer required, and the child sleeps through the night. Travel on airplanes or far away from a medical facility  is not recommended for two weeks following surgery.

Breathing: The parent may notice snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is normal. Most scabs fall off in small pieces five to ten days after surgery.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (so called referred pain) and a few may have  pain in the jaw and neck.

Pain control: Your physician will prescribe pain medication for the young patient such as acetaminophen, ibuprofen  acetaminophen with codeine, or acetaminophen with hydrocodone. The pain medication will be in a liquid form or sometimes a rectal suppository will be recommended. Pain medication should be given as prescribed.  Contact your physician if side effects are suspected or if pain is not well-controlled. If you are troubled about any phase of your child’s recovery, contact your physician immediately.

Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box muscles (laryngeal muscles). Paralysis is the total interruption of nerve impulse, resulting in no movement; paresis is the partial interruption of nerve impulse, resulting in weak or abnormal motion of laryngeal muscles. Paresis/paralysis can happen at any age, from birth to advanced age, in males and females, from a variety of causes. The effect on patients may vary greatly, depending on the patient’s use of his or her voice: A mild vocal fold paresis can be the end to a singer’s career, but have only a marginal effect on a computer programmer. If you notice any change in your voice quality, immediately contact an otolaryngologist—head and neck surgeon.

What Nerves Are Involved?

Vocal fold movements are a result of the coordinated contraction of various muscles that are controlled by the brain through a specific set of nerves.

The superior laryngeal nerve (SLN) carries signals to the cricothyroid muscle. Since this muscle adjusts the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in abnormalities in voice pitch and the inability to sing with smooth change to each higher note. Sometimes patients with SLN paresis/paralysis may have a normal speaking voice but an abnormal singing voice.

The recurrent laryngeal nerve (RLN) carries signals to different voice box muscles responsible for opening vocal folds (as in breathing, coughing), closing the folds for vibration during voice use, and closing them during swallowing. The RLN goes into the chest cavity and curves back into the neck until it reaches the larynx. Because the nerve is relatively long and takes a “detour” to the voice box, it is at greater risk for injury from different causes–infections and tumors of the brain, neck, chest, or voice box. It can also be damaged by complications during surgery in the head, neck, or chest, that directly injure, stretch, or compress the nerve. Consequently, the RLN is involved in the majority of cases of vocal fold paresis/paralysis.

What Are the Causes?

The cause of vocal fold paralysis or paresis can indicate whether the disorder will resolve over time or whether it may be permanent. When a reversible cause is present, surgical treatment is not usually recommended, given the likelihood of spontaneous resolution of the problem. Despite advances in diagnostic technology, physicians are unable to detect the cause in about half of all vocal fold paralyses, referred to as idiopathic (due to unknown origins). In these cases, paralysis or paresis might be due to a viral infection affecting the voice box nerves (RLN or SLN), or the vagus nerve, but this cannot be proven in most cases. Known reasons can include:

• Inadvertent injury during surgery: Surgery in the neck (thyroid gland, carotid artery) or in the chest (lungs, esophagus, heart, or large blood vessels) may inadvertently result in RLN paresis or paralysis. The SLN may also be injured during head and neck surgery.
• Complication from endotracheal intubation: Injury to the RLN may occur when breathing tubes are used for general anesthesia or assisted breathing. However, this type of injury is rare, given the large number of operations done under general anesthesia.
• Blunt neck or chest trauma: Any type of penetrating, hard impact on the neck or chest region may injure the RLN; impact to the neck may injure the SLN.
• Tumors of the skull base, neck, and chest: Tumors (both cancerous and non-cancerous) can grow around nerves and squeeze them, resulting in varying degrees of paresis or paralysis.
• Viral infections: Inflammation from infections may directly involve and injure the vagus nerve or its nerve branches to the voice box (RLN and SLN). Systemic illnesses affecting nerves in the body may also affect the nerves to the voice box.

What Are the Symptoms?

Both paresis and paralysis of voice box muscles result in voice changes and may also result in airway problems and swallowing difficulties.

Voice changes: Hoarseness; breathy voice; extra effort on speaking; excessive air pressure required to produce usual conversational voice; and diplophonia (voice sounds like a gargle).

Airway problems: Shortness of breath with exertion, noisy breathing, and ineffective cough.

Swallowing problems: Choking or coughing when swallowing food, drink, or even saliva, and food sticking in throat.

How Is Vocal Fold Paralysis/Paresis Diagnosed?

An otolaryngologist—head and neck surgeon conducts a general examination and then questions you about your symptoms and lifestyle (voice use, alcohol/tobacco use). Examining the voice box will determine whether one or both vocal folds are abnormal, and will help determine the treatment plan.

Laryngeal electromyography (LEMG) measures electrical currents in the voice box muscles that are the result of nerve inputs. Looking at the pattern of the electric currents will indicate whether there is recovery or repair of nerve inputs and the degree of the nerve input problem. During the LEMG test, patients perform a number of tasks that would normally elicit characteristic actions in the tested muscles. Because a wide list of diseases  may cause nerve injury, further tests (blood tests, x-rays, CT scans, etc) are usually required to identify the cause.

What Is the Treatment?

The two treatment strategies to improve vocal function are voice therapy (like physical therapy for large muscle paralysis), and phonosurgery, an operation that repositions and/or reshapes the vocal folds to improve voice function. Voice therapy is normally the first treatment option. After voice therapy, the decision for surgery depends on the severity of the symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for recovery, and the cause of paresis/paralysis, if known.

Insight into the diagnosis, prevention, and treatment

• What are the symptoms of GERD and LPR?
• Who gets GERD or LPR?
• How are GERD and LPR diagnosed and treated?
• and more…

What is GERD?

Gastroesophageal reflux disease, often referred to as GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from “refluxing” or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid and other contents of the digestive tract to move up–to “reflux”–the esophagus.

When stomach acid touches the sensitive tissue lining the esophagus and throat, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn.

In some cases, reflux can be silent, with no heartburn or other symptoms until a problem arises. Almost all individuals have experienced reflux (GER), but the disease (GERD) occurs when reflux happens often over a long period of time.

What is LPR?

During gastroesophageal reflux, the contents of the stomach and upper digestive tract may reflux all the way up the esophagus, beyond the upper esophageal sphincter (a ring of muscle at the top of the esophagus), and into the back of the throat and possibly the back of the nasal airway. This is known as laryngopharyngeal reflux (LPR), which can affect anyone. Adults with LPR often complain that the back of their throat has a bitter taste, a sensation of burning, or something “stuck.” Some patients have hoarseness, difficulty swallowing, throat clearing, and difficulty with the sensation of drainage from the back of the nose (“postnasal drip”). Some may have difficulty breathing if the voice box is affected. Many patients with LPR do not experience heartburn.

In infants and children, LPR may cause breathing problems such as: cough, hoarseness, stridor (noisy breathing), croup, asthma, sleep-disordered breathing, feeding difficulty (spitting up), turning blue (cyanosis), aspiration, pauses in breathing (apnea), apparent life-threatening event (ALTE), and even a severe deficiency in growth. Proper treatment of LPR, especially in children, is critical.

What are the symptoms of GERD and LPR?

The symptoms of GERD may include persistent heartburn, acid regurgitation, nausea, hoarseness in the morning, or trouble swallowing. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be severe enough to mimic the pain of a heart attack. GERD can also cause a dry cough and bad breath. (Symtoms of LPR were outlined in the last section.)

While GERD and LPR may occur together, patients can also have GERD alone (without LPR) or LPR alone (without GERD). If you experience any symptoms on a regular basis (twice a week or more), then you may have GERD or LPR. For proper diagnosis and treatment, you should be evaluated by your primary care doctor or an otolaryngologist—head and neck surgeon (ENT doctor).

Who gets GERD or LPR?

Women, men, infants, and children can all have GERD or LPR. These disorders may result from physical causes or lifestyle factors. Physical causes can include a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors include diet (chocolate, citrus, fatty foods, spices), destructive habits (overeating, alcohol and tobacco abuse) and even pregnancy. Young children experience GERD and LPR due to the developmental immaturity of both the upper and lower esophageal sphincters. It should also be noted that some patients are just more susceptible to injury from reflux than others. A given amount of refluxed material in one patient may cause very different symptoms in other patients. Unfortunately, GERD and LPR are often overlooked in infants and children, leading to repeated vomiting, coughing in GERD, and airway and respiratory problems in LPR, such as sore throat and ear infections. Most infants grow out of GERD or LPR by the end of their first year, but the problems that resulted from the GERD or LPR may persist.

What role does an ear, nose, and throat specialist have in treating GERD and LPR?

A gastroenterologist, a specialist in treating gastrointestinal orders, will often provide initial treatment for GERD. But there are ear, nose, and throat problems that are caused by reflux reaching beyond the esophagus, such as hoarseness, laryngeal nodules in singers, croup, airway stenosis (narrowing), swallowing difficulties, throat pain, and sinus infections. These problems require an otolaryngologist—head and neck surgeon, or a specialist who has extensive experience with the tools that diagnose GERD and LPR. They treat many of the complications of GERD and LPR, including: sinus and ear infections, throat and laryngeal inflammation and lesions, as well as a change in the esophageal lining called Barrett’s esophagus, a serious complication that can lead to cancer.

Your primary care physician or pediatrician will often refer a case of LPR to an otolaryngologist—head and neck surgeon for evaluation, diagnosis, and treatment.

How are GERD and LPR diagnosed and treated?

GERD and LPR can be diagnosed or evaluated by a physical examination and the patient’s response to a trial of treatment with medication. Other tests that may be needed include an endoscopic examination (a long tube with a camera inserted into the nose, throat, windpipe, or esophagus), biopsy, x-ray, examination of the esophagus, 24 hour pH probe with or without impedance testing, esophageal motility testing (manometry), and emptying studies of the stomach. Endoscopic examination, biopsy, and x-ray may be performed as an outpatient or in a hospital setting. Endoscopic examinations can often be performed in your ENT’s office, or may require some form of sedation and occasionally anesthesia.

Most people with GERD or LPR respond favorably to a combination of lifestyle changes and medication. Medications that could be prescribed include antacids, histamine antagonists, proton pump inhibitors, pro-motility drugs, and foam barrier medications. Some of these products are now available over the counter and do not require a prescription.

Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention. Such treatment includes fundoplication, a procedure where a part of the stomach is wrapped around the lower esophagus to tighten the LES, and endoscopy, where hand stitches or a laser are used to make the LES tighter.

Adult lifestyle changes to prevent GERD and LPR

• Avoid eating and drinking within two to three hours prior to bedtime
• Do not drink alcohol
• Eat small meals and slowly
• Limit problem foods:
  
  • Caffeine
  • Carbonated drinks
  • Chocolate
  • Peppermint
  • Tomato
  • Citrus fruits
  • Fatty and fried foods
• Lose weight
• Quit smoking
• Wear loose clothing

We rely on our voices every day to interact with others, and a healthy voice is critical for clear communication. But just as we walk without thinking about it, we usually speak without thinking how our body makes it happen. However, knowing how we make sound is useful to maintaining the health and effectiveness of our voices. So this year on World Voice Day, April 16, take a minute to learn how your voice works. The following overview describes the body parts that work together to produce the sounds we make when we speak and sing.

The main parts of voice production:

• The Power Source: Your Lungs
• The Vibrator: Your Voice Box
• The Resonator: Your Throat, Nose, Mouth, and Sinuses

The Power Source : The power for your voice comes from air that you exhale. When we inhale, the diaphragm lowers and the rib cage expands, drawing air into the lungs. As we exhale, the process reverses and air exits the lungs, creating an airstream in the trachea. This airstream provides the energy for the vocal folds in the voice box to produce sound. The stronger the airstream, the stronger the voice. Give your voice good breath support to create a steady strong airstream that helps you make clear sounds.

The Vibrator : The larynx (or voice box) sits on top of the windpipe. It contains two vocal folds (also known as vocal cords) that open during breathing and close during swallowing and voice production. When we produce voice, the airstream passes between the two vocal folds that have come together. These folds are soft and are set into vibration by the passing airstream. They vibrate very fast – from 100 to 1000 times per second, depending on the pitch of the sound we make. Pitch is determined by the length and tension of the vocal folds, which are controlled by muscles in the larynx.

The Resonator : By themselves, the vocal folds produce a noise that sounds like simple buzzing, much like the mouthpiece on a trumpet. All of the structure above the folds, including the throat, nose, and mouth, are part of the resonator system. We can compare these structures to those of a horn or trumpet. The buzzing sound created by vocal fold vibration is changed by the shape of the resonator tract to produce our unique human sound.

When our voices are healthy, the three main parts work in harmony to provide effortless voice during speech and singing.

Insight into effects and prevention

• What is secondhand smoke?
• Who is at risk?
• Effects on children…

Secondhand smoke is a combination of the smoke from a burning cigarette and the smoke exhaled by a smoker. Also known as environmental tobacco smoke (ETS), it can be recognized easily by its distinctive odor. ETS contaminates the air and is retained in clothing, hair, curtains, and furniture. Many people find ETS unpleasant, annoying, and irritating to the eyes and nose. More importantly, it represents a dangerous health hazard. Over 4,000 different chemicals have been identified in ETS, and at least 43 of these chemicals cause cancer.

Is exposure to ETS common?

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children under five live in homes with at least one adult smoker.

Smoke’s effect on…

The fetus and newborn

Maternal, fetal, and placental blood flow change when pregnant women smoke, although the long-term health effects of these changes are not known. Some studies suggest that smoking during pregnancy causes birth defects such as cleft lip or palate. Smoking mothers produce less milk, and their babies have a lower birth weight. Maternal smoking also is associated with neonatal death from Sudden Infant Death Syndrome, the major cause of death in infants between one month and one year old.

Children’s lungs and respiratory tracts

Exposure to ETS decreases lung efficiency and impairs lung function in children of all ages. It increases both the frequency and severity of childhood asthma. Secondhand smoke can aggravate sinusitis, rhinitis, cystic fibrosis, and chronic respiratory problems such as cough and postnasal drip. It also increases the number of children’s colds and sore throats. In children under two, ETS exposure increases the likelihood of bronchitis and pneumonia. In fact, a 1992 study by the Environmental Protection Agency says ETS causes 150,000 – 300,000 lower respiratory tract infections each year in infants and children under 18 months old. These illnesses result in as many as 15,000 hospitalizations. Children of parents who smoke half a pack a day or more are at nearly double the risk of hospitalization for a respiratory illness.

The ears

Exposure to ETS increases both the number of ear infections a child will experience, and the duration of the illness. Inhaled smoke irritates the eustachian tube, which connects the back of the nose with the middle ear. This causes swelling and obstruction which interferes with pressure equalization in the middle ear, leading to pain, fluid and infection. Ear infections and middle ear fluid are the most common cause of children’s hearing loss. When they do not respond to medical treatment, the surgical insertion of tubes into the ears is often required.

The brain

Children of mothers who smoked during pregnancy are more likely to suffer behavioral problems such as hyperactivity than children of non-smoking mothers. Modest impairment in school performance and intellectual achievement has also been demonstrated.

Who is at risk?

Although ETS is dangerous to everyone, fetuses, infants, and children are at most risk because it can damage developing organs, such as the lungs and brain.

Secondhand smoke causes cancer

You have read how ETS harms the development of your child, but did you know that your risk of developing cancer from ETS is about 100 times greater than from outdoor cancer-causing pollutants? Did you know that ETS causes more than 3,000 non-smokers to die of lung cancer each year? While these facts are alarming for everyone, you can stop your child’s exposure to secondhand smoke right now.

What can you do?

• If you smoke, stop now. Consult your physician for help, if needed. There are many new pharmaceutical products available to help you quit.
• If you have household members who smoke, help them stop. If it is not possible to stop their smoking, do not allow them to smoke in your home or near your children.
• Do not smoke or allow smoking in your car.
• Be certain that your children’s schools and day-care facilities are smoke-free.

Acknowledgment to the American Society of Pediatric Otolaryngology for contributions to this content.

Insight into relief for a sore throat

• What causes a sore throat?
• What are my treatment options?
• How can I prevent a sore throat?
• and more…

Infections from viruses or bacteria are the main cause of sore throats and can make it difficult to talk and breathe. Allergies and sinus infections can also contribute to a sore throat. If you have a sore throat that lasts for more than five to seven days, you should see your doctor. While increasing your liquid intake, gargling with warm salt water, or taking over-the-counter pain relievers may help, if appropriate, your doctor may write you a prescription for an antibiotic.

What are the causes and symptoms of a sore throat?

Infections by contagious viruses or bacteria are the source of the majority of sore throats.

Viruses: Sore throats often accompany viral infections, including the flu, colds, measles, chicken pox, whooping cough, and croup. One viral infection, infectious mononucleosis, or “mono,” takes much longer than a week to be cured. This virus lodges in the lymph system, causing massive enlargement of the tonsils, with white patches on their surface. Other symptoms include swollen glands in the neck, armpits, and groin; fever, chills, and headache. If you are suffering from mono, you will likely experience a severe sore throat that may last for one to four weeks and, sometimes, serious breathing difficulties. Mono causes extreme fatigue that can last six weeks or more, and can also affect the liver, leading to jaundice-yellow skin and eyes.

Bacteria: Strep throat is an infection caused by a particular strain of streptococcus bacteria. This infection can also damage the heart valves (rheumatic fever) and kidneys (nephritis), cause scarlet fever, tonsillitis, pneumonia, sinusitis, and ear infections. Symptoms of strep throat often include fever (greater than 101°F), white draining patches on the throat, and swollen or tender lymph glands in the neck. Children may have a headache and stomach pain.

Tonsillitis is an infection of the lumpy-appearing lymphatic tissues on each side of the back of the throat.

Infections in the nose and sinuses also can cause sore throats, because mucus from the nose drains down into the throat and carries the infection with it.

The most dangerous throat infection is epiglottitis, which infects a portion of the larynx (voice box) and causes swelling that closes the airway. Epiglottitis is an emergency condition that requires prompt medical attention. Suspect it when swallowing is extremely painful (causing drooling), when speech is muffled, and when breathing becomes difficult. Epiglottitis may not be obvious just by looking in the mouth. A strep test may overlook this infection.

Other causes

Allergies to pollens and molds such as cat and dog dander and house dust are common causes of sore throats.

Irritation caused by dry heat, a chronic stuffy nose, pollutants and chemicals, and straining your voice can also irritate your throat.

Reflux, or a regurgitation of stomach acids up into the back of the throat, can cause you to wake up with a sore throat.

Tumors of the throat, tongue, and larynx (voice box) can cause a sore throat with pain radiating to the ear and/or difficulty swallowing. Other important symptoms can include hoarseness, noisy breathing, a lump in the neck, unexplained weight loss, and/or spitting up blood in the saliva or phlegm.

HIV infection can sometimes cause a chronic sore throat, due not to HIV itself but to a secondary infection that can be extremely serious.

When should I see a doctor?

Whenever a sore throat is severe, persists longer than the usual five-to-seven day duration of a cold or flu, and is not associated with an avoidable allergy or irritation, you should seek medical attention. The following signs and symptoms should alert you to see your physician:

• Severe and prolonged sore throat
• Difficulty breathing
• Difficulty swallowing
• Difficulty opening the mouth
• Joint pain
• Earache
• Rash
• Fever (over 101°)
• Blood in saliva or phlegm
• Frequently recurring sore throat
• Lump in neck
• Hoarseness lasting over two weeks

How will I be tested for a sore throat?

To test for strep throat, your doctor may want to do a throat culture, a non-surgical procedure that uses an instrument to take a sampling of the infected cells. Because the culture will not detect other infections, when it is negative, your physician will base his/her decision for treatment on the severity of your symptoms and the appearance of your throat on examination.

What are my treatment options?

A mild sore throat associated with cold or flu symptoms can be made more comfortable with the following remedies:

• Increase your liquid intake.
• Warm tea with honey is a favorite home remedy.
• Use a steamer or humidifier in your bedroom.

· Gargle with warm salt water several times daily: ¼ tsp. salt to ½ cup water.

· Take over-the-counter pain relievers such as acetaminophen (Tylenol Sore Throat®, Tempra®) or ibuprofen (Motrin IB®, Advil®).

If you have a bacterial infection your doctor will prescribe an antibiotic to alleviate your symptoms. Antibiotics are drugs that kill or impair bacteria. Penicillin or erythromycin (well-known antibiotics) are prescribed when the physician suspects streptococcal or another bacterial infection that responds to them. However, a number of bacterial throat infections require other antibiotics instead.

Antibiotics do not cure viral infections, but viruses do lower the patient’s resistance to bacterial infections. When such a combined infection occurs, antibiotics may be recommended. When an antibiotic is prescribed, it should be taken as the physician directs for the full course (usually 7-10 days). Otherwise the infection may not be completely eliminated, and could return. Some children will experience recurrent infection despite antibiotic treatment. When some of these are strep infections or are severe, your child may be a candidate for a tonsillectomy.

How can I prevent a sore throat?

• Avoid smoking or exposure to secondhand smoke. Tobacco smoke, whether primary or secondary, contains hundreds of toxic chemicals that can irritate the throat lining.
• If you have seasonal allergies or ongoing allergic reactions to dust, molds, or pet dander, you’re more likely to develop a sore throat than people who don’t have allergies.
• Avoid exposure to chemical irritants. Particulate matter in the air from the burning of fossil fuels, as well as common household chemicals, can cause throat irritation.
• If you experience chronic or frequent sinus infections you are more likely to experience a sore throat, since drainage from nose or sinus infections can cause throat infections as well.
• If you live or work in close quarters such as a child care center, classroom, office, prison, or military installation, you are at greater risk because viral and bacterial infections spread easily in environments where people are in close proximity.
• Maintain good hygiene. Do not share napkins, towels, and utensils with an infected person. Wash your hands regularly with soap or a sanitizing gel, for 10-15 seconds.
• If you have HIV or diabetes, are undergoing steroid treatment or chemotherapy, are experiencing extreme fatigue or have a poor diet, you have reduced immunity and are more susceptible to infections.

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)

Insight into tonsillectomy and adenoidectomy

• What conditions affect the tonsils and adenoids?
• When should I see a doctor?
• Common symptoms of tonsillitis and enlarged adenoids
• and more…

Tonsils and adenoids are the body’s first line of defense as part of the immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. Your ear, nose, and throat (ENT) specialist can suggest the best treatment options.

What are tonsils and adenoids?

Tonsils and adenoids are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two round lumps in the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth or nose without special instruments.

What affects tonsils and adenoids?

The two most common problems affecting the tonsils and adenoids are recurrent infections of the nose and throat, and significant enlargement that causes nasal obstruction and/or breathing, swallowing, and sleep problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling white deposits can also affect the tonsils and adenoids, making them sore and swollen. Cancers of the tonsil, while uncommon, require early diagnosis and aggressive treatment.

When should I see a doctor?

You should see your doctor when you or your child experience the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she may use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

• Medical history
• Physical examination
• Throat cultures/Strep tests – helpful in determining infections in the throat
• X-rays – helpful in determining the size and shape of the adenoids
• Blood tests – helpful in diagnosing infections such as mononucleosis
• Sleep study, or polysomnogram-helpful in determining whether sleep disturbance is occurring because of large tonsils and adenoids.

Tonsillitis and its symptoms

Tonsillitis is an infection of the tonsils. One sign is swelling of the tonsils. Other symptoms are:

• Redder than normal tonsils
• A white or yellow coating on the tonsils
• A slight voice change due to swelling
• Sore throat, sometimes accompanied by ear pain.
• Uncomfortable or painful swallowing
• Swollen lymph nodes (glands) in the neck
• Fever
• Bad breath

Enlarged tonsils and/or adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. If the tonsils and adenoids are enlarged, breathing during sleep may be disturbed. Other signs of adenoid and or tonsil enlargement are:

• Breathing through the mouth instead of the nose most of the time
• Nose sounds “blocked” when the person speaks
• Chronic runny nose
• Noisy breathing during the day
• Recurrent ear infections
• Snoring at night
• Restlessness during sleep, pauses in breathing for a few seconds at night(may indicate sleep apnea).

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy) may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness, and may even cause behavioral or school performance problems in some children.

Chronic infections of the adenoids can affect other areas such as the eustachian tube–the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and buildup of fluid in the middle ear that may cause temporary hearing loss. Studies also find that removal of the adenoids may help some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., prednisone) is sometimes helpful.

How to prepare for surgery

Children

• Talk to your child about his/her feelings and provide strong reassurance and support
• Encourage the idea that the procedure will make him/her healthier.
• Be with your child as much as possible before and after the surgery.
• Tell him/her to expect a sore throat after surgery, and that medicines will be used to help the soreness.
• Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
• It may be helpful to talk about the surgery with a friend who has had a tonsillectomy or adenoidectomy.
• Your otolaryngologist can answer questions about the surgical procedure.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome). Your doctor may ask to you to stop taking other medications that may interfere with clotting.

• Tell your surgeon if the patient or patient’s family has had any problems with anesthesia or clotting of blood. If the patient is taking medications, has sickle cell anemia, has a bleeding disorder, is pregnant, or has concerns about the transfusion of blood, the surgeon should be informed.
• A blood test may be required prior to surgery.
• A visit to the primary care doctor may be needed to make sure the patient is in good health at surgery.
• You will be given specific instructions on when to stop eating food and drinking liquids before surgery. These instructions are extremely important, as anything in the stomach may be vomited when anesthesia is induced.

When the patient arrives at the hospital or surgery center, the anesthesiologist and nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until discharge. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of preoperative and postoperative care and answer your questions.

After surgery

There are several postoperative problems that may arise. These include swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately. It is also important to drink liquids after surgery to avoid dehydration.

Any questions or concerns you have should be discussed openly with your surgeon.

Excessive body weight contributes to snoring and obstructive sleep apnea, in addition to being a major influence on general health and well-being. Obstructive sleep apnea occurs in about 50-60 percent of those who are obese.

A recent report from the National Center for Health Statistics concludes that  35 percent of adults exercise regularly (more than 6 of 10 don’t), and nearly four in 10 aren’t physically active. Lack of exercise can increase the risk of diabetes, heart disease, and stroke. The CDC estimates that “about 112,000 deaths are associated with obesity each year in the United States.” However, this estimate is likely to change in the future as more data become available.

Proper diet and exercise are the mainstays for a healthy lifestyle, although many Americans turn to costly fad diets and exercise programs that fail to provide weight loss and a healthy lifestyle. The basic tenets to gradual weight loss and good health include developing healthy eating habits and increasing daily physical activity.

Self-Help Guidelines for Healthy Activity:

• Consult a physician – men over age 40; women over 50; people with (or at risk for) chronic health problems such as heart disease, diabetes, or obesity.
  Start out slowly and build up activity gradually over a period of months. This will help avoid soreness and injury.
• Try to accumulate 30 minutes or more of moderate-intensity cardiovascular activity each day. You can do all 30 minutes together or through short bouts of intermittent activity (e.g., 10 minutes at a time).
• Add strength-developing exercises at least twice per week.
• Incorporate physical activity into your day (walk to the office or store, take the stairs instead of the elevator, walk or jog at lunch time, etc.).
• Make leisure time active – garden, walk, ride a bike with family and friends, participate in an exercise class, join in a sports activity.
• Select activities you enjoy, find satisfying, and that give you a feeling of accomplishment. Success leads to increased motivation to be physically active.
• Be sure your activities are compatible with your age and physical condition.
• Make it convenient to be active. Choose activities that are readily accessible (right outside your door) like gardening, walking, or jogging.
• Try “active commuting.” Cycle, walk, or in-line skate to work or to the store.
• Make your activity enjoyable – listen to music, include family and friends, etc.

For those who are already moderately active, increase the duration and intensity for additional benefits.

Weight Loss Tips:

Take in fewer calories than you expend. Few people understand this basic, simple concept.

• Eat smaller meals 3-5 times per day.
• Eat nutrient dense foods such as whole grains, lean proteins, fruits, and vegetables.
• Eat slowly, and wait 10-15 minutes before taking second helpings.
• Don’t eliminate everything you like from your diet. Eat those things in small amounts (pizza, candy, cookies, etc.).
• Prepare healthy snacks that are easily available (cut carrots, apples, etc.).
• Avoid buffets.
• Drink plenty of water, especially immediately before meals.

The Healthy Weight Approach to Dieting:

• Enjoy a variety of foods that will provide essential nutrients.
• Three-quarters of your lunch and dinner should be vegetables, fruits, cereals, breads, and other grain products. Snack on fruits and vegetables. Eat lots of dark green and orange vegetables. Choose whole-grain and enriched products more often.
• Choose lower-fat dairy products, leaner meats and alternatives, and foods prepared with little or no fat. Shop for low fat (2% or less) or fat-free products such as milk, yogurt, and cottage cheese. Eat smaller portions of leaner meats, poultry, and fish; remove visible fat from meat and the skin from poultry. Limit the use of extra fat like butter, margarine, and oil. Choose more peas, beans, and lentils
• Limit salt, caffeine, and alcohol. Minimize the consumption of salt. Cut down on added sugar such as jams, etc. Limit beverages with a high caffeine content (tea, sodas, chocolate drinks) and caffeinated coffee to two cups per day. Minimize alcohol to one to two drinks per day.
• Limit consumption of snack foods such as cookies, donuts, pies, cakes, potato chips, etc. They are high in salt, sugar, fat, and calories, and low in nutritional value.
• Eat in moderation. If you are not hungry, don’t eat.

Insight into causes, treatment, and prevention

• Why does the body develop allergies?
• What are common allergens?
• When should a doctor be consulted?
• and more…

Millions of Americans suffer from nasal allergies, commonly known as hay fever. Often fragrant flowers are blamed for the uncomfortable symptoms, yet they are rarely the cause; their pollens are too heavy to be airborne. An ear, nose, and throat specialist can help determine the substances causing your discomfort and develop a management plan that will help make life more enjoyable.

Why does the body develop allergies?

Allergy symptoms appear when the immune system reacts to an allergic substance that has entered the body as though it were an unwelcome invader. The immune system will produce special antibodies capable of recognizing the same allergic substance if it enters the body at a later time.

When an allergen reenters the body, the immune system rapidly recognizes it, causing a series of reactions. These reactions often involve tissue destruction, blood vessel dilation, and production of many inflammatory substances, including histamine. Histamine produces common allergy symptoms such as itchy, watery eyes, nasal and sinus congestion, headaches, sneezing, scratchy throat, hives, shortness of breath, etc. Other less common symptoms are balance disturbances, skin irritations such as eczema, and even respiratory problems like asthma.

What are common allergens?

Many common substances can be allergens. Pollens, food, mold, dust, feathers, animal dander, chemicals, drugs such as penicillin, and environmental pollutants commonly cause many to suffer allergic reactions.

Pollens

One of the most significant causes of allergic rhinitis in the United States is ragweed. It begins pollinating in late August in most of the U.S. and continues until the first frost. Late springtime pollens come from grasses like timothy, orchard, red top, sweet vernal, Bermuda, Johnson, and some bluegrasses. Early springtime hay fever is most often caused by pollens of trees such as elm, maple, birch, poplar, beech, ash, oak, walnut, sycamore, cypress, hickory, pecan, cottonwood, and alder. Flowering plants rarely cause allergy symptoms.

Household allergens

Certain allergens are present all year long. These include house dust, pet danders, and some foods and chemicals. Symptoms caused by these allergens often worsen in the winter when the house is closed up, due to poor ventilation..

Mold

Mold spores also cause allergy problems. Molds are present all year long and grow both outdoors and indoors. Dead leaves and farm areas are common sources for outdoor molds. Indoor plants, old books, bathrooms, and damp areas are common sources of indoor mold growth. Mold is also common in foods.

How can allergies be managed?

Allergies are rarely life-threatening, but often cause lost work days, decreased work efficiency, poor school performance, and a negative effect on the quality of life. Considering the millions of dollars spent on antiallergy medications and the cost of lost work time, allergies cannot be considered a minor problem.

For some allergy sufferers, symptoms may be seasonal, but for others they produce year-round discomfort. Symptom control is most successful when multiple approaches are used simultaneously to manage the allergy. They may include minimizing exposure to allergens, desensitization with allergy shots or drops, and medications. If used properly, medications, including antihistamines, nasal decongestant sprays, steroid sprays, saline sprays, and cortisone-type preparations, can be helpful. Even over-the-counter drugs can be beneficial, but some may cause drowsiness.

When should a doctor be consulted?

The most appropriate person to evaluate allergy problems is an otolaryngologist (ear, nose, and throat specialist). Aside from gathering a detailed history and completing a thorough examination of the ears, nose, throat, head, ENT doctors will offer advice on proper environmental control. They will also evaluate the sinuses to determine if infection or structural abnormality (deviated septum, polyps) is contributing to the symptoms.

In addition, the doctor may advise testing to determine the specific allergen that is causing discomfort. In some cases subcutaneous immunotherapy (allergy shots) or sublingual immunotherapy (allergy drops) may be recommended.  Immunotherapy is a method of treating allergies by desensitizing individuals to allergens over time, in many cases with the goal that they be cured of their allergies.

Tips for reducing the exposure to common allergens

• Wear a pollen mask when mowing grass or cleaning house (most drugstores sell them).
• Change your air filters regularly in heating and air conditioning systems and vacuum cleaners and/or install an air purifier. Consider a HEPA filter in your bedroom or other rooms where you spend a lot of time.
• Keep windows and doors closed during heavy pollen seasons.
• Wipe down indoor-outdoor animals as they return inside to remove pollen on their fur.
• Use daily saline nasal rinses to cleanse your nose and sinuses of the offending allergens.
• Rid your home of sources of mildew.
• Try not to allow dander-producing animals (i.e., cats, dogs, etc.) into your home and bedroom. However, if you have a pet, ask your ENT for suggestions to allow you to enjoy your pet while also enjoying a life free of allergies.
• Change feather pillows, woolen blankets, and woolen clothing to cotton or synthetic materials.
• Enclose mattress, box springs, and pillows in a plastic barrier.
• Use over-the-counter antihistamines and decongestants as needed and as tolerated.  However, you will likely find the best allergy symptom control with topical nasal sprays and eye drops that can be prescribed by your ENT.
• Sleep with the head of the bed tilted upward. Elevating it helps relieve nasal congestion.

Discuss hay fever and allergy symptoms with a physician when experiencing an allergic reaction.

Insight into recommended use and side effects

• What are the side effects of antihistamines?
• Who should not use decongestants?
• What are combination remedies?
• and more…

Drugs for stuffy nose, sinus trouble, congestion and drainage, and the common cold constitute a large segment of the over-the-counter market for America’s medication industry. Even though they do not cure allergies, colds, or the flu, they provide welcome relief for at least some of the discomforts of seasonal allergies and upper respiratory infections. However, it’s essential for consumers to read the ingredient labels, evaluate their symptoms, and choose the most appropriate remedy. It is not necessary to take medication if your symptoms are mild to moderate. Seek care from a physician if your symptoms persist beyond 7-10 days or are accompanied by fevers greater than 101.5 and worsening illness.

Some patients may benefit from non-drug therapies for nasal symptoms, such as nasal salt-water sprays or mists and nasal saline irrigations. As with all over-the-counter medications and treatments, read and follow the product’s instructions before use.

What are antihistamines?

Histamine is an important body chemical that is responsible for the congestion, sneezing, runny nose, and itching that a patient suffers with an allergic attack or an infection. Antihistamine drugs block the action of histamine, therefore reducing these symptoms. For the best result, antihistamines should be taken before allergic symptoms get well established, but they can also be very effective if taken after the onset of symptoms.

What are the side effects of antihistamines?

Most of the older over-the-counter antihistamines produce drowsiness, and are therefore not recommended for anyone who may be driving a car or operating equipment that could be dangerous. The first few doses cause the most sleepiness; subsequent doses are usually less troublesome. Some of the newer over-the-counter and prescription antihistamines do not produce drowsiness.

Typical antihistamines include: generic names: cetirizine, levocetirizine, loratadine, desloratadine, fexofenadine, diphenhydramine, chlorpheniramine, azelastine, brompheniramine.

Brand names: Benadryl®*, Chlor-Trimetron®*, Claritin®, Dimetane®*, Hismanal®, Nolahist®*, PBZ®*, Polaramine®, Tavist®*, Zyrtec®, Xyzal®, Allegra®, Claritin®, Clarinex®, and Alavert®.

What are decongestants?

Congestion in the nose, sinuses, and chest is due to swollen, expanded, or dilated blood vessels in the membranes of the nose and air passages. These membranes, with a great capacity for expansion, have an abundant supply of blood vessels. Once the membranes swell, you start to feel congested.

Decongestants help to shrink the blood vessels in the nasal membranes and allow the air passages to open up. Decongestants are chemically related to adrenaline, the natural decongestant, which is also a type of stimulant. Therefore, the side effect of decongestants taken as a pill or liquid is a jittery or nervous feeling, causing difficulty in going to sleep and elevating blood pressure and pulse rate.

Who should not use decongestants?

Decongestants should not be used by a patient who has an irregular heart rhythm, high blood pressure, heart disease, or glaucoma. Some patients taking decongestants experience difficulty with urination. Furthermore, decongestants are often used as ingredients in diet pills. To avoid excessively stimulating effects, patients taking diet pills should not take decongestants.

Typical decongestants in pill or liquid form are Drixoral®, Dimetapp®, Dura-Vent®, Exgest®, Entex®, Propagest®, Novafed®*, and Sudafed®*.

Decongestants are also available over the counter in nasal spray form. This method of medication delivery brings immediate relief to the nasal mucous membranes without the usual side effects that accompany pills or liquids that you swallow. Over-the-counter decongestant nose sprays should be reserved for urgent, emergency, and short-term use. Because repetitive use can lead to lack of effectiveness and return of the congestion, and thus lead to the urge to use more sprays more frequently, these medications often carry a warning label: “Do not use this product for more than three days.” This problem will improve only when the use of the nasal drops or spray is discontinued.

What are combination remedies?

Theoretically, if the side effects could be properly balanced, the sleepiness caused by antihistamines could be cancelled by the stimulation of decongestants. For instance, one might take the antihistamine only at night and take the decongestant alone in the daytime. Alternatively, you could take them together, increasing the dosage of antihistamine at night (while decreasing the decongestant dose) and then doing the opposite for daytime use. Since no one reacts exactly the same as another to drug side effects, you may wish to adjust the time of day the medications are taken until you find the combination that works best.

Antihistamines/decongestants: Many pharmaceutical companies have combined antihistamines and decongestants together in one pill. Typical combinations include (brand names): Actifed®*, A.R.M.®*, Chlor-Trimeton D®*, Claritin D®, Contac®*, CoPyronil 2®*, Deconamine®, Demazin®*, Dimetapp®*, Drixoral®*, Isoclor®*, Nolamine®, Novafed A®, Ornade®, Sudafed Plus®, Tavist D®*, Triaminic®*, and Trinalin®.

What should I look for in a “cold” remedy?

Decongestants and/or antihistamines are the principal ingredients in “cold” remedies, but drying agents, aspirin (or aspirin substitutes), and cough suppressants may also be added. Therefore, consumers should choose remedies with ingredients best suited to combat their own symptoms. If the label does not clearly state the ingredients and their functions, ask the pharmacist to explain them.

* May be available over the counter without a prescription, although often obtained at the counter itself. Read labels carefully, and use only as directed.

Which medicine do I need?

The chart below makes it simple for you to determine which type of medicine is right for you, based on the symptoms that each treats.

What Is CPAP?

The most common and effective nonsurgical treatment for sleep apnea is Continuous Positive Airway Pressure or CPAP which is applied through a nasal or facial mask while you sleep.  The CPAP device does not breathe for you.  Instead, it creates a flow of air pressure when you inhale that is strong enough to keep your airway passages open.   Once your otolaryngologist determines that CPAP is the right treatment, you will need to wear the CPAP mask every night.

How Do You Know if You Need CPAP?

When evaluating sleep apnea, your otolaryngologist may ask the following questions:

• Does your snoring disturb your family and friends?
• Do you have daytime sleepiness?
• Do you wake frequently throughout the night?
• Have you had episodes of obstructed breathing during sleep?
• Do you have morning headaches or tiredness?

After a review of your medical history and an examination of your airway, your otolaryngologist will order an overnight sleep study.  A CPAP recommendation is made after your otolaryngologist reviews the results of the study.

How Do You Get CPAP?

If your otolaryngologist recommends CPAP, you may be scheduled for a second sleep study during which you will be fitted for a mask and CPAP device.  The level of air pressure will be adjusted during the study to eliminate the airway obstruction. Alternatively, you may be placed on a self- adjusting CPAP machine which will determine the pressure needed to keep the airway open.

What Are the Advantages of CPAP?

CPAP is the most effective means of treating snoring and sleep apnea.  It keeps airway passages open which prevents pauses in breathing and helps you to get better sleep.  This, in turn, reduces daytime sleepiness, fatigue and other sleep apnea related health problems such as high blood pressure, heart disease, diabetes, and stroke.

What Are the Disadvantages Of CPAP?

The CPAP device needs to be used every night.  Some patients complain of mask discomfort, nasal congestion, and nose and throat dryness when using CPAP.  Others find the device to be too constrictive and cumbersome, particularly when traveling.  Unfortunately, these complaints sometimes lead to inconsistent use or abandonment of the device altogether.  Proper mask fitting and use of a humidifier can resolve these issues.

What Are the Alternative Treatments For Sleep Apnea?

Lifestyle change including weight loss and exercise can help to improve sleep apnea and its related health problems.  Sleep positioning and oral appliances have also been found to be effective.  In cases when non-invasive treatments fail, a surgical solution might be necessary.  Your otolaryngologist will be able to advise you on the treatment options.

Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.

Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it’s your response that can make the difference between a temporary inconvenience and permanent injury.

When Someone Gets Hurt:

What First Aid Supplies Should You Have on Hand in Case of An Emergency?

• Sterile cloth or pads
• Scissors
• Ice pack
• Tape
• Sterile bandages
• Cotton tipped swabs
• Hydrogen peroxide
• Nose drops
• Antibiotic ointment
• Eye pads
• Cotton balls
• Butterfly bandages

Ask “Are you all right?” Determine whether the injured person is breathing and knows who and where they are.
Be certain the person can see, hear and maintain balance. Watch for subtle changes in behavior or speech, such as slurring or stuttering. Any abnormal response requires medical attention.

Note weakness or loss of movement in the forehead, eyelids, cheeks and mouth.
Look at the eyes to make sure they move in the same direction and that both pupils are the same size.
If any doubts exist, seek immediate medical attention.

When Medical Attention Is Required, What Can You Do?

• Call for medical assistance (911).
• Do not move the victim, or remove helmets or protective gear.
• Do not give food, drink or medication until the extent of the injury has been determined.
• Remember HIV…be very careful around body fluids. In an emergency protect your hands with plastic bags.
• Apply pressure to bleeding wounds with a clean cloth or pad, unless the eye or eyelid is affected or a loose bone can be felt in a head injury. In these cases, do not apply pressure but gently cover the wound with a clean cloth.
• Apply ice or a cold pack to areas that have suffered a blow (such as a bump on the head) to help control swelling and pain.
• Remember to advise your doctor if the patient has HIV or hepatitis.

Facial Fractures

Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:

• Swelling and bruising, such as a black eye
• Pain or numbness in the face, cheeks or lips
• Double or blurred vision
• Nosebleeds
• Changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face; and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some require medical attention.
You should get immediate medical care when you have:

• Deep skin cuts
• Obvious deformity or fracture
• Loss of facial movement
• Persistent bleeding
• Change in vision
• Problems breathing and/or swallowing
• Alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen is important during the healing process to prevent pigment changes. Scars that look too obvious after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:

• Breathing difficulties
• Deformity of the nose
• Persistent bleeding
• Cuts

Bleeding

Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.

Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist-head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later.

Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose may last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist — head and neck surgeon. Injuries may involve specific structures within the neck, such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.

Prevention Of Facial Sports Injuries

The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:

• Be sure the playing areas are large enough that players will not run into walls or other obstructions.
• Cover unremoveable goal posts and other structures with thick, protective padding.
• Carefully check equipment to be sure it is functioning properly.
• Require protective equipment – such as helmets and padding for football, bicycling and rollerblading; face masks, head and mouth guards for baseball; ear protectors for wrestlers; and eyeglass guards or goggles for racquetball and snowmobiling are just a few.
• Prepare athletes with warm-up exercises before engaging in intense team activity.
• In the case of sports involving fast-moving vehicles, for example, snowmobiles or dirt bikes – check the path of travel, making sure there are no obstructing fences, wires or other obstacles.
• Enlist adequate adult supervision for all children’s competitive sports.

Q. How common is sinusitis?

A. More than 37 million Americans suffer from at least one episode of acute sinusitis each year. The prevalence of sinusitis has soared in the last decade possibly due to increased pollution, urban sprawl, and increased resistance to antibiotics.

Q. What is sinusitis?

A. Sinusitis is an inflammation of the membrane lining of any sinus, especially one of the paranasal sinuses. Acute sinusitis is a short-term condition that responds well to antibiotics and decongestants; chronic sinusitis is characterized by at least four recurrences of acute sinusitis. Either medication or surgery is a possible treatment.

Q. What are the signs and symptoms of acute sinusitis?

A. For acute sinusitis, symptoms include facial pain/pressure, nasal obstruction, nasal discharge, diminished sense of smell, and cough not due to asthma (in children). Additionally, sufferers of this disorder could incur fever, bad breath, fatigue, dental pain, and cough.
Acute sinusitis can last four weeks or more. This condition may be present when the patient has two or more symptoms and/or the presence of thick, green or yellow nasal discharge. Acute bacterial infection might be present when symptoms worsen after five days, persist after ten days, or the severity of symptoms is out of proportion to those normally associated with a viral infection.

Q. How is acute sinusitis treated?

A. Acute sinusitis is generally treated with ten to 14 days of antibiotic care. With treatment, the symptoms disappear, and antibiotics are no longer required for that episode. Oral and topical decongestants also may be prescribed to alleviate the symptoms.

Q. What are the signs and symptoms of chronic sinusitis?

A. Victims of chronic sinusitis may have the following symptoms for 12 weeks or more: facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage, thick nasal discharge/discolored post-nasal drainage, pus in the nasal cavity, and at times, fever. They may also have headache, bad breath, and fatigue.

Q. What measures can be taken at home to relieve sinus pain?

A. Warm moist air may alleviate sinus congestion. Experts recommend a vaporizer or steam from a pan of boiled water (removed from the heat). Humidifiers should be used only when a clean filter is in place to preclude spraying bacteria or fungal spores into the air. Warm compresses are useful in relieving pain in the nose and sinuses. Saline nose drops are also helpful in moisturizing nasal passages.

Q. How effective are non-prescription nose drops or sprays?

A. Use of nonprescription drops or sprays might help control symptoms. However, extended use of non-prescription decongestant nasal sprays could aggravate symptoms and should not be used beyond their label recommendation. Saline nasal sprays or drops are safe for continuous use.

Q. How does a physician determine the best treatment for acute or chronic sinusitis?
A. To obtain the best treatment option, the physician needs to properly assess the patient’ s history and symptoms and then progress through a structured physical examination.

Q. What should one expect during the physical examination for sinusitis?

A. At a specialist’ s office, the patient will receive a thorough ear, nose, and throat examination. During that physical examination, the physician will explore the facial features where swelling and erythema (redness of the skin) over the cheekbone exist. Facial swelling and redness are generally worse in the morning; as the patient remains upright, the symptoms gradually improve. The physician may feel and press the sinuses for tenderness. Additionally, the physician may tap the teeth to help identify an inflamed paranasal sinus.

Q. What other diagnostic procedures might be taken?

A. Other diagnostic tests may include a study of a mucous culture, endoscopy, x-rays, allergy testing, or CT scan of the sinuses.

Q. What is nasal endoscopy?

A. An endoscope is a special fiber optic instrument for the examination of the interior of a canal or hollow viscus. It allows a visual examination of the nose and sinus drainage areas.

Q. Why does an ear, nose, and throat specialist perform nasal endoscopy?

A. Nasal endoscopy offers the physician specialist a reliable, visual view of all the accessible areas of the sinus drainage pathways. First, the patient’ s nasal cavity is anesthetized; a rigid or flexible endoscope is then placed in a position to view the nasal cavity. The procedure is utilized to observe signs of obstruction as well as detect nasal polyps hidden from routine nasal examination. During the endoscopic examination, the physician specialist also looks for pus as well as polyp formation and structural abnormalities that may cause recurrent sinusitis.

Q. What course of treatment will the physician recommend?

A. To reduce congestion, the physician may prescribe nasal sprays, nose drops, or oral decongestants. Antibiotics will be prescribed for any bacterial infection found in the sinuses (antibiotics are not effective against a viral infection). Antihistamines may be recommended for the treatment of allergies.

Q. Will any changes in lifestyle be suggested during treatment?

A. Smoking is never condoned, but if one has the habit, it is important to refrain during treatment for sinus problems. A special diet is not required, but drinking extra fluids helps to thin mucus.

Q. When is sinus surgery necessary?

A. Mucus is developed by the body to act as a lubricant. In the sinus cavities, the lubricant is moved across mucous membrane linings toward the opening of each sinus by millions of cilia (a mobile extension of a cell). Inflammation from allergy causes membrane swelling and the sinus opening to narrow, thereby blocking mucus movement. If antibiotics are not effective, sinus surgery can correct the problem.

Q. What does the surgical procedure entail?

A. The basic endoscopic surgical procedure is performed under local or general anesthesia. The patient returns to normal activities within four days; full recovery takes about four weeks.

Q. What does sinus surgery accomplish?

A. The surgery should enlarge the natural opening to the sinuses, leaving as many cilia in place as possible. Otolaryngologist–head and neck surgeons have found endoscopic surgery to be highly effective in restoring normal function to the sinuses. The procedure removes areas of obstruction, resulting in the normal flow of mucus.

Q. What are the consequences of not treating infected sinuses?

A. Not seeking treatment for sinusitis will result in unnecessary pain and discomfort. In rare circumstances, meningitis or brain abscess and infection of the bone or bone marrow can occur.

Q. Where should sinus pain sufferers seek treatment?

A. If you suffer from severe sinus pain, you should seek treatment from an otolaryngologist–head and neck surgeon, a specialist who can treat your condition with medical and/or surgical remedies.

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food – and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

When should my child see a doctor?

If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician.

Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?

The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens.

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days.

How is allergic rhinitis treated?

The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures.

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks.

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food – and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

When should my child see a doctor?

If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician.

Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?

The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens.

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days.

How is allergic rhinitis treated?

The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures.

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks.

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.

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: This condition occurs when the body’s immune system over-responds to specific, non-infectious particles such as plant pollens, 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: This form of 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.

An antibiotic is a soluble substance derived from a mold or bacterium that inhibits the growth of other microorganisms.

The first antibiotic was Penicillin, discovered by Alexander Fleming in 1929, but it was not until World War II that the effectiveness of antibiotics was acknowledged, and large-scale fermentation processes were developed for their production.

Acute sinusitis is one of many medical disorders that can be caused by a bacterial infection. However, it is important to remember that colds, allergies, and environmental irritants, which are more common than bacterial sinusitis, can also cause sinus problems. Antibiotics are effective only against sinus problems caused by a bacterial infection.

The following symptoms may indicate the presence of a bacterial infection in your sinuses:

• Pain in your cheeks or upper back teeth
• A lot of bright yellow or green drainage from your nose for more than 10 days
• No relief from decongestants, and/or
• Symptoms that get worse instead of better after your cold is gone.

Most patients with a clinical diagnosis of acute sinusitis caused by a bacterial infection improve without antibiotic treatment. The specialist will initially offer appropriate doses of analgesics (pain-relievers), antipyretics (fever reducers), and decongestants. However if symptoms persist, a treatment consisting of antibiotics may be recommended.

Antibiotic Treatment For Sinusitis

Antibiotics are labeled as narrow-spectrum drugs when they work against only a few types of bacteria. On the other hand, broad-spectrum antibiotics are more effective by attacking a wide range of bacteria, but are more likely to promote antibiotic resistance. For that reason, your ear, nose, and throat specialist will most likely prescribe narrow-spectrum antibiotics, which often cost less. He/she may recommend broad-spectrum antibiotics for infections that do not respond to treatment with narrow-spectrum drugs.

Acute Sinusitis

In most cases, antibiotics are prescribed for patients with specific findings of persistent purulent nasal discharge and facial pain or tenderness who are not improving after seven days or those with severe symptoms of rhinosinusitis, regardless of duration. On the basis of clinical trials, amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole are preferred antibiotics.

Chronic Sinusitis

Even with a long regimen of antibiotics, chronic sinusitis symptoms can be difficult to treat. In general, however, treating chronic sinusitis, such as with antibiotics and decongestants, is similar to treating acute sinusitis. When antibiotic treatment fails, allergy testing, desensitization, and/or surgery may be recommended as the most effective means for treating chronic sinusitis. Research studies suggest that the vast majority of people who undergo surgery have fewer symptoms and better quality of life.

Pediatric Sinusitis

Antibiotics that are unlikely to be effective in children who do not improve with amoxicillin include trimethoprim-sulfamethoxazole (Bactrim) and erythromycin-sulfisoxazole (Pediazole), because many bacteria are resistant to these older antibiotics. For children who do not respond to two courses of traditional antibiotics, the dose and length of antibiotic treatment is often expanded, or treatment with intravenous cefotaxime or ceftriaxone and/or a referral to an ENT specialist is recommended.

As many as 20 percent of high school boys and two percent of high school girls continue to use smokeless tobacco, according to the Centers for Disease Control and Prevention. Despite public education campaigns sponsored by medical societies, organized baseball, and individuals, 12 to 14 million American users, one third are under age 21, and more than half of those developed the habit before they were 13. Peer pressure is just one of the reasons for starting the habit. Serious users often graduate from brands that deliver less nicotine to stronger ones. With each use, you need a little more of the drug to get the same feeling.

There has been some progress. The organizer of America’s fastest growing sport, National Association for Stock Car Auto Racing (NASCAR) has dropped its long-time affiliation with Winston tobacco. NASCAR president Mike Helton says a total tobacco ban is “an issue that’s on our radar for next year.”

And there have been setbacks in the fight against smoking tobacco. New marketing campaigns that feature flavored smokeless products have won over new young users. Journalistic coverage of Dr. Brad Rodu and his support of smokeless tobacco as a substitute for cigarettes has diluted the Academy’s “No Smokeless Tobacco Use” message that has been an official campaign for this Academy since 1989. In a November 10, 2005 study; “New Cigarette Brands with Flavors That Appeal to Youth: Tobacco Marketing Strategies; Health Affairs, November/December 2005, Volume 24, number 6, funded by the American Legacy Foundation and the National Cancer Institute noted that candy flavors were also added to smokeless tobacco products, cigars and cigarette rolling papers. “

Gregory Connolly, senior author of the study and a professor of the practice of public health at the Harvard School of Pubic Health noted, “Tobacco companies are using candy-like flavors and high tech delivery devices to turn a blowtorch into a flavored popsicle, misleading millions of youngsters to try a deadly product. Although the study focuses primarily on cigarettes, it noted that the addiction to smokeless tobacco or “chew” is as strong if not stronger than to cigarettes. Additional research has shown that there continues to be substantial evidence that smokeless tobacco is deadly. A December 18, 2003 study by Patricia Richter, Ph.D and Francis Spierto, Ph.D, two CDC researchers released by the Center for the Advancement of Health reported that the most popular brands of smokeless tobacco contain the highest amounts of nicotine that can be readily absorbed by the body. According to Richter, “Consumers need to know that smokeless tobacco products, including loose-leaf and moist snuff, are not safe alternatives to smoking,” Richter says. “The amount of nicotine absorbed per dose from using smokeless tobacco is greater than the amount of nicotine absorbed from smoking one cigarette.

Kicking Tobacco Means Kicking It All

In November 11, 2005 Reuters story, “Oral Tocacco Not Safe Sbustiute for Smoking,” Dr. Stephen Hecht and colleagues from the University of Minnesota Cancer Center in Minneapolis related data from their current research that compared the levels of cancer-causing nitrosamines in popular smokeless tobacco products and medicinal nicotine products such as the nicotine patch, nicotine gum, and nicotine lozenges.

The results “clearly showed that the levels of cancer-causing nitrosamines are far higher in smokeless tobacco products than they are in medicinal nicotine products,” Hecht said during a press briefing. While smokeless tobacco has “demonstrably less carcinogens and toxins than cigarette smoke,” said Hecht, smokeless tobacco still has “remarkably high levels of carcinogenic tobacco-specific nitrosamines — levels that are 100 to 1,000 times higher than in any other consumer product that is designed for oral consumption.” In a separate study, the team evaluated carcinogen biomarker levels in individuals using these products. They had 54 users of popular US smokeless tobacco products use their usual brand for two weeks and then had them switch to either Swedish snus or a nicotine patch for four weeks.

The team found that carcinogen levels in urine were statistically significantly lower after the switch from US-made smokeless tobacco brands to snus or to the nicotine patch. When comparing snus users to patch users, levels of cancer- causing compounds were significantly lower in patch users, indicating that medicinal nicotine is safer than snus, Hecht said. These results conflict with some prior studies that suggested that smokeless tobacco including moist snuff may be a less harmful habit than cigarette smoking because many of the carcinogens in cigarette smoke are either reduced or absent in smokeless tobacco. The bottom line, Dr.Hecht said, is that “smokeless tobacco products are dangerous.”

“The evidence suggests,” he continued, “that smokeless products are in fact a cause of oral cancer and pancreatic cancer in humans. The current evidence does not support smokeless tobacco as a substitute for cigarette smoking.”

What is cleft lip and cleft palate?

We all start out life with a cleft lip and palate. During normal fetal development between the 6th and 11th week of pregnancy, the clefts in the lip and palate fuse together. In babies born with cleft lip or cleft palate, one or both of these splits failed to fuse.

A “cleft” means a split or separation; the palate is the “roof” of the mouth. A cleft palate or lip then is a split in the oral (mouth) structure. Physicians call clefting a “craniofacial anomaly.” A child can be born with both a cleft lip and cleft palate or a cleft in just one area. Oral clefts are one of the most common birth defects.

Clefts in the lip can range from a tiny notch in the upper lip to a split that extends into the nose. A cleft palate can range from a small malformation that results in minimal problems to a large separation of the palate that interferes with eating, speaking, and even breathing. Clefts are often referred to as unilateral, a split on one side, or bilateral, one split on each side. There are three primary types of clefts:

• Cleft lip/palate refers to the condition when both the palate and lip are cleft. About one in 1,000 babies are born with cleft lip/palate.
• About 50 percent of all clefts
• More common in Asians and certain groups of American Indians
• Occurs less frequently in African Americans
• Up to 13 percent of cases present with other birth defects
• Occurs more often in male children
• Isolated cleft palate is the term used when a cleft occurs only in the palate. About one in 2,000 babies are born with this type of cleft (the incidence of submucous cleft palate, a type of isolated cleft palate, is one in 1,200).
• About 30 percent of all clefts
• All racial groups have similar risk
• Occurs more often in female children
  Isolated cleft lip refers to a cleft in the lip only accounting for 20 percent of all clefts.

What causes clefts?

No one knows exactly what causes clefts, but most believe they are caused by one or more of three main factors: an inherited characteristic (gene) from one or both parents, environment (poor early pregnancy health or exposure to toxins such as alcohol or cocaine), and genetic syndromes. A syndrome is an abnormality in genes on chromosomes that result in malformations or deformities that form a recognizable pattern. Cleft lip/palate is a part of more than 400 syndromes including Waardenburg, Pierre Robin, and Down syndromes. Approximately 30 percent of cleft deformities are associated with a syndrome, so a thorough medical evaluation and genetic counseling is recommended for cleft patients.

How is a cleft diagnosed?

Clefting of the lip and palate is usually visible during the baby’s first examination. One exception is a submucous cleft where the palate is cleft, but remains covered by smooth, unbroken lining of the mouth. A child with cleft lip or palate is often referred to a multidisciplinary team of experts for treatment. The team may include: an otolaryngologist (ear, nose, and throat specialist), plastic surgeon, oral surgeon, speech pathologist, pediatric dentist, orthodontist, audiologist, geneticist, pediatrician, nutritionist, and psychologist/social worker.

How are clefts treated?

Treatment of clefts is highly individual, depending on the overall health of the child and the severity and location of the cleft(s). Multiple surgeries and long-term follow-up are often necessary. Because clefts can interfere with physical, language and psychological development, treatment is recommended as early as possible. Surgery to repair a cleft lip is usually done between 10 and 12 weeks of age. A cleft palate is repaired through a procedure called palatoplasy, which is done between nine and 18 months. Additional surgeries are often needed to achieve the best results. In addition to surgery, the child may receive follow-up care from members of the multidisciplinary team on issues of speech, hearing, growth, dental, and psychological development.

What are the complications of clefts?

The complications of cleft lip and cleft palate can vary greatly depending on the degree and location of the cleft. They can include all or some or all of the following:

Breathing: When the palate and jaw are malformed, breathing becomes difficult. Treatments include surgery and oral appliances.
Feeding: Problems with feeding are more common in cleft children. A nutritionist and speech therapist that specializes in swallowing may be helpful. Special feeding devices are also available.
Ear infections and hearing loss: Any malformation of the upper airway can affect the function of the Eustachian tube and increase the possibility of persistent fluid in the middle ear, which is a primary cause of repeat ear infections. Hearing loss can be a consequence of repeat ear infections and persistent middle ear fluid. Tubes can be inserted in the ear by an otolaryngologist to alleviate fluid build-up and restore hearing.
Speech and language delays: Normal development of the lips and palate are essential for a child to properly form sounds and speak clearly. Cleft surgery repairs these structures; speech therapy helps with language development.
Dental problems: Sometimes a cleft involves the gums and jaw, affecting the proper growth of teeth and alignment of the jaw. A pediatric dentist or orthodontist can assist with this problem.

Sleep apnea is known to affect 1 to 3 percent of children, but because there may be many unreported cases, could actually affect more. Sleep apnea can affect your child’s sleep and behavior and if left untreated can lead to more serious problems. Because sleep apnea can be difficult to diagnose, it is important to monitor your child for the symptoms and have a doctor see her if she exhibits any.

What is sleep apnea?

Obstructive sleep apnea occurs when breathing is disrupted during sleep. This occurs when the airway is blocked, resulting in choking that causes a slower heart rate and increased blood pressure, alerting your child’s brain and causing him to wake up.

What are the symptoms?

The first sign that your child may have sleep apnea is loud snoring that occurs regularly. You may also notice behavioral changes. Due to a lack of sleep, he or she may be more cranky, have more or less energy, and have difficulty concentrating in school.

How is sleep apnea diagnosed?

If you notice that your child has any of those symptoms, have him or her checked by an otolaryngologist- head and neck surgeon, who can use a sleep test to determine sleep apnea. For the test, electrodes are attached to the head to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and can be performed in a sleep laboratory or at home.

Results can vary, so it is important to have the otolaryngologist determine whether your child needs treatment. Often, in mild cases, treatment will be delayed while you are asked to monitor your child and let the doctor know if the symptoms worsen. In severe cases, the doctor will determine the appropriate treatment.

What are the dangers if sleep apnea is left untreated?

Because sleep apnea can lead to more serious problems, it is important that it be properly treated. When left untreated, sleep apnea can cause:

• snoring
• sleep deprivation
• increased bed wetting
• slowed growth
• attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)
• breathing difficulty
• heart trouble

What causes sleep apnea?

In children, sleep apnea can occur for several physical reasons, including enlarged tonsils and adenoids, and abnormalities of the jaw bone and tongue. These factors cause the airway to be blocked, resulting in vibration of the tonsils, or snoring. Overweight children are at increased risk for sleep apnea. Of the 37 percent of children who are considered overweight, 25 percent of them likely have sleeping difficulties that may include sleep apnea. This is because extra fat around the neck and throat block the airway, making it difficult for these children to sleep soundly. Studies have shown that after three months of exercise, the number of children at risk for sleep apnea dropped by 50 percent.

How is sleep apnea treated?

Because enlarged tonsils and adenoids are a common cause of sleep apnea in children, routine treatment often involves an adenotonsillectomy, an operation to remove the tonsils and adenoids. This is a routine operation with a 90 percent success rate. Studies published in Otolaryngology-Head and Neck Surgery (October 2005) and presented at the Academy’s 2006 annual meeting in Toronto showed that when children with sleep apnea were tested one to five months after their surgery, they showed extreme improvement in their sleep and behavior, and that these improvements remained nearly a year and a half later.

Who is in day care?

The 2000 census reported that of among the nation’s 19.6 million preschoolers, grandparents took care of 21 percent, 17 percent were cared for by their father (while their mother was employed or in school); 12 percent were in day care centers; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in nursery schools or preschools. More than one-third of preschoolers (7.2 million) had no regular child-care arrangement and presumably were under maternal care.

Day care establishments are defined as those primarily engaged in care of infants or children, or in providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary function or major element. Some may or may not have substantial educational programs, and some may care for older children when they are not in school.

What are your child’s risks of being exposed to a contagious illness at a day care center?

Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centers do pose some degree of an increased health risk for children, because of the exposure to other children who may be sick.

When your child is in a day care center, the risk is greatest for viral upper respiratory infection (affecting the nose, throat, mouth, voice box) and the common cold, ear infections, and diarrhea. Some studies have tried to link asthma to day care. Other studies suggest that being exposed to all the germs in day care actually IMPROVES your child’s immune system.

Studies suggest that the average child will get eight to ten colds per year, lasting ten – 14 days each, and occurring primarily in the winter months. This means that if a child gets two colds from March to September, and eight colds from September to March, each lasting two weeks, the child will be sick more than over half of the winter.

At the same time, children in a day care environment, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media annually. This is four times the incidence of children staying at home.

When should your child remain at home instead of day care or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

• When your child has a temperature higher than 100 degrees, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
• When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home.
• Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
• If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?

The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:

• Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.
• Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:

• Look for otitis (inflammation) in the ear. This is an indicator of future ear infections.
• Review with you any allergies your child may have. This will assist in determining if the diet offered at the day care center may be harmful to your child.
• Examine the child’s tonsils for infection and size. Enlarged tonsils could indicate that your child may not be getting a healthy sleep at night, resulting in a tired condition during the day.

Alert the day care center manager when your child is ill, and include the nature of the illness.

Day care has become a necessity for millions of families. Monitoring the health of your own child is key to preventing unnecessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

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.

Sinusitis is inflammation of the lining membrane of any sinus. Take the following quiz to see if you have sinusitis.

Choose “yes” if you have any of the following symptoms for ten days or longer; otherwise, choose “no.”

1. Facial pressure/pain?

yes no

2. Headache pain?

yes no

3. Congestion or stuffy nose?

yes no

4. Thick, yellow-green nasal discharge?

yes no

5. Low fever (99-100°)?

yes no

6. Bad breath?

yes no

7. Pain in the upper teeth?

yes no

If you answered “Yes” to three or more of the symptoms listed above, you may have a sinus infection resulting from allergies, bacteria, or a response to fungi. An examination by an ear, nose, and throat specialist may be warranted.

©Editor’s Note: The text from this quiz may be freely used. Attribution to the American Academy of Otolaryngology – Head and Neck Surgery is required.

Your child has been diagnosed with allergic rhinitis, a physiological response to specific allergens such as pet dander or ragweed. The symptoms are fairly simple — a runny nose (rhinitis), watery eyes, and some periodic sneezing. The best solution is to administer over-the-counter antihistamine, and the problem will resolve on its own ….right?

Not really – the interrelated structures of the ears, nose, and throat can cause certain medical problems which trigger additional disorders – all with the possibility of serious consequences.

Simple hay fever can lead to long term problems in swallowing, sleeping, hearing, and breathing. Let’s see what else can happen to a child with a case of hay fever.

Ear infections:

One of children’s most common medical problems is otitis media, or middle ear infection. These infections are especially common in early childhood. They are even more common when children suffer from allergic rhinitis (hay fever) as well. Allergic inflammation can cause swelling in the nose and around the opening of the Eustachian tube (ear canal). This swelling has the potential to interfere with drainage of the middle ear. When bacteria laden discharge clogs the tube, infection is more likely.

Sore throats:

The hay fever allergens may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats, and husky voice. Although more common in older people and in dry inland climates, thick, dry mucus can also irritate the throat and be hard to clear. Air conditioning, winter heating, and dehydration can aggravate the condition. Paradoxically, antihistamines will do so as well. Some newer antihistamines do not produce dryness.

Snoring:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis (hay fever) and perennial (year-round) allergic rhinitis. This allergic condition may have a debilitating effect on the nasal turbinates, the small, shelf-like, bony structures covered by mucous membranes (mucosa). The turbinates protrude into the nasal airway and help to warm, humidify, and cleanse air before it reaches the lungs. When exposed to allergens, the mucosa can become inflamed. The blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose. This inflammation, or rhinitis, can cause chronic nasal obstruction that affects individuals during the day and night.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

Pediatric sinusitis:

Allergic rhinitis can cause enough inflammation to obstruct the openings to the sinuses. Consequently, a bacterial sinus infection occurs. The disease is similar for children and adults. Children may or may not complain of pain. However, in acute sinusitis, they will often have pain and typically have fever and a purulent nasal discharge. In chronic sinusitis, pain and fever are not evident. Some children may have mood or behavior changes. Most will have a purulent, runny nose and nasal congestion even to the point where they must mouth breathe. The infected sinus drains around the Eustachian tube, and therefore many of the children will also have a middle ear infection.

Seasonal allergic rhinitis may resolve after a short period. Administration of the proper over-the-counter antihistamines may alleviate the symptoms. However, if your child suffers from perennial (year round) allergic rhinitis, an examination by specialist will assist in preventing other ear, nose, and throat problems from occurring.

What Is Injection Snoreplasty?

Injection snoreplasty is a nonsurgical treatment for snoring that involves the injection of a hardening agent into the upper palate. Army researchers from Walter Reed Army Medical Center introduced this procedure at the 2000 Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Their early findings indicate that this treatment may reduce the loudness and incidence of primary snoring (snoring without apnea, or cessation of breath). The Academy neither endorses nor discourages the use of injection snoreplasty for the treatment of snoring.

Those seeking injection snoreplasty to reduce snoring should first be screened for obstructive sleep apnea or OSA (frequent cessation of breathing due to upper airway obstruction) by undergoing a sleep test. If sleep apnea is confirmed, other treatment may be recommended.

Treatment for Injection Snoreplasty

Injection snoreplasty is performed on an outpatient basis under local anesthesia. After numbing the upper palate with topical anesthetic, a hardening agent is injected just under the skin on the top of the mouth in front of the uvula (upper palate), creating a small blister. Within a couple of days the blister hardens, forms scar tissue, and pulls the floppy uvula forward to eliminate or reduce the palatal flutter that causes snoring.

In some patients, the treatment needs to be repeated for optimum benefits. If snoring occurs from vibrations beyond the palate and uvula and/or obstructive sleep apnea is suspected, further testing and alternative treatment options may be advised. A thorough examination by an ear, nose and throat specialist is recommended to diagnose the source and type of snoring, and determine whether injection snoreplasty may be helpful.

Post-Treatment Follow-Up for Injections Snoreplasty

After injection of the hardening agent, patients are observed in the otolaryngologist’s office and then sent home. Tylenol and throat lozenges or spray are suggested for pain management. Patients can return to work the next day. Though snoring may continue for a few days, it should eventually lessen. A post-procedure sleep test may be administered to fully evaluate the effects of the procedure.

Possible Side Effects of Injection Snoreplasty

A residual sore throat or feeling that something is “stuck” in the back of the mouth may occur. Suggestions for treatment of sore throat include Tylenol and/or throat lozenges or spray.

Statement on the Use of Sotradecolâ

Sotradecolâ, a trade name for sodium tetradecyl sulfate, is the most common hardening agent used in injection snoreplasty. This agent is indicated by the Food and Drug Administration (FDA) for “intravenous use only” and “for small uncomplicated varicose veins of the lower extremities that show simple dilation with competent valves.” Warnings include: 1) “severe adverse local effects including tissue necrosis,” and 2) “allergic reactions, including anaphylaxis, have been reported that led to death.”

Snoring is a Problem

Forty-five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. Thirty percent of adults over age 30 are snorers. By middle age, that number reaches 40 percent. Clearly, snoring is a dilemma affecting spouses, family members, and sometimes neighbors.

Snoring sounds are caused when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. When these structures strike each other and vibrate during breathing, snoring results.

Treatment for Snoring

Snoring can be diagnosed as primary snoring (simple snoring) or obstructive sleep apnea. Primary snoring is characterized by loud upper airway breathing sounds during sleep without episodes of apnea (cessation of breath).Obstructive sleep apnea is a serious medical condition where individuals have frequent episodes of apnea during sleep, contributing to an overall lack of restful sleep and severe health risks including heart attack and stroke.

Various methods are used to alleviate primary snoring. They include behavior modification (such as weight loss), surgical and non-surgical treatments, and dental devices.

Surgical treatments for primary snoring include: laser assisted uvulopalatoplasty (LAUP), an outpatient treatment for primary snoring and mild OSA that involves use of a laser under local anesthesia to make vertical incisions in the upper palate, shortening the uvula and lessening airway obstruction; and radiofrequency volumetric reduction of the palate, a relatively new procedure performed in an otolaryngologist’s office that utilizes targeted radio waves to heat and shrink tissue in the upper palate.

Not every headache is the consequence of sinus and nasal passage problems. For example, many patients visit an ear, nose, and throat specialist to seek treatment for a sinus headache and learn they actually have a migraine or tension headache. The confusion is common, a migraine can cause irritation of the trigeminal or fifth cranial nerve (with branches in the forehead, cheeks and jaw). This may produce pain at the lower-end branches of the nerve, in or near the sinus cavity.

Symptoms Of Sinusitis

Pain in the sinus area does not automatically mean that you have a sinus disorder. On the other hand, sinus and nasal passages can become inflamed leading to a headache. Headache is one of the key symptoms of patients diagnosed with acute or chronic sinusitis. In addition to a headache, sinusitis patients often complain of:

• Pain and pressure around the eyes, across the cheeks and the forehead
• Achy feeling in the upper teeth
• Fever and chills
• Facial swelling
• Nasal stuffiness
• Yellow or green discharge

However, it is important to note that there are some cases of headaches related to chronic sinusitis without other upper respiratory symptoms. This suggests that an examination for sinusitis be considered when treatment for a migraine or other headache disorder is unsuccessful.

Treatment For A Sinus Headache

Sinus headaches are associated with a swelling of the membranes lining the sinuses (spaces adjacent to the nasal passages). Pain occurs in the affected region – the result of air, pus, and mucus being trapped within the obstructed sinuses. The discomfort often occurs under the eye and in the upper teeth (disguised as a headache or toothache). Sinus headaches tend to worsen as you bend forward or lie down. The key to relieving the symptoms is to reduce sinus swelling and inflammation and facilitate mucous drainage from the sinuses.

There are several at-home steps that help prevent sinus headache or alleviate its pain. They include:

Breathe moist air: Relief for a sinus headache can be achieved by humidifying the dry air environment. This can be done by using a steam vaporizer or cool-mist humidifier, steam from a basin of hot water, or steam from a hot shower.

Alternate hot and cold compresses: Place a hot compress across your sinuses for three minutes, and then a cold compress for 30 seconds. Repeat this procedure three times per treatment, two to six times a day.

Nasal irrigation: Some believe that when nasal irrigation or rinse is performed, mucus, allergy creating particles and irritants such as pollens, dust particles, pollutants and bacteria are washed away, reducing the inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better and will reduce the symptoms. Nasal irrigation helps shrink the sinus membranes and thus increases drainage. There are several over-the-counter nasal rinse products available. Consult your ear, nose, and throat specialist for directions on making a home nasal rinse or irrigation solution.

Over-the-counter medications: Some over-the-counter (OTC) drugs are highly effective in reducing sinus headache pain. The primary ingredient in most OTC pain relievers is aspirin, acetaminophen, ibuprofen, naproxen, or a combination of them. The best way to choose a pain reliever is by determining which of these ingredients works best for you.

Decongestants: Sinus pressure headaches caused by allergies are usually treated with decongestants and antihistamines. In difficult cases, nasal steroid sprays may be recommended.

Alternative medicine: Chinese herbalists use Magnolia Flower as a remedy for clogged sinus and nasal passages. In conjunction with other herbs, such as angelica, mint, and chrysanthemum, it is often recommended for upper respiratory tract infections and sinus headaches, although its effectiveness for these problems has not been scientifically confirmed.

If none of these preventative measures or treatments is effective, a visit to an ear, nose, and throat specialist may be warranted. During the examination, a CT scan of the sinuses may be ordered to determine the extent of blockage caused by chronic sinusitis. If no chronic sinusitis were found, treatment might then include allergy testing and desensitization (allergy shots). Acute sinusitis is treated with antibiotics and decongestants. If antibiotics fail to relieve the chronic sinusitis and accompanying headaches, endoscopic or image-guided surgery may be the recommended treatment.

Can Over-the-Counter Medications Help?

Why Do We Suffer From Nasal And Sinus Discomfort?

The body’s nasal and sinus membranes have similar responses to viruses, allergic insults, and common bacterial infections. Membranes become swollen and congested. This congestion causes pain and pressure; mucus production increases during inflammation, resulting in a drippy, runny nose. These secretions may thicken over time, may slow in their drainage, and may predispose to future bacterial infection of the sinuses.

Congestion of the nasal membranes may even block the eustachian tube leading to the ear, resulting in a feeling of blockage in the ear or fluid behind the eardrum. Additionally, nasal airway congestion causes the individual to breathe through the mouth.

Each year, more than 37 million Americans suffer from sinusitis, which typically includes nasal congestion, thick yellow-green nasal discharge, facial pain, and pressure. Many do not understand the nature of their illness or what produces their symptoms. Consequently, before visiting a physician, they seek relief for their nasal and sinus discomfort by taking non-prescription or over-the-counter (OTC) medications.

What Is The Role Of OTC Medication For Sinus Pain?

There are many different OTC medications available to relieve the common complaints of sinus pain and pressure, allergy problems, and nasal congestion. Most of these medications are combination products that associate either a pain reliever such as acetaminophen with a decongestant or an antihistamine. Knowledge of these products and of the probable cause of symptoms will help the consumer to decide which product is best suited to relieve the common symptoms associated with nasal or sinus inflammation.

OTC nasal medications are designed to reduce symptoms produced by the inflammation of nasal membranes and sinuses. The goals of OTC medications are to: (1) reopen to nasal passages; (2) reduce nasal congestion; (3) relieve pain and pressure symptoms; and (4) reduce potential for complications. The medications come in several forms.

Nasal Saline Sprays: Non-Medicated Nasal Sprays

Nasal saline is an invaluable addition to the list of over-the-counter medications. It is ideal for all types of nasal problems. The added moisture produced by the saline reduces thick secretions and assists in the removal of infectious agents. There is no risk of becoming “addicted” to nasal saline. It should be applied as a mist to the nose up to six times per day. Nasal saline can also be made at home: contact your otolaryngologist for details.

Nasal Decongestant Sprays: Medicated Nasal Sprays

Afrin nasal spray, Neo-Synephrine, Otrivin, Dristan nasal spray, and other brands decongest the swollen nasal membranes. They clear nasal passages almost immediately and are useful in treating the initial stages of a common cold or viral infection. Nasal decongestant sprays are safe to use, especially appropriate for preventing eustachian tube problems when flying, and to halt progression of sinus infections following colds. However, they should only be utilized for 3-5 days because prolonged use leads to rebound congestion or “getting hooked on nasal sprays.” The patient with nasal swelling caused by seasonal allergy problems should use a cromolyn sodium nasal spray. The spray must be used frequently (four times a day) during allergy season to prevent the release of histamine from the tissues, which starts the allergic reaction. It works best before symptoms become established by stabilizing the nasal membranes and has few side effects.

Decongestant Medications

Pressure and congestion are common symptoms of nasal passage swelling. Decongestant medications are OTC products that relieve nasal swelling, pressure, and congestion but do not treat the cause of the inflammation. They reduce blood flow to the nasal membranes leading to improved airflow, less breathing through the mouth, decreased pressure in the sinuses and head, and subsequently less discomfort. Decongestants do not relieve drippy noses. Their side effects may include light headedness or giddiness and increased blood pressure and heart rate. (Patients with high blood pressure or heart problems should consult a physician before use.) In addition, other medications may interact with oral decongestants causing side effects. Both of these are available as single products or in combination with a pain reliever or an antihistamine. They are labeled as “non-drowsy” due to a side effect of stimulation of the nervous system.

Decongestant-Combination Products

Some medications are combined to reduce the number of pills. Tylenol® Sinus or Advil Cold and Sinus® exemplify products that join a pain reliever (acetaminophen or ibuprophen) with a decongestant (pseudoephedrine). These products relieve both sinus and cold/flu symptoms yet retain all the attributes of the individual drug including side effects.

Antihistamine Medications

Antihistamines combat allergic problems leading to nasal congestion. OTC antihistamines such as diphenhydramine (Benadryl®), or clemastine (Tavist®) may be used for relieving allergic symptoms of itching, sneezing, and nasal congestion. They relieve the drainage associated with the allergic inflammation but not obstruction or congestion. Antihistamines have a potential for sedation causing grogginess and dryness after use. Newer nonsedating antihistamines are available.

Antihistamine-Decongestant Combination Products

Antihistamines and decongestant products are often combined to relieve multiple symptoms of congestion and drainage and reduce the side effects of both products. Antihistamines produce sedation; decongestants are added to make them “non-drowsy.” The combined allergy product then relieves congestion and a runny nose.

The ear, nose, and throat specialist will prescribe many medications (antibiotics, decongestants, nasal steroid sprays, antihistamines) and procedures (flushing) for treating acute sinusitis. There are occasions when physician and patient find that the infections are recurrent and/or non-responsive to the medication. When this occurs, surgery to enlarge the openings that drain the sinuses is an option.

A recommendation for sinus surgery in the early 20th century would easily alarm the patient. In that era, the surgeon would have to perform an invasive procedure, reaching the sinuses by entering through the cheek area, often resulting in scarring and possible disfigurement. Today, these concerns have been eradicated with the latest advances in medicine. A trained surgeon can now treat sinusitis with minimal discomfort, a brief convalescence, and few complications.

A clinical history of the patient will be created before any surgery is performed. A careful diagnostic workup is necessary to identify the underlying cause of acute or chronic sinusitis, which is often found in the anterior ethmoid area, where the maxillary and frontal sinuses connect with the nose. This may necessitate a sinus computed tomography (CT) scan (without contrast), nasal physiology (rhinomanometry and nasal cytology), smell testing, and selected blood tests to determine an operative strategy. Note: Sinus X–rays have limited utility in the diagnosis of acute sinusitis and are of no value in the evaluation of chronic sinusitis.

Sinus Surgical Options Include:

Functional endoscopic sinus surgery (FESS): Developed in the 1950s, the nasal endoscope has revolutionized sinusitis surgery. In the past, the surgical strategy was to remove all sinus mucosa from the major sinuses. The use of an endoscope is linked to the theory that the best way to obtain normal healthy sinuses is to open the natural pathways to the sinuses. Once an improved drainage system is achieved, the diseased sinus mucosa has an opportunity to return to normal.

FESS involves the insertion of the endoscope, a very thin fiber-optic tube, into the nose for a direct visual examination of the openings into the sinuses. With state of the art micro-telescopes and instruments, abnormal and obstructive tissues are then removed. In the majority of cases, the surgical procedure is performed entirely through the nostrils, leaving no external scars. There is little swelling and only mild discomfort.

The advantage of the procedure is that the surgery is less extensive, there is often less removal of normal tissues, and can frequently be performed on an outpatient basis. After the operation, the patient will sometimes have nasal packing. Ten days after the procedure, nasal irrigation may be recommended to prevent crusting.

Image guided surgery: The sinuses are physically close to the brain, the eye, and major arteries, always areas of concern when a fiber optic tube is inserted into the sinus region. The growing use of a new technology, image guided endoscopic surgery, is alleviating that concern. This type of surgery may be recommended for severe forms of chronic sinusitis, in cases when previous sinus surgery has altered anatomical landmarks, or where a patient’s sinus anatomy is very unusual, making typical surgery difficult.

Image guidance is a near-three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments using infrared signals. In this way, surgeons can navigate their surgical instruments through complex sinus passages and provide surgical relief more precisely. Image guidance uses some of the same stealth principles used by the United States armed forces to guide bombs to their target.

Caldwell Luc operation: Another option is the Caldwell-Luc operation, which relieves chronic sinusitis by improving the drainage of the maxillary sinus, one of the cavities beneath the eye. The maxillary sinus is entered through the upper jaw above one of the second molar teeth. A “window” is created to connect the maxillary sinus with the nose, thus improving drainage. The operation is named after American physician George Caldwell and French laryngologist Henry Luc and is most often performed when a malignancy is present in the sinus cavity.

More than 20 percent of U.S. residents will be 65 or older in 2030. Of all Americans 65 and older, 14.1 percent report that they suffer from chronic sinusitis; for those 75 years and older, the rate declines to 13.5 percent.

Geriatric Rhinitis Complaints Are:

• Constant need to clear the throat
• A sense of nasal obstruction
• Nasal crusting
• Vague facial pressure
• Decreased sense of smell and taste

For the most part, sinusitis symptoms, diagnosis, and treatment are the same for the elderly as other adult age groups. However, there are special considerations for older Americans.

Changing Physiology: With aging, the physiology and function of the nose changes. The nose lengthens, and the nasal tip begins to droop due to weakening of the supporting cartilage. This in turn causes a restriction of nasal airflow, particularly at the nasal valve region (where the upper and lower lateral cartilages meet). Narrowing in this area results in the complaint of nasal obstruction, often referred to as geriatric rhinitis.

Patients with geriatric rhinitis typically complain of constant “sinus drainage,” a chronic need to clear the throat or “hawk” mucus, and a sense of nasal obstruction, most often when they lie down. Other features include nasal crusting especially in the winter and in patients taking diuretics, vague facial pressure (attributed to “sinus trouble”), and a decreased sense of smell and taste.

However, it is a mistake to blame all upper respiratory problems on the aging process. Elderly patients with symptoms such as repeated sneezing, and watery eyes, nasal obstruction with clear profuse watery runny nose, and soft, pale turbinates (top-shaped bones in the nose) may have allergic rhinitis. Patients with this diagnosis will benefit from consultation with an otolaryngic allergist.

Patients with chronic sinusitis will have a long history of thick drainage that is often foul smelling and tasting and is associated with nasal obstruction, headaches, and facial pressure. These patients usually have pus drainage and nasal redness. In contrast, the geriatric rhinitis patient usually has a dry, irritated nose. The diagnosis of chronic sinusitis can be confirmed with a computed tomography scan (CT scan) of the sinuses.

Sinusitis or rhinosinusitis, which is it? In recent studies, otolaryngologist–head and neck surgeons 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. Symptoms associated with rhinosinusitis include nasal obstruction, nasal congestion, nasal discharge, nasal purulence, postnasal drip, facial pressure and pain, alteration in the sense of smell, cough, fever, halitosis, fatigue, dental pain, pharyngitis, otologic symptoms (e.g., ear fullness and clicking), and headache. Patients with documented chronic sinusitis unresponsive to medications should be referred to an otolaryngologist.

Osteoporosis: Osteoporosis is a significant health problem in the United States affecting approximately 24 million Americans, 15 to 20 million of whom are women over 45 years of age. Because of the concerns regarding prolonged estrogen use in postmenopausal women, a nasal calcitonin spray is sometimes prescribed to prevent bone loss. The most common side effect reported with nasal calcitonin spray is a runny nose. Other symptoms that may occur include nasal crust, dryness, redness, irritation, sinusitis, nosebleeds, and headache. Sinusitis sufferers using a nasal calcitonin spray should inform their physicians.

Medications For Geriatric Rhinitis: Treatment for this age group needs to be more individualized to meet the patient’s slower metabolism and the increasing potential for side effects. The majority (80 to 85 percent) of the nation’s elderly have chronic diseases and take multiple drugs including over-the-counter medications, Placing them at higher risk for drug interactions than other patients.

Surgery For Geriatric Rhinitis: Nasal and sinus surgery is occasionally advised for older patients. Patients with structural abnormalities, such as a deviated septum or nasal valve collapse causing severe nasal problems, should be referred to an otolaryngologist for evaluation and possible surgical management.

Sources For Aging Patients: Administration on Aging (AoA), U.S. Department of Health and Human Services; Geriatrics.

Symptoms Of Sinusitis:

• Symptoms of upper respiratory infection lasting ten days or more
• Facial pressure or pain
• Nasal discharge that is yellow or green
• Post-nasal drip
• Cough

At-Home Treatments For Sinusitis:

• Saline nasal sprays that moisturize the nasal cavity, reduce dryness, and help clear thick or crusty mucus
• Humidification (moisturizing the air) of living spaces in dry climates will aid the movement of mucus through the sinuses

A Physician Visit For Your Sinus Pain Will:

• Determine if you have an infection requiring an appropriate antibiotic treatment
• Discover if you require intensive medical treatment for a condition such as a nasal obstructions, necessitating sinus surgery

Most of us think of tongue-tie as a situation we find ourselves in when we are too excited to speak. Actually, tongue-tie is the non-medical term for a relatively common physical condition that limits the use of the tongue, ankyloglossia.

Before we are born, a strong cord of tissue that guides development of mouth structures is positioned in the center of the mouth. It is called a frenulum. After birth, the lingual frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins. This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason having tongue-tie can lead to eating or speech problems, which may be serious in some individuals.

When Is Tongue-tie a Problem That Needs Treatment?

In Infants
Feeding

A new baby with a too tight frenulum can have trouble sucking and may have poor weight gain. Such feeding problems should be discussed with your child’s pediatrician who may refer you to an otolaryngologist-head and neck surgeon (ear, nose, and throat specialist) for additional treatment.

NOTE: Nursing mothers who experience significant pain while nursing or whose baby has trouble latching on should have their child evaluated for tongue tie. Although it is often overlooked, tongue tie can be an underlying cause of feeding problems that not only affect a child’s weight gain, but lead many mothers to abandon breast feeding altogether.

In Toddlers and Older Children

Speech

While the tongue is remarkably able to compensate and many children have no speech impediments due to tongue-tie, others may. Around the age of three, speech problems, especially articulation of the sounds – l, r, t, d, n, th, sh, and z may be noticeable. Evaluation may be needed if more than half of a three-year-old child’s speech is not understood outside of the family circle. Although, there is no obvious way to tell in infancy which children with ankyloglossia will have speech difficulties later, the following associated characteristics are common:

• V-shaped notch at the tip of the tongue
• Inability to stick out the tongue past the upper gums
• Inability to touch the roof of the mouth
• Difficulty moving the tongue from side to side

As a simple test, caregivers or parents might ask themselves if the child can lick an ice cream cone or lollipop without much difficulty. If the answer is no, they cannot, then it may be time to consult a physician.

Appearance

For older children with tongue-tie, appearance can be affected by persistent dental problems such as a gap between the bottom two front teeth. Your child’s physician can guide you in the diagnosis and treatment of tongue-tie. If he/she recommends surgery, an otolaryngologist-head and neck surgeon (ear, nose, and throat specialist), can perform a surgical procedure called a frenulectomy.

Tongue-tie Surgery Considerations

Tongue-tie surgery is a simple procedure and there are normally no complications. For very young infants (less than six-weeks-old), it may be done in the office of the physician. General anesthesia may be recommended when frenulectomy is performed on older children. But in some cases, it can be done in the physician’s office under local anesthesia. While frenulectomy is relatively simple, it can yield big results. Parents should consider that this surgery often yields more benefit than is obvious by restoring ease of speech and self-esteem.

You might not think your nose is a “vital organ,” but indeed it is! To understand its importance, all that most people need to experience is a bad cold. Nasal congestion and a runny nose have a noticeable effect on quality of life, energy level, ability to breathe, ability to sleep, and ability to function in general.

Why Is Your Nose So Important?

It processes the air that you breathe before it enters your lungs. Most of this activity takes place in and on the turbinates, located on the sides of the nasal passages. In an adult, 18,000 to 20,000 liters of air pass through the nose each day.

Your Nose Protects Your Health By:

Filtering all that air and retaining particles as small as a pollen grain with 100% efficiency.

Humidifiing the air that you breathe, adding moisture to the air to prevent dryness of the lining of the lungs and bronchial tubes.

Warming cold air to body temperature before it arrives in your lungs.

For these and many other reasons, normal nasal function is essential. Do your lungs a favor; take care of your nose.

TIP: Keep a list of all your medications; know all the potential side effects; and discuss possible interactions with your doctors.

Because the connection between the nose and lungs is so important, paying attention to problems in the nose–allergic rhinitis for instance – can reduce or avoid problems in the lungs such as bronchitis and asthma. Ignoring nasal symptoms such as congestion, sneezing, runny nose, or thick nasal discharge can aggravate lung problems and lead to other problems:

Nasal congestion reduces the sense of smell.

Mouth breathing causes dry mouth, which increases the risk of mouth and throat infections and reduces the sense of taste. Mouth breathing also pulls all pollution and germs directly into the lungs; dry cold air in the lungs makes the secretions thick, slows the cleaning cilia, and slows down the passage of oxygen into the blood stream.

Ignoring nasal allergies increases the chance that you will develop asthma; it also makes asthma worse if you already have it.

So, it is important to treat nasal symptoms promptly to prevent worsening of lung problems.

Tips To Improve The Health Of Your Nose And Lungs:

If your nose is dry, its various functions will be impaired. Try over-the-counter salt-water (saline) nasal mists and sprays to help maintain nasal health. These can be used liberally and at your discretion.

Beware of over-the-counter nasal decongestant sprays; prolonged use of these sprays may damage the cilia that clear the nose and sinuses. Decongestants can become addictive and actually cause nasal congestion to get worse.

Think of your nose when you’re traveling. Air-conditioned cruise ships may have high levels of mold in the cabins. Airplane air is very dry and contains a lot of recirculated particles and germs; a dry nose is more susceptible to germs. Use saline nasal mist frequently during the flight, and drink lots of water.

Medications Prescribed To Treat Nasal Problems:

Be aware of the nasal effects of other medications

• Diuretic blood pressure medications cause dryness in the nose and throat, making them more susceptible to germs and pollens.
• Many anti-anxiety medications also have a drying effect on the nose and throat.
• Birth control pills, blood pressure medicines called beta-blockers, and Viagra can cause increased nasal congestion.
• Eye drops can aggravate nasal symptoms when they drain into the nose with tears.

Be sure you understand their purpose. Each one is important and plays a separate role in treating nasal symptoms.

The foundation of the treatment of chronic nasal conditions is the regular use of an anti-inflammatory prescription nasal spray, which address all types of nose and sinus inflammation. These sprays should be used only as directed by your doctor. This is in contrast to medications that are inhaled by mouth into the lungs, which often have high levels of absorption into the blood stream. Always aim nasal sprays to the side of the nose; spraying into the center of the nose can cause too much dryness.

Antihistamines effectively relieve sneezing, itching and runny nose, but they have no effect on nasal congestion at least in the short term. Over-the-counter antihistamines cause drowsiness, slow the cleaning function of the cilia, and increase the stickiness of nasal mucus–causing germs and pollens to stay in the nose longer. There are prescription antihistamines that do not have any of these side effects. To achieve this safety, the relief is often slower starting, so patience is required.

Decongestants help to unclog stopped up noses but do very little for runny noses and sneezing. They work much faster to unclog the nose, but to achieve this quick action, there are often side-effects such as dry mouth, nervousness, and insomnia. The correct dose often has to be customized to get the benefit without the side-effects.

Be aware of medication side effects; no medicine works well for all people, and all medications can cause side effects.

What Is A Fungus? Fungi are plant-like organisms that lack chlorophyll. Since they do not have chlorophyll, fungi must absorb food from dead organic matter. Fungi share with bacteria the important ability to break down complex organic substances of almost every type (cellulose) and are essential to the recycling of carbon and other elements in the cycle of life. Fungi are supposed to “eat” only dead things, but sometimes they start eating when the organism is still alive. This is the cause of fungal infections; the treatment selected has to eradicate the fungus to be effective.

In the past 30 years, there has been a significant increase in the number of recorded fungal infections. This can be attributed to increased public awareness, new immunosuppressive therapies (medications such as cyclosporine that “fool” the body’s immune system to prevent organ rejection) and overuse of antibiotics (anti-infectives).

When the body’s immune system is suppressed, fungi find an opportunity to invade the body and a number of side effects occur. Because these organisms do not require light for food production, they can live in a damp and dark environment. The sinuses, consisting of moist, dark cavities, are a natural home to the invading fungi. When this occurs, fungal sinusitis results.

There Are Four Types Of Fungal Sinusitis:

Mycetoma Fungal Sinusitis produces clumps of spores, a “fungal ball,” within a sinus cavity, most frequently the maxillary sinuses. The patient usually maintains an effective immune system, but may have experienced trauma or injury to the affected sinus(es). Generally, the fungus does not cause a significant inflammatory response, but sinus discomfort occurs. The noninvasive nature of this disorder requires a treatment consisting of simple scraping of the infected sinus. An anti-fungal therapy is generally not prescribed.

Allergic Fungal Sinusitis (AFS) is now believed to be an allergic reaction to environmental fungi that is finely dispersed into the air. This condition usually occurs in patients with an immunocompetent host (possessing the ability to mount a normal immune response). Patients diagnosed with AFS have a history of allergic rhinitis, and the onset of AFS development is difficult to determine. Thick fungal debris and mucin (a secretion containing carbohydrate-rich glycoproteins) are developed in the sinus cavities and must be surgically removed so that the inciting allergen is no longer present. Recurrence is not uncommon once the disease is removed. Anti-inflammatory medical therapy and immunotherapy are typically prescribed to prevent AFS recurrence.

Note: A 1999 study published in the Mayo Clinic Proceedings asserts that allergic fungal sinusitis is present in a significant majority of patients diagnosed with chronic rhinosinusitis. The study found 96 percent of the study subjects with chronic rhinosinusitis to have a fungus in cultures of their nasal secretions. In sensitive individuals, the presence of fungus results in a disease process in which the body’s immune system sends eosinophils (white blood cells distinguished by their lobulated nuclei and the presence of large granules that attract the reddish-orange eosin stain) to attack fungi, and the eosinophils irritate the membranes in the nose. As long as fungi remain, so will the irritation.

Chronic Indolent Sinusitis is an invasive form of fungal sinusitis in patients without an identifiable immune deficiency. This form is generally found outside the US, most commonly in the Sudan and northern India. The disease progresses from months to years and presents symptoms that include chronic headache and progressive facial swelling that can cause visual impairment. Microscopically, chronic indolent sinusitis is characterized by a granulomatous inflammatory infiltrate (nodular shaped inflammatory lesions). A decreased immune system can place patients at risk for this invasive disease.

Fulminant Sinusitis is usually seen in the immunocompromised patient (an individual whose immunologic mechanism is deficient either because of an immunodeficiency disorder or because it has been rendered so by immunosuppressive agents). The disease leads to progressive destruction of the sinuses and can invade the bony cavities containing the eyeball and brain.

The recommended therapies for both chronic indolent and fulminant sin

The Problem

Some 45 percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight persons and it usually grows worse with age. Snoring sounds are caused by an obstruction to the free flow of air through the passages at the back of the mouth and nose.

Only recently have the adverse medical effects of snoring and its association with Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS) been recognized. Various methods are used to alleviate snoring and/or OSA. They include behavior modification, sleep positioning, Continuous Positive Airway Pressure (CPAP), jaw adjustment techniques, Uvulopalatopharyngoplasty (UPPP), and Laser Assisted Uvula Palatoplasty (LAUP).

What Is Laser Assisted Uvula Palatoplasty (LAUP)?

LAUP allows treatment of snoring and mild OSA by removing the obstruction in your airway in an outpatient setting under local anesthesia. A laser is used to vaporize the uvula and a specified portion of the palate in a series of small procedures. LAUP is performed while you are positioned in an upright sitting position in an examination chair.

Before administration of anesthesia, you are informed that the back of your throat will become numb and that you will lose the sensation of swallowing and breathing. A local anesthesia is sprayed over the back oral cavity, soft palate, tonsils, and uvula followed by an injection of additional anesthesia in the muscle layer of the uvula. After several minutes, a CO2 laser is used to make both, vertical incisions in the palate on both sides of the uvula. The uvula is shortened, eliminating the obstruction that has contributed to the snoring.

LAUP requires up to five treatments spaced four to eight weeks apart (although one to three are usual).

How Long Will It Take To Recover From LAUP?

If you undergo the LAUP procedure you can expect to return to a normal routine almost immediately. For the majority of those undergoing this procedure there will be swallowing pain similar to a severe sore throat. This discomfort lasts for approximately ten days and can be relieved by oral analgesic and anti-inflammatory medicines.

Improvement is noted by the reduction in or disappearance of your snoring.

Should You Consider LAUP?

If your snoring is habitual and disruptive to others, you may be a prime candidate for LAUP. Your otolaryngologist will evaluate you and ask the following questions:

• Do you snore loudly and disturb your family and friends?
• Do you have daytime sleepiness?
• Do you wake up frequently in the middle of the night?
• Do you have frequent episodes of obstructed breathing during sleep?
• Do you have morning headaches or tiredness?

Suitability for LAUP is determined after a review your health history, lifestyle factors (alcohol and tobacco intake as well as exercise), cardiovascular condition, and current medications in use. You will also receive a physical and otolaryngological (ear, nose, and throat) examination to evaluate the cause of the snoring.

Before the laser procedure is conducted, you will participate in a “sleep study,” which will grade the level of actual snoring and sleep apnea. This will complete the evaluation necessary for prescribing the appropriate treatment for your needs.

Insight into causes, treatment, and prevention

• What are fever blisters and cold sores?
• What are canker sores?
• When should a physician be consulted?
• and more…

Oral lesions (mouth sores) make it painful to eat and talk. Two of the most common recurrent oral lesions are fever blisters (also known as cold sores) and canker sores. Though similar, fever blisters and canker sores have important differences.

What are fever blisters?

Fever blisters are fluid-filled blisters that commonly occur on the lips. They also can occur on the gums and roof of the mouth (hard palate), but this is rare. Fever blisters are usually painful; pain may precede the appearance of the lesion by a few days. The blisters rupture within hours, then crust over. They last about seven to ten days.

Why do fever blisters reoccur?

Fever blisters result from a herpes simplex virus that becomes active. This virus is latent (dormant) in afflicted people, but can be activated by conditions such as stress, fever, trauma, hormonal changes, and exposure to sunlight. When lesions reappear, they tend to form in the same location.

Are fever blisters contagious?

Yes, the time from blister rupture until the sore is completely healed is the time of greatest risk for spread of infection. The virus can spread to the afflicted person’s eyes and genitalia, as well as to other people.

How are fever blisters treated?

Treatment consists of coating the lesions with a protective barrier ointment containing an antiviral agent, for example 5% acyclovir ointment. While there is no cure now, scientists are trying to develop one, so hopefully fever blisters will be a curable disorder in the future.

Tips to prevent spreading fever blisters

• Avoid mucous membrane contact when a lesion is present.
• Do not squeeze, pinch, or pick the blisters.
• Wash hands carefully before touching eyes, genital area, or another person.

Note: Despite all caution, it is possible to transmit herpes virus even when no blisters are present.

What are canker sores?

Canker sores (also called aphthous ulcers) are different than fever blisters. They are small, red or white, shallow ulcers occurring on the tongue, soft palate, or inside the lips and cheeks; they do not occur in the roof of the mouth or the gums. They are quite painful, and usually last 5-10 days.

Who is most likely to get canker sores, and what causes them?

Eighty percent of the U.S. population between the ages of 10 to 20, most often women, get canker sores. The best available evidence suggests that canker sores result from an altered local immune response associated with stress, trauma, or irritation. Acidic foods (e.g., tomatoes, citrus fruits, and some nuts) are known to cause irritation in some patients.

Are canker sores contagious? How are they treated?

Because they are not caused by bacteria or viral agents, they are not contagious and cannot be spread locally or to anyone else. Treatment is directed toward relieving discomfort and guarding against infection. A topical corticosteroid preparation such as triamcinolone dental paste (Kenalog in Orabase 0.1%®) is helpful.

When should a physician be consulted?

Consider consulting a physician if a mouth sore has not healed within two weeks. Mouth sores offer an easy way for germs and viruses to get into the body, so it is easy for infections to develop.

People who consume alcohol, smokers, smokeless tobacco users, chemotherapy or radiation patients, bone marrow or stem cell recipients, or patients with weak immune systems should also consider having regular oral screenings by a physician. The first sign of oral cancer is a mouth sore that does not heal.

What kind of screenings are performed?

The physician will most likely examine the head, face, neck, lips, gums, and high-risk areas inside the mouth, such as the floor of the mouth, the area under the tongue, the front and sides of the tongue, and the roof of the mouth or soft palate. If a suspicious lesion is found, the physician may recommend collecting and testing soft tissue from the oral cavity.

What are other types of oral lesions to be concerned about?

Leukoplakia – A thick, whitish-color patch that forms on the inside of the cheeks, gums, or tongue. These patches are caused by excess cell growth and are common among tobacco users. They can result from irritations such as ill-fitting dentures or the habit of chewing on the inside of the cheek. Leukoplakia can progress to cancer.

Candidiasis – A fungal infection (also called moniliasis or oral thrush) that occurs when yeast reproduce in large numbers. It is common among denture wearers and most often occurs in people who are very young, elderly, debilitated by disease, or who have a problem with their immune system. People who have dry mouth syndrome are very susceptible to candidiasis. Candida may flourish after antibiotic treatment, which can decrease normal bacteria in the mouth.

Hairy tongue – A relatively rare condition caused by the elongation of the taste buds. It can be caused by poor oral hygiene, chronic oral irritation, or smoking.

Torus palatinus – A hard bony growth in the center of the roof of the mouth (palate). It commonly occurs in females over the age of 30 and rarely needs treatment. A torus palatinus is often seen in patients who suffer from tooth grinding. Occasionally it is removed for the proper fitting of dentures.

Oral cancer – It may appear as a white or red patch of tissue in the mouth, or a small ulcer that looks like a common canker sore. Other than the lips, the most common areas for oral cancer to develop are on the tongue and the floor of the mouth. Other symptoms include a lump or mass that can be felt inside the mouth or neck; pain or difficulty in swallowing, speaking, or chewing; any wart-like mass; hoarseness that lasts for more than two weeks; or any numbness in the oral/facial region.

Tips to prevent mouth sores

• Stop smoking.
• Reduce stress.
• Avoid injury to the mouth caused by hard tooth brushing, hard foods, braces, or dentures.
• Chew slowly.
• Practice good dental hygiene, including regular visits to the dentist.
• Eat a well-balanced diet.
• Identify and eliminate food sensitivities.
• Drink plenty of water.
• Avoid very hot food or beverages.
• Follow nutritional guidelines for multivitamin supplements.

Insight into diagnosis and treatment

• What is a nasal fracture?
• What are my treatment options?
• and more…

Projecting prominently from the central part of the face, it is no surprise that the nose is the most commonly broken bone on the head. A broken nose (nasal fracture) can significantly alter your appearance. It can also make it much harder to breathe through the nose.

What is a nasal fracture?

Getting struck on the nose, whether by another person, a door, or the floor is not pleasant. Your nose will hurt-usually a lot. You’ll likely have a nose bleed and soon find it difficult to breathe through your nose. Swelling develops both inside and outside the nose, and you may get dark bruises around your eyes (“black eyes”).

Nasal fractures can affect both bone and cartilage. A collection of blood (called a “septal hematoma”) can sometimes form on the nasal septum (a wall made of bone and cartilage inside the nose that separates the sides of the nose).

What causes a nasal fracture?

Nasal fractures, or broken noses, result from facial injuries in contact sports or falls. Injuries affecting the teeth and mouth may also affect the nose.

How can I prevent a broken nose?

• Wear protective gear to shield your face when participating in contact sports.
• Avoid fist fights.

When should I see a doctor?

If you’ve been struck in the nose, it’s important to see a physician to check for septal hematoma. Seeing your primary doctor or an emergency room physician is usually adequate to determine if you have a septal hematoma or other associated problems from your accident. If a septal hematoma is present, it must be treated promptly to prevent worse problems from developing in the nose. If you suspect your nose may be broken, see an otolaryngologist-head and neck surgeon within one week of the injury. If you are seen within one to two weeks, it may be possible to repair your nose immediately. If you wait longer than two weeks (one week for children) you will likely need to wait several months before your nose can be surgically straightened and fixed.

If left untreated, a broken nose can leave you with an undesirable appearance as well as permanent difficulty in trying to breathe.

How will my doctor determine if I have a broken nose?

Your doctor will ask you several questions and will examine your nose and face. You will be asked to explain how the fracture occurred, the state of your general health, and how your nose looked before the injury. The doctor will examine not only your nose, but also the surrounding areas including your eyes, jaw, and teeth, and will look for bruising, lacerations, and swelling.

Sometimes your physician will recommend an x-ray or computed tomography (CT) scan. These can help to identify other facial fractures but are not always helpful in determining if you have a broken nose. The best way to determine that your nose is broken is if it looks very different or is harder to breathe through.

What are my treatment options?

If your nose is broken but not out of position, you may need no treatment other than rest and being careful not to bump your nose.

If your nose is broken so badly that it needs to be repositioned, you have several options. You can have your nose repaired in the office in some situations. Your doctor can give you some local anesthesia, reposition the broken bones into place, and then hold them in the right location with a “cast” made of plastic, plaster, or metal. This cast will then stay in place for a week. In the first two weeks after the injury, your doctor may offer you this kind of repair, or a similar approach using general anesthesia in the operating room.

What if I need surgery?

If more than two weeks have passed since the time of your injury, you may need to wait a while before having your nose straightened surgically. It may be necessary to wait two to three months before a good repair can be done, by which time there will be less swelling and your nose will have begun to heal. Reduced swelling will allow the surgeon to get a more accurate picture of how your nose originally looked. This type of surgery is considered reconstructive plastic surgery, as its goal is to restore your appearance to the way it was prior to injury. If your repair is done within two weeks of the injury, restoring prior appearance is the only possible goal. If you have waited several months for the repair, it is often possible to change the appearance of your nose as you desire. Should you be interested in this kind of appearance change as well as repair, you can feel confident that your otolaryngologist is a specialist in all surgery of the nose. No other specialty has more training in surgery on the nose, and some otolaryngologists focus exclusively on plastic surgery of the face.

Improving Form And Function Of The Nose

Each year thousands of people undergo surgery of the nose. Nasal surgery may be performed for cosmetic purposes, or a combination procedure to improve both form and function. It also may alleviate or cure nasal breathing problems, correct deformities from birth or injury, or support an aging, drooping nose.

Patients who are considering nasal surgery for any reason should seek a doctor who is a specialist in nasal airway function, as well as plastic surgery. This will ensure that efficient breathing is as high a priority as appearance.

Can Cosmetic Nasal Surgery Create A “Perfect” Nose?

Aesthetic nasal surgery (rhinoplasty) refines the shape of the nose, bringing it into balance with the other features of the face. Because the nose is the most prominent facial feature, even a slight alteration can greatly improve appearance. (Some patients elect chin augmentation in conjunction with rhinoplasty to better balance their features.) Rhinoplasty alone cannot give you a perfect profile, make you look like someone else, or improve your personal life. Before surgery, it is very important that the patient have a clear, realistic understanding of what change is possible as well as the limitations and risks of the procedure.

Skin type, ethnic background, and age will be among the factors considered preoperatively by the surgeon. Except in cases of severe breathing impairment, young patients usually are not candidates until their noses are fully grown, at 15 or 16 years of age. The surgeon will also discuss risk factors, which are generally minor, as well as where the surgery will be performed-in a hospital, freestanding outpatient surgical center, or a certified office operating room.

To reshape the nose, the skin is lifted, allowing the surgeon to remove or rearrange the bone and cartilage. The skin is then redraped and sutured over the new frame. A nasal splint on the outside of the nose helps retain the new shape during healing. If soft, absorbent material is placed inside the nose to stabilize the septum, it will normally be removed the morning after surgery. External nasal dressings and splints are usually removed five to seven days after surgery.

When Should Surgery Be Considered to Correct a Chronically Stuffy Nose?

Millions of Americans perennially suffer the discomfort of nasal stuffiness. This may be indicative of chronic breathing problems that don’t respond well to ordinary treatment. The blockage may be related to structural abnormalities inside the nose or to swelling caused by allergies or viruses.

There are numerous causes of nasal obstruction. A deviated septum (the partition between the nostrils) can be crooked or bent as the result of abnormal growth or injury. This can partially or completely close one or both nasal passages. The deviated septum can be corrected with a surgical procedure called septoplasty. Cosmetic changes to the nose are often performed at the same time, in a combination procedure called septorhinoplasty.

Overgrowth of the turbinates is yet another cause of stuffiness. (The turbinates are the tissues that line the inside of the nasal passages.) Sometimes the turbinates need treatment to make them smaller and expand the nasal passages. Treatments include injection, freezing, and partial removal. Allergies, too, can cause internal nasal swelling, and allergy evaluation and therapy may be necessary.

Can Surgery Correct a Stuffy, Aging Nose?

Aging is a common cause of nasal obstruction. This occurs when cartilage in the nose and its tip are weakened by age and droop because of gravity, causing the sides of the nose to collapse inward, obstructing air flow. Mouth breathing or noisy and restricted breathing are common.

Try lifting the tip of your nose to see if you breathe better. If so, the external adhesive nasal strips that athletes have popularized may help. Or talk to a facial plastic surgeon/otolaryngolgist about septoplasty, which will involve trimming, reshaping or repositioning portions of septal cartilage and bone. (This is an ideal time to make other cosmetic improvements as well.) Internal splints or soft packing may be placed in the nostrils to hold the septum in its new position. Usually, patients experience some swelling for a week or two. However, after the packing is removed, most people enjoy a dramatic improvement in breathing.

What Treatment Is Needed for a Broken Nose?

Bruises around the eyes and/or a slightly crooked nose following injury usually indicate a fractured nose. If the bones are pushed over or out to one side, immediate medical attention is ideal. But once soft tissue swelling distorts the nose, waiting 48-72 hours for a doctor’s appointment may actually help the doctor in evaluating your injury as the swelling recedes. (Apply ice while waiting to see the doctor.) What’s most important is whether the nasal bones have been displaced, rather than just fractured or broken.

For markedly displaced bones, surgeons often attempt to return the nasal bones to a straighter position under local or general anesthesia. This is usually done within seven to ten days after injury, so that the bones don’t heal in a displaced position. Because so many fractures are irregular and won’t “pop” back into place, the procedure is successful only half the time. Displacement due to injury often results in compromised breathing so corrective nasal surgery, typically septorhinoplasty, may then be elected. This procedure is typically done on an outpatient basis, and patients usually plan to avoid appearing in public for about a week due to swelling and bruising.

Will Insurance Cover Nasal Surgery?

Insurance usually does not cover cosmetic surgery. However, surgery to correct or improve breathing function, major deformity, or injury is frequently covered in whole or in part. Patients should obtain cost information from their surgeons and discuss with their insurance carrier prior to surgery.

Insight into care and prevention of nosebleeds

• What is an anterior and posterior nosebleed?
• How do I stop a nosebleed?
• Tips to prevent a nosebleed
• and more…

The nose is an area of the body that contains many tiny blood vessels (or arterioles) that can break easily. In the United States, one of every seven people will develop a nosebleed some time in their lifetime. Nosebleeds can occur at any age but are most common in children aged 2-10 years and adults aged 50-80 years. Nosebleeds are divided into two types, depending on whether the bleeding is coming from the front or back of the nose.

What is an anterior nosebleed?

Most nosebleeds (or epistaxes) begin in the lower part of the septum, the semi-rigid wall that separates the two nostrils of the nose. The septum contains blood vessels that can be broken by a blow to the nose or the edge of a sharp fingernail. Nosebleeds coming from the front of the nose,  (anterior nosebleeds) often begin with a flow of blood out one nostril when the patient is sitting or standing.

Anterior nosebleeds are common in dry climates or during the winter months when dry, heated indoor air dehydrates the nasal membranes. Dryness may result in crusting, cracking, and bleeding. This can be prevented by placing a light coating of petroleum jelly or an antibiotic ointment on the end of a fingertip and then rubbing it inside the nose, especially on the middle portion of the nose (the septum).

How do I stop an anterior nosebleed?

• Stay calm, or help a young child stay calm. A person who is agitated may bleed more profusely than someone who’s been reassured and supported.
• Keep head higher than the level of the heart. Sit up.
• Lean slightly forward so the blood won’t drain in the back of the throat.
• Gently blow any clotted blood out of the nose.  Spray a nasal decongestant in the nose.
• Using the thumb and index finger, pinch all the soft parts of the nose.  Do not pack the inside of the nose with gauze or cotton.
• Hold the position for five minutes. If it’s still bleeding, hold it again for an additional 10 minutes.

What is a posterior nosebleed?

More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat, even if the patient is sitting or standing.

Obviously, when lying down, even anterior (front of nasal cavity) nosebleeds may seem to flow toward the back of the throat, especially if coughing or blowing the nose. It is important to try to make the distinction between the anterior and posterior nosebleed, since posterior nosebleeds are often more severe and almost always require a physician’s care. Posterior nosebleeds are more likely to occur in older people, persons with high blood pressure, and in cases of injury to the nose or face.

What are the causes of recurring nosebleeds?

• Allergies, infections, or dryness that cause itching and lead to picking of the nose.
• Vigorous nose-blowing that ruptures superficial blood vessels.
• Clotting disorders that run in families or are due to medications.
• Drugs (such as anticoagulants or anti-inflammatories).
• Fractures of the nose or the base of the skull. Head injuries that cause nosebleeds should be regarded seriously.
• Hereditary hemorrhagic telangiectasia, a disorder involving a blood vessel growth similar to a birthmark in the back of the nose.
• Tumors, both malignant and nonmalignant, have to be considered, particularly in the older patient or in smokers.

When should an otolaryngologist be consulted?

If frequent nosebleeds are a problem, it is important to consult an otolaryngologist. An ear, nose, and throat specialist will carefully examine the nose using an endoscope, a tube with a light for seeing inside the nose, prior to making a treatment recommendation. Two of the most common treatments are cautery and packing the nose. Cautery is a technique in which the blood vessel is burned with an electric current, silver nitrate, or a laser. Sometimes, a doctor may just pack the nose with a special gauze or an inflatable latex balloon to put pressure on the blood vessel.

Tips to prevent a nosebleed

• Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime. Commonly used products include Bacitracin, A and D Ointment, Eucerin, Polysporin, and Vaseline.
• Keep children’s fingernails short to discourage nose-picking.
• Counteract the effects of dry air by using a humidifier.
• Use a saline nasal spray to moisten dry nasal membranes.
• Quit smoking. Smoking dries out the nose and irritates it.

Tips to prevent rebleeding after initial bleeding has stopped

• Do not pick or blow nose.
• Do not strain or bend down to lift anything heavy.
• Keep head higher than the heart.

If rebleeding occurs:

• Attempt to clear nose of all blood clots.
• Spray nose four times in the bleeding nostril(s) with a decongestant spray.
• Repeat the steps to stop an anterior nosebleed.
• Call a doctor if bleeding persists after 30 minutes or if nosebleed occurs after an injury to the head.

Insight into treating a runny nose

• What is post-nasal drip?
• How is swallowing affected?
• How is it treated?
• and more…

Glands in your nose and throat continually produce mucus (one to two quarts a day). Mucus moistens and cleans the nasal membranes, humidifies air, traps and clears inhaled foreign matter, and fights infection. Although it is normally swallowed unconsciously, the feeling of it accumulating in the throat or dripping from the back of your nose is called post-nasal drip. This sensation can be caused by excessively thick secretions or by throat muscle and swallowing disorders.

What causes abnormal secretions?

Thin secretions:

Increased thin clear secretions can be due to colds and flu, allergies, cold temperatures, bright lights, certain foods/spices, pregnancy, and other hormonal changes. Various drugs (including birth control pills and high blood pressure medications) and structural abnormalities can also produce increased secretions. These abnormalities might include a deviated or irregular nasal septum (the cartilage and bony dividing wall that separates the two nostrils).

Thick secretions:

Increased thick secretions in the winter often result from dryness in heated buildings and homes. They can also result from sinus or nose infections and allergies, especially to foods such as dairy products. If thin secretions become thick, and turn green or yellow, it is likely that a bacterial sinus infection is developing. In children, thick secretions from one side of the nose can mean that something is stuck in the nose such as a bean, wadded paper, or piece of toy. If these symptoms are observed, seek a physician for examination.

How is swallowing affected?

Swallowing problems may result in accumulation of solids or liquids in the throat that may complicate or feel like post-nasal drip. When the nerves and muscles in the mouth, throat, and food passage (esophagus) aren’t interacting properly, overflow secretions can spill into the voice box (larynx) and breathing passages (trachea and bronchi), causing hoarseness, throat clearing, or coughing.

Several factors contribute to swallowing problems:

• With age, swallowing muscles often lose strength and coordination, making it difficult for even normal secretions to pass smoothly into the stomach.
• During sleep, swallowing occurs much less frequently, and secretions may gather. Coughing and vigorous throat clearing are often needed upon waking.
• When nervous or under stress, throat muscles can trigger spasms that make it feel as if there is a lump in the throat. Frequent throat clearing, which usually produces little or no mucus, can make the problem worse by increasing irritation.
• Growths or swelling in the food passage can slow or prevent the movement of liquids and/or solids.

Swallowing problems may also be caused by gastroesophageal reflux disease (GERD). This is when a backup of stomach contents and acid gets into the esophagus or throat. Heartburn, indigestion, and sore throat are common symptoms. GERD may be aggravated by lying down, especially following eating. Hiatal hernia, a pouch-like tissue mass where the esophagus meets the stomach, often contributes to the reflux.

How is the throat affected?

Post-nasal drip often leads to a sore, irritated throat. Although there is usually no infection, the tonsils and other tissues in the throat may swell. This can cause discomfort or a feeling that there is a lump in the throat. Successful treatment of the post-nasal drip will usually clear up these throat symptoms.

How is it treated?

A correct diagnosis requires a detailed ear, nose, and throat exam, and possibly laboratory, endoscopic (procedures that use a tube to look inside the body), and x-ray studies. Treatment varies according to the following causes:

• Bacterial infections are treated with antibiotics. These drugs may only provide temporary relief. In cases of chronic sinusitis, surgery to open the blocked sinuses may be required.
• Allergies are managed by avoiding the causes. Antihistamines and decongestants, cromolyn and steroid (cortisone type) nasal sprays, and other forms of steroids may offer relief. Immunotherapy, either by shots or sublingual (under the tongue drops) may also be helpful. However, some older, sedating antihistamines may dry and thicken post-nasal secretions even more; newer nonsedating antihistamines, available by prescription only, do not have this effect. Decongestants can aggravate high blood pressure, heart, and thyroid disease. Steroid sprays may be used safely under medical supervision. Oral and injectable steroids rarely produce serious complications in short-term use. Because significant side-effects can occur, steroids must be monitored carefully when used for more than one week.
• Gastroesophageal reflux is treated by elevating the head of the bed six to eight inches, avoiding foods and beverages for two to three hours before bedtime, and eliminating alcohol and caffeine from the daily diet. Antacids such as Maalox®, Mylanta®, Gaviscon® and drugs that block stomach acid production such as Zantac®, Tagamet®, or Pepcid®) may be prescribed. If these are not successful, stronger medications can be prescribed. Trial treatments are usually suggested before x-rays and other diagnostic studies are performed.

General measures that allow mucus secretions to pass more easily may be recommended when it is not possible to determine the cause. Many people, especially older persons, need more fluids to thin out secretions. Drinking more water, eliminating caffeine, and avoiding diuretics (medications that increase urination) will help. Mucous-thinning agents such as guaifenesin (Humibid®, Robitussin®) may also thin secretions. Nasal irrigations may alleviate thickened secretions. These can be performed two to four times a day either with a nasal douche device or a Water Pik® with a nasal irrigation nozzle. Warm water with baking soda or salt (½ to 1 tsp. to the pint) or Alkalol®, a nonprescription irrigating solution (full strength or diluted by half warm water), may be helpful. Finally, use of simple saline (salt) nonprescription nasal sprays (e.g., Ocean®, Ayr®, or Nasal®) to moisten the nose is often very beneficial.

Sinus Conditions

Sinuses are air-filled cavities in the skull. They drain into the nose through small openings. Blockages in the openings from swelling due to colds, flu, or allergies may lead to acute sinus infection. A viral cold that persists for 10 days or more may have become a bacterial sinus infection. This infection may increase post-nasal drip. If you suspect that you have a sinus infection, you should see your physician to see if it needs antibiotic treatment.

Chronic sinusitis occurs when sinus blockages persist, causing the lining of the sinuses to swell further. Polyps (growths in the nose) may develop with chronic sinusitis. Patients with polyps tend to have irritating, persistent post-nasal drip. Evaluation by an otolaryngologist may include an exam of the interior of the nose with a fiberoptic scope and CAT scan x-rays. If medication does not relieve the problem, surgery may be recommended.

Vasomotor Rhinitis describes a nonallergic “hyperirritable nose” that feels congested, blocked, or wet.

Where Are Your Salivary Glands?

The glands are found in and around your mouth and throat. We call the major salivary glands the parotid, submandibular, and sublingual glands.

They all secrete saliva into your mouth, the parotid through tubes that drain saliva, called salivary ducts, near your upper teeth, submandibular under your tongue, and the sublingual through many ducts in the floor of your mouth.

Besides these glands, there are many tiny glands called minor salivary glands located in your lips, inner cheek area (buccal mucosa), and extensively in other linings of your mouth and throat. Salivary glands produce the saliva used to moisten your mouth, initiate digestion, and help protect your teeth from decay.

As a good health measure, it is important to drink lots of liquids daily. Dehydration is a risk factor for salivary gland disease.

What Causes Salivary Gland Problems?

Salivary gland problems that cause clinical symptoms include:

Obstruction: Obstruction to the flow of saliva most commonly occurs in the parotid and submandibular glands, usually because stones have formed. Symptoms typically occur when eating. Saliva production starts to flow, but cannot exit the ductal system, leading to swelling of the involved gland and significant pain, sometimes with an infection. Unless stones totally obstruct saliva flow, the major glands will swell during eating and then gradually subside after eating, only to enlarge again at the next meal. Infection can develop in the pool of blocked saliva, leading to more severe pain and swelling in the glands. If untreated for a long time, the glands may become abscessed.

It is possible for the duct system of the major salivary glands that connects the glands to the mouth to be abnormal. These ducts can develop small constrictions, which decrease salivary flow, leading to infection and obstructive symptoms.

Infection: The most common salivary gland infection in children is mumps, which involves the parotid glands. While this is most common in children who have not been immunized, it can occur in adults. However, if an adult has swelling in the area of the parotid gland only on one side, it is more likely due to an obstruction or a tumor.

Infections also occur because of ductal obstruction or sluggish flow of saliva because the mouth has abundant bacteria.

You may have a secondary infection of salivary glands from nearby lymph nodes. These lymph nodes are the structures in the upper neck that often become tender during a common sore throat. In fact, many of these lymph nodes are actually located on, within, and deep in the substance of the parotid gland or near the submandibular glands. When these lymph nodes enlarge through infection, you may have a red, painful swelling in the area of the parotid or submandibular glands. Lymph nodes also enlarge due to tumors and inflammation.

Tumors: Primary benign and malignant salivary gland tumors usually show up as painless enlargements of these glands. Tumors rarely involve more than one gland and are detected as a growth in the parotid, submandibular area, on the palate, floor of mouth, cheeks, or lips. An otolaryngologist-head and neck surgeon should check these enlargements.

Malignant tumors of the major salivary glands can grow quickly, may be painful, and can cause loss of movement of part or all of the affected side of the face. These symptoms should be immediately investigated.

Other Disorders: Salivary gland enlargement also occurs in autoimmune diseases such as HIV and Sjögren’s syndrome where the body’s immune system attacks the salivary glands causing significant inflammation. Dry mouth or dry eyes are common. This may occur with other systemic diseases such as rheumatoid arthritis. Diabetes may cause enlargement of the salivary glands, especially the parotid glands. Alcoholics may have salivary gland swelling, usually on both sides.

How Does Your Doctor Make the Diagnosis?

Diagnosis of salivary gland disease depends on the careful taking of your history, a physical examination, and laboratory tests.

If your doctor suspects an obstruction of the major salivary glands, it may be necessary to anesthetize the opening of the salivary ducts in the mouth, and probe and dilate the duct to help an obstructive stone pass. Before these procedures, dental x-rays may show where the calcified stones are located.

If a mass is found in the salivary gland, it is helpful to obtain a CT scan or a MRI (magnetic resonance imaging). Sometimes, a fine needle aspiration biopsy in the doctor’s office is helpful. Rarely, dye will be injected through the parotid duct before an x-ray of the gland is taken (a sialogram).

A lip biopsy of minor salivary glands may be needed to identify certain autoimmune diseases.

How Is Salivary Gland Disease Treated?

Treatment of salivary diseases falls into two categories: medical and surgical. Selection of treatment depends on the nature of the problem. If it is due to systemic diseases (diseases that involve the whole body, not one isolated area), then the underlying problem must be treated. This may require consulting with other specialists. If the disease process relates to salivary gland obstruction and subsequent infection, your doctor will recommend increased fluid intake and may prescribe antibiotics. Sometimes an instrument will be used to open blocked ducts.

If a mass has developed within the salivary gland, removal of the mass may be recommended. Most masses in the parotid gland area are benign (noncancerous). When surgery is necessary, great care must be taken to avoid damage to the facial nerve within this gland that moves the muscles face including the mouth and eye. When malignant masses are in the parotid gland, it may be possible to surgically remove them and preserve most of the facial nerve. Radiation treatment is often recommended after surgery. This is typically administered four to six weeks after the surgical procedure to allow adequate healing before irradiation.

The same general principles apply to masses in the submandibular area or in the minor salivary glands within the mouth and upper throat. Benign diseases are best treated by conservative measures or surgery, whereas malignant diseases may require surgery and postoperative irradiation. If the lump in the vicinity of a salivary gland is a lymph node that has become enlarged due to cancer from another site, then obviously a different treatment plan will be needed. An otolaryngologist-head and neck surgeon can effectively direct treatment.

Removal of a salivary gland does not produce a dry mouth, called xerostomia. However, radiation therapy to the mouth can cause the unpleasant symptoms associated with reduced salivary flow. Your doctor can prescribe medication or other conservative treatments that may reduce the dryness in these instances.

Salivary gland diseases are due to many different causes. These diseases are treated both medically and surgically. Treatment is readily managed by an otolaryngologist-head and neck surgeon with experience in this area.

Access to quality healthcare for children is forwarded by the availability of good healthcare information.

With this year’s release of a new surgeon general’s report on secondhand smoke, the following information should beshared with patients.

New Warning on Secondhand Smoke

The Surgeon General released new evidence this year-July 2006-supporting the fact that secondhand smoke, smoke from a burning cigarette and the smoke exhaled by the smoker, represents a dangerous health hazard.

The new report states that there is no risk-free level of secondhand smoke exposure. Although secondhand smoke is dangerous to everyone, fetuses, infants, and children are at most risk. Even brief exposures can be harmful to children. This is because secondhand smoke can damage developing organs, such as the lungs and brain.

Infants and Children Effects and Exposure

Babies of mothers who smoked and those exposed to smoke are more likely to die from Sudden Infant Death Syndrome (SIDS) than babies who are not exposed to smoke.

Babies of mothers who smoked and those exposed to smoke after birth have weaker lungs and thereby increased risk of more health problems.

Children with asthma exposed to secondhand smoke experience more frequent and severe attacks.

Children exposed to secondhand smoke are at increased risk for ear infections and are more likely to need an operation to insert ear tubes for drainage.

Youth and Teens Effects and Exposure

Secondhand smoke exposure causes respiratory symptoms, including cough, phlegm, wheeze, and breathlessness, among school-aged children.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Statistics

More than 4,000 different chemicals have been identified in secondhand smoke and at least 43 of these chemicals cause cancer.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children less than five years of age live in homes with at least one adult smoker.

28 percent of high schoolers are exposed to secondhand smoke in their own homes.

A recent study found that 34 percent of teens begin smoking as a result of tobacco company promotional activities.

Among middle school students who were current smokers, 71 percent reported never being asked to show proof of age when buying cigarettes in a store, and 66 percent were not refused purchase because of their age.

Checklist for Protection Against Secondhand Smoke:

Young children

Remember that you are a powerful role model. If you don’t smoke, your children are less likely to smoke.

Make your home and car smoke-free spaces. Put up no-smoking stickers and signs in your home.

Make sure you and your kids aren’t exposed to second-hand smoke at daycare, school, or friends’ homes.

Support businesses and activities that are smoke-free. Let other businesses owners know that you can’t support their businesses until they become 100 percent smoke-free too.

If you can’t find a smoke-free restaurant and must go to one that allows some smoking, ask to sit in the nonsmoking section.

If your asthma or COPD is triggered by smoke, don’t risk it-stay away from any place that allows smoking.

Support laws that restrict smoking.

Youth and Teens

Parents-

Talk to your children about smoking; they’ll be less likely to smoke than if you ignore the problem.

Support tobacco education in the schools and ban all smoking on school grounds, on school buses, and at school-sponsored events for students, school personnel, and visitors.

Ask that schools enforce the policy and consistently administer penalties for violations and that this is communicated in written and oral form to students, staff, and visitors.

Vote for public smoking restrictions as an important component of the social environment that supports healthy behavior, reducing the number of opportunities to smoke, and making smoking less socially acceptable.

Support tax increases on tobacco products so young people cannot afford them.

Teens-

If your friends smoke, ask them in a caring way to quit or at least not to smoke around you.

Peers, siblings, and friends are powerful influences on you and others. Understand that the most common situation for first trying a cigarette is with a friend who already smokes.

Families-

Work together to uphold restrictions on tobacco advertising

and promotions.

Sources and Resources

The Health Consequences of Involuntary Exposure to Tobacco Smoke: Children are Hurt by Secondhand Smoke. A Report of the Surgeon General, U.S. Department of Health and Human Services, 2006; Available at: www.surgeongeneral.gov/library/secondhandsmoke/factsheets/factsheet2.html.

CDC. Tobacco Use, Access & Exposure to Tobacco Among Middle & High School Students, US 2004 MMWR. Vol. 54(12) April 2005.

American Legacy Foundation. 2004 National Youth Tobacco Survey. 2005

CDC. Cigarette Use Among High School Students – United States, 1991-2003. Morbidity and Mortality Weekly Report 2004; 53(23): 499-502.

King C, Siegel M. The Master Settlement Agreement with the Tobacco Industry and Cigarette Advertising in Magazines. New England Journal of Medicine 2001; 345: 504-511.

Insight into sinus problems in adults and children

• How are sinusitis symptoms different than a cold or allergy?
• When does acute sinusitis become chronic?
• What treatments are available?

Have you ever had a cold or allergy attack that wouldn’t go away? If so, there’s a good chance you actually had sinusitis. Experts estimate that 37 million people are afflicted with sinusitis each year, making it one of the most common health conditions in America. That number may be significantly higher, since the symptoms of bacterial sinusitis often mimic those of colds or allergies, and many sufferers never see a doctor for proper diagnosis and treatment.

What is sinusitis?

Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.

Normally, mucus collecting in the sinuses drains into the nasal passages. When you have a cold or allergy attack, your sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Your doctor will diagnosis acute sinusitis if you have up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both. The sinus infection is likely bacterial if it persists for 10 days or longer, or if the symptoms worsen after an initial improvement.

When does acute sinusitis become chronic?

When you have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.

What treatments are available?

Antibiotic therapy – Therapy for bacterial sinusitis may include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart), be sure to see your doctor for diagnosis. An oral or nasal spray or drop decongestant may be recommended to relieve congestion, although you should avoid prolonged use of nonprescription nasal sprays or drops. Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.

Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections, such as sinusitis, challenging to treat. You can help prevent antibiotic resistance. One way is to wait up to 7 days before taking antibiotics for mild sinus infections, allowing time for your body to fight the infection naturally. If the doctor prescribes an antibiotic, it is important that you take all of the medication just as your doctor instructs, even if your symptoms are gone before the medicine runs out.

Intensive antibiotic therapy – If your doctor thinks you have chronic sinusitis, intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.

Sinus surgery – Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease. Surgery can be performed under the upper lip, behind the eyebrow, next to the nose or scalp, or inside the nose itself.

Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope, the surgeon can look directly into the nose, while at the same time, removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor, depending on your individual circumstances.

Before surgery, be sure that you have realistic expectations for the results, recovery, and postoperative care. Good results require not only good surgical techniques, but a cooperative effort between the patient and physician throughout the healing process. It is equally important for patients to follow pre- and postoperative instructions.

When should a doctor be consulted?

Because the symptoms of sinusitis sometimes mimic those of colds and allergies, you may not realize you need to see a doctor. If you suspect you have sinusitis, review these signs and symptoms. If you suffer from three or more, you should see your doctor.

Can children suffer from sinus infections?

Your child’s sinuses are not fully developed until age 20. However, children can still suffer from sinus infection. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Sinusitis is difficult to diagnose in children because respiratory infections are more frequent, and symptoms can be subtle. Unlike a cold or allergy, bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to prevent future complications.

The following symptoms may indicate a sinus infection in your child:

• A “cold” lasting more than 10 to 14 days, sometimes with low-grade fever
• Thick yellow-green nasal drainage
• Post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
• Headache, usually not before age 6
• Irritability or fatigue
• Swelling around the eyes

If despite appropriate medical therapy these symptoms persist, care should be taken to seek an underlying cause. The role of allergy and frequent upper respiratory infections should be considered.

Tips to prevent sinusitis

As always, an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack, keep your sinuses clear by:

• Using an oral decongestant or a short course of nasal spray decongestant
• Gently blowing your nose, blocking one nostril while blowing through the other
• Drinking plenty of fluids to keep nasal discharge thin
• Avoiding air travel. If you must fly, use a nasal spray decongestant before take-off to prevent blockage of the sinuses, allowing mucus to drain
• If you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks.

Allergy testing, followed by appropriate allergy treatments, may increase your tolerance of allergy-causing substances. If you believe you may have sinusitis, see our tips for sinusitis sufferers.

Insight into important senses

• How do smell and taste work?
• What causes loss of smell and taste?
• How are smell and taste loss diagnosed?
• and more…

Problems with these senses have a big impact on our lives. Smell and taste contribute to our enjoyment of life by stimulating a desire to eat – which not only nourishes our bodies, but also enhances our social activities. When smell and taste become impaired, we eat poorly, socialize less, and feel worse. Smell and taste warn us of dangers, such as fire, poisonous fumes, and spoiled food. Loss of the sense of smell may indicate sinus disease, growths in the nasal passages, or, at times, brain tumors.

How do smell and taste work?

Smell and taste belong to our chemical sensing system (chemosensation). The complicated process of smelling and tasting begins when molecules released by the substances around us stimulate special nerve cells in the nose, mouth, or throat. These cells transmit messages to the brain, where specific smells or tastes are identified.

• Olfactory (smell nerve) cells are stimulated by the odors around us-the fragrance from a rose, the smell of bread baking. These nerve cells are found in a tiny patch of tissue high up in the nose, and they connect directly to the brain.
• Gustatory (taste nerve) cells are clustered in the taste buds of the mouth and throat. They react to food or drink mixed with saliva. Many of the small bumps that can be seen on the tongue contain taste buds. These surface cells send taste information to nearby nerve fibers, which send messages to the brain.

Our body’s ability to sense chemicals is another chemosensory mechanism that contributes to our senses of smell and taste. In this system, thousands of free nerve endings-especially on the moist surfaces of the eyes, nose, mouth, and throat-identify sensations like the sting of ammonia, the coolness of menthol, and the “heat” of chili peppers.

What causes loss of smell and taste?

Scientists have found that the sense of smell is most accurate between the ages of 30 and 60 years. It begins to decline after age 60, and a large proportion of elderly persons lose their smelling ability. Women of all ages are generally more accurate than men in identifying odors.

Some people are born with a poor sense of smell or taste. Upper respiratory infections are blamed for some losses, and injury to the head can also cause smell or taste problems.

Loss of smell and taste may result from polyps in the nasal or sinus cavities, hormonal disturbances, or dental problems. They can also be caused by prolonged exposure to certain chemicals such as insecticides, and by some medicines.

Tobacco smoking is the most concentrated form of pollution that most people are exposed to. It impairs the ability to identify odors and diminishes the sense of taste. Quitting smoking improves the smell function.

Radiation therapy patients with cancers of the head and neck often complain of lost smell and taste. These senses can also be lost in the course of some diseases of the nervous system.

Patients who have lost their larynx (voice box) commonly complain of poor ability to smell and taste. Laryngectomy patients can use a special “bypass” tube to breathe through the nose again. The enhanced air flow through the nose helps smell and taste sensations to be re-established.

How are smell and taste loss diagnosed?

The extent of loss of smell or taste can be tested using the lowest concentration of a chemical that a person can detect and recognize. A patient may also be asked to compare the smells or tastes of different chemicals, and how the intensities of smells and tastes grow when a chemical concentration is increased.

• Smell-Scientists have developed an easily administered “scratch-and-sniff” test to evaluate the sense of smell.
• Taste-Patients react to different chemical concentrations in taste testing; this may involve a simple “sip, spit, and rinse” test, or chemicals may be applied directly to specific areas of the tongue.

Can these disorders be treated?

Sometimes certain medications are the cause of smell or taste disorders, and improvement occurs when that medicine is stopped or changed. Although certain medications can cause chemosensory problems, others-particularly anti-allergy drugs-seem to improve the senses of taste and smell. Some patients, notably those with serious respiratory infections or seasonal allergies, regain their smell or taste simply by waiting for their illness to run its course. In many cases, nasal obstructions, such as polyps, can be removed to restore airflow to the receptor area and can correct the loss of smell and taste. Occasionally, chemosenses return to normal just as spontaneously as they disappeared.

How do you cope with smell or taste problems?

If you experience problems in smelling or tasting, try to identify and record the circumstances surrounding it. When did you first become aware of it? Did you have a cold or flu then? A head injury? Were you exposed to air pollutants, pollens, danders, or dust to which you might be allergic? Is this a recurring problem? Does it come in any special season, like hayfever time?

Bring all this information with you when you visit a physician who deals with diseases of the nose and throat (an otolaryngologist-head and neck surgeon). Proper diagnosis by a trained professional can provide reassurance that your illness is not imaginary. You may even be surprised by the results. For example, what you may think is a taste problem could actually be a smell problem, because much of what you taste is really caused by smell.

Diagnosis may also lead to treatment of an underlying cause for the disturbance. Remember, many types of smell and taste disorders are reversible.

Flavor

Four commonly identified taste sensations:

• sweet
• sour
• bitter
• salty

Certain tastes combine with texture, temperature, and odor to produce a flavor that allows us to identify what we are eating.

Many flavors are recognized through the sense of smell. If you hold your nose while eating chocolate, for example, you will have trouble identifying the chocolate flavor, even though you can distinguish the food’s sweetness or bitterness. This is because the familiar flavor of chocolate is sensed largely by odor. So is the well known flavor of coffee. This is why a person who wishes to fully savor a delicious flavor (e.g., an expert chef testing his own creation) will exhale through his nose after each swallow.

Taste and smell cells are the only cells in the nervous system that are replaced when they become old or damaged. Scientists are examining this phenomenon while studying ways to replace other damaged nerve cells.

Insight into its effects on the body

• What chemicals are in smokeless tobacco?
• Who uses smokeless tobacco?
• Tips for quitting
• and more…

Three percent of American adults are smokeless tobacco users. They run the same risks of gum disease, heart disease, and addiction as cigarette users, but an even greater risk of oral cancer. Each year about 30,000 Americans are diagnosed with oral and pharyngeal cancers, and more than 8,000 people die of these diseases. Despite the health risks associated with tobacco use, consumers continue to demand the product. In 2001, the five largest tobacco manufacturers spent $236.7 million on smokeless tobacco advertising and promotion.

What is smokeless tobacco?

There are two forms of smokeless tobacco: chewing tobacco and snuff. Chewing tobacco is usually sold as leaf tobacco (packaged in a pouch) or plug tobacco (in brick form). Both are placed between the cheek and gum. Users keep chewing tobacco in their mouths for several hours to get a continuous high from the nicotine in the tobacco.

Snuff is a powdered tobacco (usually sold in cans) that is put between the lower lip and the gum. It is also referred to as “dipping.” Just a pinch is all that’s needed to release the nicotine, which is then swiftly absorbed into the bloodstream, resulting in a quick high.

The chemicals contained in chew or snuff are poisonous and addictive. Every time smokeless tobacco is used, the body adjusts to the amount of tobacco needed to get a high. Consequently, the next time tobacco is used, the body will need a little more to get the same feeling. Holding an average-sized dip or chew in the mouth for 30 minutes gives the user as much nicotine as smoking four cigarettes.

Is smokeless tobacco less harmful than cigarettes?

In 1986, the U.S. Surgeon General declared that the use of smokeless tobacco “is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous conditions and can lead to nicotine addiction and dependence.” Also, since 1991, the National Cancer Institute has recommended that the public avoid the use of all tobacco products, due to their high levels of nitrosamines.

In a recent study, cancer researchers found that oral tobacco products, including lozenges and moist snuff, are not a good alternative to smoking, since the levels of cancer-causing nitrosamines in smokeless tobacco and lozenges are very high. Some smokeless products contain the highest amounts of nicotine that can be readily absorbed by the body.

What are the ingredients in smokeless tobacco?

• Polonium 210 (nuclear waste)
• N-Nitrosamines (cancer-causing)
• Formaldehyde (embalming fluid)
• Nicotine (addictive drug)
• Cadmium (used in batteries and nuclear reactor shields)
• Cyanide (poisonous compound)
• Arsenic (poinsonous metallic element)
• Benzene (used in insecticides and motor fuels)
• Lead (nerve poison

Who are the most common smokeless tobacco users?

According to the 2000 National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration, young adults between the ages of 18-25 are the most common smokeless tobacco users. This trend may be influenced by innovative marketing tactics targeted at a younger audience.

Smokeless tobacco manufacturers are marketing flavored smokeless tobacco. A 2005 American Legacy Foundation and National Cancer Institute study noted, “Tobacco companies are using candy-like flavors and high tech delivery devices to turn a blowtorch into a flavored popsicle, misleading millions of youngsters to try a deadly product.”

What are the physical and mental effects of smokeless tobacco use?

Cancer. Smokeless tobacco is a cancer-causing agent, also knows as a carcinogen. Cancers are most likely to develop at the site where tobacco is held in the mouth, but it may also include the lips, tongue, cheek, and throat.

Leukoplakia. Smokeless tobacco users may develop a condition in which white spots form on the gums, inside of the cheeks, and sometimes on the tongue. It can be caused by the irritation from the tobacco juice, and the disorder can be considered pre-cancerous. Therefore, if a white patch does not heal within one week, consult a doctor.

Heart disease. The stimulating effects of nicotine, an organic compound made of carbon, hydrogen, nitrogen, and sometimes oxygen, increase the heart rate and blood pressure and may trigger irregular heartbeats.

Gum and tooth disease. Smokeless tobacco permanently discolors teeth, causes halitosis (bad breath), and may contribute to tooth loss. Smokeless tobacco contains a lot of sugar which forms an acid that may eat away the tooth enamel, causing cavities and mouth sores. Also, its direct and repeated contact with the gums may cause them to recede.

Social effects. Bad breath, discolored teeth.

What are some early warning signs of oral cancer?

• A sore that bleeds easily and does not heal
• A lump or thickening anywhere in the mouth or neck
• Soreness or swelling that does not go away
• A red or white patch that does not go away
• Trouble chewing, swallowing, or moving the  tongue or jaw

Tips to quit using smokeless tobacco for a lifetime

Write down a list of reasons to quit. For example:

• Don’t want to risk getting cancer.
• Family members find it offensive.
• Don’t like having bad breath after chewing and dipping.
• Don’t want stained teeth or no teeth.
• Don’t like being addicted to nicotine.
• Want to start leading a healthier life.
• Pick a date to quit and throw out all chewing tobacco and snuff.
• Remember daily your decision to stop chewing tobacco.
• Ask friends and family to help you stay committed to the decision to quit, by giving you support and encouragement.
• Find alternatives to smokeless tobacco to chew, such as sugarless gum, pumpkin or sunflower seeds, apple slices, raisins, or dried fruit.
• Engage in recreational activities to keep your mind off smokeless tobacco.
• Develop a personalized plan that works best; set realistic goals.
• Reward your successes.

Insight into sleeping disorders and sleep apnea

Forty-five percent of normal adults snore at least occasionally and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight people and usually worsens with age. Snoring may be an indication of obstructed breathing and should not be taken lightly. An otolaryngologist can help you to determine where the anatomic source of your snoring may be, and offer solutions for this noisy and often embarrassing behavior.

What causes snoring?

The noisy sounds of snoring occur when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures strike each other and vibrate during breathing.

In children, snoring may be a sign of problems with the tonsils and adenoids. A chronically snoring child should be examined by an otolaryngologist, who may recommend a tonsillectomy and adenoidectomy to return the child to full health.

People who snore may suffer from:

• Poor muscle tone in the tongue and throat: When muscles are too relaxed, the tongue falls backwards into the airway or the throat muscles draw in from the sides into the airway. Some relaxation is natural during deep sleep, but may become a problem if exacerbated by alcohol or drugs that cause sleepiness
• Excessive bulkiness of throat tissue: Children with large tonsils and adenoids often snore. Overweight people may have excess soft tissue in the neck that can lead to airway narrowing. Cysts or tumors are rare causes of airway narrowing.
• Long soft palate and/or uvula: A long palate narrows the opening from the nose into the throat. The excessive length of the soft palate and/or uvula acts as a noisy flutter valve during relaxed breathing.
• Obstructed nasal airways: A stuffy or blocked nose requires extra effort to pull air through it. This creates an exaggerated vacuum in the throat that pulls together the floppy tissues of the throat, and snoring results. So snoring may only occur during the hay fever season or with a cold or sinus infection. Also, deformities of the nose or nasal septum, such as a deviated septum (a deformity of the wall that separates one nostril from the other) can cause such an obstruction.

Why is snoring serious?

Socially – Snoring can make the snorer an object of ridicule and can cause the bed partner to experience sleepless nights and fatigue.

Medically – It disturbs sleeping patterns and deprives the snorer of adequate rest.  It may be a sign of obstructive sleep apnea (OSA), which can lead to serious, long-term health problems.

What is obstructive sleep apnea?

Snoring may be a sign of a more serious condition known as obstructive sleep apnea (OSA).  OSA is characterized by multiple episodes of breathing pauses greater than 10 seconds at a time, due to upper airway narrowing or collapse. This results in lower amounts of oxygen in the blood, which causes the heart to work harder. It also causes disruption of the natural sleep cycle, which makes people feel poorly rested despite adequate time in bed. Apnea patients may experience 30 to 300 such events per night.

The immediate effect of sleep apnea is that the snorer must sleep lightly and keep the throat muscles tense in order to keep airflow to the lungs. Because the snorer does not get a good rest, he or she may be sleepy during the day, which impairs job performance and makes him or her a hazardous driver or equipment operator. Untreated obstructive sleep apnea increases the risk of developing heart attacks, strokes, diabetes, and many other medical problems.

How is heavy snoring evaluated?

Heavy snorers should seek medical advice to ensure that sleep apnea is not a problem. Heavy snorers include people who snore constantly in any position or who negatively impact a bed partner’s sleep. An otolaryngologist will provide a thorough examination of the nose, mouth, throat, palate, and neck, often using a fiberoptic scope. An examination can reveal if the snoring is caused by nasal allergy, infection, nasal obstruction, or enlargement of tonsils and adenoids.  A sleep study in a laboratory or at home may be necessary to determine if snoring is due to OSA.
All snorers with any of the following symptoms should be evaluated for possible obstructive sleep apnea:

• Witnessed episodes of breath pauses or apnea during sleep
• Daytime sleepiness or fatigue
• High blood pressure
• Heart disease
• History of a stroke

What treatments are available?

Treatment depends on the diagnosis and level(s) of upper airway narrowing. In some cases, more than one area may be involved.

Snoring or OSA may respond to various treatments offered by many otolaryngologist—head and neck surgeons:

• Obstructive sleep apnea is most often treated with a device that opens the airway with a small amount of positive pressure. This pressure is delivered via a nasal mask worn during sleep. This treatment is called CPAP; it is currently the initial treatment of choice for patients with OSA.
• Uvulopalatopharyngoplasty (UPPP) is surgery for treating snoring and obstructive sleep apnea. It removes excess soft palate tissue and opens the airway. In addition, the remaining tissue stiffens as it heals, thereby minimizing tissue vibration. The size of the air passage may be further enlarged when a tonsillectomy is added to the procedure.
• Thermal ablation procedures reduce tissue bulk in the nasal turbinates, tongue base, and/or soft palate. These procedures are used for both snoring and OSA. Different methods of thermal ablation include bipolar cautery, laser, and radiofrequency. These procedures may be done in the operating room or during an office visit. Several treatments may be required.
• Methods to increase the stiffness of the soft palate without removing tissue include injecting an irritating substance that causes stiffness in the injected area near the uvula.  Another method is inserting stiffening rods (Pillar implants) into the soft palate.
• Genioglossus and hyoid advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway.
• A custom-fit oral appliance, which repositions the lower jaw forward, may also be considered for certain patients with snoring/ OSA. This should be fitted by an otolaryngologist, dentist, or oral surgeon with expertise in sleep dentistry.
• In some patients, significant weight loss can also improve snoring and OSA.

Do you recommend the use of over-the-counter devices?

There is no specific device recommended. More than 300 devices are registered in the U.S. Patent and Trademark Office as cures for snoring. Different methods include products that help a person avoid sleeping on their back, since snoring is often worse in that position. Some devices open nasal air passages; others have been designed to condition a person not to snore by producing unpleasant stimuli when snoring occurs. While a person may find a product that works for him or her, underlying poor sleep quality may remain.

Self-help for the light snorer

Adults who suffer from mild or occasional snoring should try the following self-help remedies:

• Adopt a healthy and athletic lifestyle to develop good muscle tone and lose weight.
• Avoid tranquilizers, sleeping pills, and antihistamines before bedtime.
• Avoid alcohol for at least four hours and heavy meals or snacks for three hours before retiring.
• Establish regular sleeping patterns.
• Sleep on your side rather than your back.
• Elevate the head of your bed four inches.

Insight into the many causes of nasal congestion

• What are the causes of nasal congestion?
• Are there any risks when treating congestion?
• Where can I find out more?

Nasal congestion, stuffiness, or obstruction to nasal breathing is one of the oldest and most common human complaints. For some, it may only be a nuisance; for others, nasal congestion can be a source of considerable discomfort.

Medical writers have established four main causes of nasal obstruction: infection, structural abnormalities, allergic, and nonallercic (vasomotor) rhinitis. Patients often have a combination of these factors which vary from person to person.

What are the causes of nasal congestion?

Infection

An average adult suffers a “common cold” two to three times per year. These viral infections occur more often in childhood because immunity strengthens with age. A cold is caused by one of many different viruses, some of which are airborne, but most are transmitted by hand-to-nose contact. Once the virus is absorbed by the nose, it causes the body to release histamine, a chemical which dramatically increases blood flow to the nose and causes nasal tissue to swell. This inflames the nasal membranes which become congested with blood and produce excessive amounts of mucus that “stuffs up” the nasal airway. Antihistamines and decongestants help relieve the symptoms of a cold, but no medication can cure it. Ultimately, time is what is needed to get rid of the infection.

During a viral infection, the nose has poor resistance to bacteria, which is why infections of the nose and sinuses often follow a “cold.” When the nasal mucus turns from clear to yellow or green, it usually means that a bacterial infection has set in. In this case, a physician should be consulted.

Acute sinus infections produce nasal congestion and thick discharge. Pain may occur in cheeks and upper teeth, between and behind the eyes, or above the eyes and in the forehead, depending on which sinuses are involved.

Chronic sinus infections may or may not cause pain, but usually involve nasal obstruction and offensive nasal or postnasal discharge. Some people develop polyps (fleshy growths in the nose) from sinus infections, and the infection can spread to the lower airways, leading to a chronic cough, bronchitis, or asthma. Acute sinus infections generally respond to antibiotic treatment; chronic sinusitis may require surgery.

Structural abnormalities

These include deformities of the nose and nasal septum; the thin, flat cartilage and bone that divides the two sides of the nose and nostrils. These deformities are usually the result of an injury, sometimes having occurred in childhood. Seven percent of newborn babies suffer significant nasal injury in the birth process. Nasal injuries are common in both children and adults. If they obstruct breathing, surgical correction may be helpful.

One of the most common causes of nasal obstruction in children is enlargement of the adenoids. These are a tonsil-like tissue located in the back of the nose, behind the palate. Children with this problem may experience noisy breathing at night and may snore. Children who are chronic mouth breathers may develop a sagging face and dental deformities. In this case, surgery to remove the adenoids and/or tonsils may be advisable.

Other causes in this category include nasal tumors and foreign bodies. Children are often known to insert small objects into their noses. If a foul-smelling discharge is observed draining from one nostril, a physician should be consulted.

Allergies

Hay fever, rose fever, grass fever, and summertime colds are various names for allergic rhinitis. Allergy is an exaggerated inflammatory response to a substance which, in the case of a stuffy nose, is usually pollen, mold, animal dander, or some element in house dust. Pollen may cause problems during spring, summer, and fall, whereas house dust allergies are often most evident in the winter. Molds may cause symptoms year-round. In the allergic patient, the release of histamine and similar substances results in congestion and excess production of watery nasal mucus. Antihistamines help relieve the sneezing and runny nose of allergy. Typical antihistamines include Benadryl®, Chlortrimetron®, Claritin®, Teldrin®, Dimetane®, Hismanal®, Nolahist®, PBZ®, Polaramine®, Seldane®, Tavist®, Zyrtec®, Allegra®, and Alavert®, which are often available without a prescription and are available in several generic forms. Combinations of antihistamines with decongestants are also available.

Allergy shots are a specific and successful treatment method. SLIT skin tests and sometimes blood tests are used to make up vials of allergy-inducing substances specific to an individual patient’s profile. The physician determines the best concentration for the first treatment. Once injected, these treatments form blocking antibodies in the patient’s blood stream that interfere with the allergic reaction. Injections are typically given for a period of three to five years. Patients with allergies are more likely to need treatment for sinus infections.

Vasomotor Rhinitis

“Rhinitis” means inflammation of the nose and nasal membranes. “Vasomotor” means pertaining to the nerves that control the blood vessels. Membranes in the nose have an abundant supply of arteries, veins, and capillaries, which have the ability to expand and constrict. Normally these blood vessels are in a half-constricted or half-open state. But when a person exercises vigorously, hormone (adrenaline) levels increase. Adrenaline causes constriction of the nasal membranes so that the air passages open up and the person breathes freely.

The opposite takes place when an allergic attack or a cold develops. During a cold, blood vessels expand, membranes become congested, and the nose becomes stuffy, or blocked.

In addition to allergies and infections, certain circumstances can cause nasal blood vessels to expand, leading to vasomotor rhinitis. These include psychological stress, inadequate thyroid function, pregnancy, certain anti-high blood pressure drugs, prolonged overuse of decongesting nasal sprays, and exposure to irritants such as perfumes and tobacco smoke.

In the early stages of these disorders, nasal stuffiness is temporary and reversible. It usually improves when the primary cause is corrected. However, if the condition persists, the blood vessels lose their capacity to constrict, much like varicose veins. When the patient lies down on one side, the lower side becomes congested, which interferes with sleep. It is helpful to sleep with the head of the bed elevated two to four inches. Surgery is another option that can provide dramatic and long-time relief.

Are there any risks when treating congestion?

Patients who get sleepy from antihistamines should not drive an automobile or operate dangerous equipment after taking them. Decongestants increase pulse rate and elevate blood pressure and therefore should be avoided by those with high blood pressure, irregular heart beat, glaucoma, or difficulty urinating.

Pregnant patients should consult their obstetricians before taking any medicine.

Cortisone-like drugs (corticosteriods) are powerful decongestants, administered as nasal sprays to minimize the risk of serious side effects associated with other dosage forms. Patients using steroid nasal sprays should follow instructions carefully, and consult a physician immediately if they develop nasal bleeding, crusting, pain, or vision changes.

Where can I find out more?

Additional information and suggestions can be found in the AAO-HNS pamphlets, “Doctor, Please Explain Antihistamines, Decongestants, and Cold Remedies,” “Doctor, Please Explain Allergies & Hay Fever,” and “Doctor, Please Explain Sinusitis.”

Insight into causes and treatments

• How does the Temporo-Mandibular Joint work?
• What causes TMJ pain?
• How is TMJ pain treated?
• and more…

Open your jaw all the way and shut it. This simple movement would not be possible without the Temporo-Mandibular Joint (TMJ). It connects the temporal bone (the bone that forms the side of the skull) and the mandible (the lower jaw). Even though it is only a small disc of cartilage, it separates the bones so that the mandible may slide easily whenever you talk, swallow, chew, kiss, etc. Therefore, damage to this complex, triangular structure in front of your ear, can cause considerable discomfort.

Where is the Temporo-Mandibular Joint?

You can locate this joint by putting your finger on the triangular structure in front of your ear. Then move your finger just slightly forward and press firmly while you open your jaw all the way and close it. You can also feel the joint motion in your ear canal.

How does the TMJ work?

When you bite down hard, you put force on the object between your teeth and on the joint. In terms of physics, the jaw is the lever and the TMJ is the fulcrum. Actually, more force is applied (per square foot) to the joint surface than to whatever is between your teeth because the cartilage between the bones provides a smooth surface, over which the joint can freely slide with minimal friction.

Therefore, the forces of chewing can be distributed over a wider surface in the joint space and minimize the risk of injury. In addition, several muscles contribute to opening and closing the jaw and aid in the function of the TMJ.

What causes TMJ pain?

In most patients, pain associated with the TMJ is a result of displacement of the cartilage disc that causes pressure and stretching of the associated sensory nerves. The popping or clicking occurs when the disk snaps into place when the jaw moves. In addition, the chewing muscles may spasm, not function efficiently, and cause pain and tenderness.

What causes damage to the TMJ?

• Major and minor trauma to the jaw
• Teeth grinding
• Excessive gum chewing
• Stress and other psychological factors
• Improper bite or malpositioned jaws
• Arthritis

What are the symptoms?

• Ear pain
• Sore jaw muscles
• Temple/cheek pain
• Jaw popping/clicking
• Locking of the jaw
• Difficulty in opening the mouth fully
• Frequent head/neck aches

The pain may be sharp and searing, occurring each time you swallow, yawn, talk, or chew, or it may be dull and constant. It hurts over the joint, immediately in front of the ear, but pain can also radiate elsewhere. It often causes spasms in the adjacent muscles that are attached to the bones of the skull, face, and jaws. Then pain can be felt at the side of the head (the temple), the cheek, the lower jaw, and the teeth.

A very common focus of pain is in the ear. Many patients come to the ear specialist quite convinced their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the doctor will consider the possibility that the pain comes from TMJ.

There are a few other symptoms besides pain that TMJ can cause. It can make popping, clicking, or grinding sounds when the jaws are opened wide. Or the jaw locks wide open (dislocated). At the other extreme, TMJ can prevent the jaws from opening fully. Some people get ringing in their ears from TMJ.

How is TMJ pain treated?

Because TMJ symptoms often develop in the head and neck, otolaryngologists are appropriately qualified to diagnose TMJ problems. Proper diagnosis of TMJ begins with a detailed history and physical, including careful assessment of the teeth occlusion and function of the jaw joints and muscles. An early diagnosis will likely respond to simple, self-remedies:

• Rest the muscles and joints by eating soft foods.
• Do not chew gum.
• Avoid clenching or tensing.
• Relax muscles with moist heat (1/2 hour at least twice daily).

In cases of joint injury, apply ice packs soon after the injury to reduce swelling. Relaxation techniques and stress reduction, patient education, non-steroidal anti-inflammatory drugs, muscle relaxants, or other medications may also offer relief.

Other treatments for advanced cases may include fabrication of an occlusal splint to prevent wear and tear on the joint, improving the alignment of the upper and lower teeth, and surgery. After diagnosis, your otolaryngologist may suggest further consultation with your dentist and oral surgeon to

Insight into tonsillectomy and adenoidectomy

• What affects tonsils and adenoids?
• When should I see a doctor?
• Common symptoms of tonsillitis and enlarged adenoids
• and more…

Tonsils and adenoids are on the body’s first line of defense-our immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose at the risk of their own infection. But at times, they become more of a liability than an asset and may even trigger airway obstruction or repeated bacterial infections. Your ear, nose, and throat specialist can suggest the best treatment options.

What are tonsils and adenoids?

Two masses of tissue that are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two masses on the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth without special instruments.

What affects tonsils and adenoids?

The most common problems affecting the tonsils and adenoids are recurrent infections (throat or ear) and significant enlargement or obstruction that causes breathing, swallowing, and sleep problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling, cheese-like formations can also affect the tonsils and adenoids, making them sore and swollen. Tumors are rare, but can grow on the tonsils.

When should I see a doctor?

You should see your doctor when you or your child suffer the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she will use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

• Medical history
• Physical examination
• Throat cultures/Strep tests – helpful in determining infections in the throat
• X-rays – helpful in determining the size and shape of the adenoids
• Blood tests – helpful in determing infections such as mononucleosis

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Sometimes, removal of the tonsils and/or adenoids may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness in adults and behavioral problems in children.

Chronic infection can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and potential hearing loss. Recent studies indicate adenoidectomy may be a beneficial treatment for some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., cortisone) is sometimes helpful.

How to prepare for surgery

Children

• Talk to your child about his/her feelings and provide strong reassurance and support
• Encourage the idea that the procedure will make him/her healthier.
• Be with your child as much as possible before and after the surgery.
• Tell him/her to expect a sore throat after surgery.
• Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
• If your child has a friend who has had this surgery, it may be helpful to talk about it with that friend.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome).

• If the patient or patient’s family has had any problems with anesthesia, the surgeon should be informed. If the patient is taking any other medications, has sickle cell anemia, has a bleeding disorder, is pregnant, has concerns about the transfusion of blood, or has used steroids in the past year, the surgeon should be informed.
• A blood test and possibly a urine test may be required prior to surgery.
• Generally, after midnight prior to the operation, nothing may be taken by mouth (including chewing gum, mouthwashes, throat lozenges, toothpaste, water.) Anything in the stomach may be vomited when anesthesia is induced, and this is dangerous.

When the patient arrives at the hospital or surgery center, the anesthesiologist or nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient until discharged. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of preoperative and postoperative care and answer any questions you may have.

After surgery

There are several postoperative symptoms that may arise. These include, but are not limited to, swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.

Any questions or concerns you have should be discussed openly with your surgeon.

Tonsillitis and its symptoms

Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs or symptoms are:

• Redder than normal tonsils
• A white or yellow coating on the tonsils
• A slight voice change due to swelling
• Sore throat
• Uncomfortable or painful swallowing
• Swollen lymph nodes (glands) in the neck
• Fever
• Bad breath

Enlarged adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. Other signs of constant enlargement are:

• Breathing through the mouth instead of the nose most of the time
• Nose sounds “blocked” when the person speaks
• Noisy breathing during the day
• Recurrent ear infections
• Snoring at night
• Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea)

About 40,000 people in the United States develop facial paralysis each year with children comprising a small percentage of that population. There are more than 50 known causes of facial paralysis but the most common in children is “Bell’s palsy,” the cause of which is not certain. This disorder effects one side of the facial muscles due to dysfunction of the seventh cranial nerve, usually thought to stem from a viral infection; Bell’s palsy is found in 20 out of 100,000 Americans, with the incidence increasing with each decade of life.

What causes Bell’s palsy?

In Bell’s palsy, facial paralysis results from damage (e.g., possibly from viral infection) to the facial nerve. Adults and children will either wake up to find they have facial paralysis or palsy, or have symptoms such as a dry eye or tingling around their lips that progress to Bell’s palsy during that same day. Occasionally symptoms may take a few days to progress to facial weakness or paralysis. Physical trauma to the head and neck region at birth and during childhood may cause facial paralysis. Other causes are:

Chicken pox: Chicken pox and shingles are both caused by a single virus of the herpes family known as varicella-zoster virus (VZV). Varicella is the primary infection that causes chickenpox; Herpes zoster is the reactivation of the virus that causes shingles. Research studies suggest that Bell’s palsy may be due to a reactivation of herpes simplex virus (HSV). Between 75 percent and 90 percent of chickenpox cases occur in children under 10 years of age. According to a 2001 study, about 10 percent of children between ages five and nine and about two percent of 10 to 14 year olds get chicken pox each year.
Infectious mononucleosis: This condition, with a peak incidence in the 15- 17 age group, can be caused by several different viruses. The leading causes are the Epstein-Barr virus and cytomegalovirus, both members of the herpes virus family. The infection is transmitted by saliva, sexual contact, respiratory droplets, and blood transfusions.
Lyme disease: Lyme disease is an infection that’s spread by Ixodes ticks (black-legged or deer ticks in the eastern United States, and western black-legged ticks in the west). The second stage of Lyme disease usually appears two to three months after the tick bite, and may include facial palsy or paralysis among other symptoms.

What are the symptoms of Bell’s palsy in children?

Not all children react the same to this disorder. However, recorded symptoms include:

• The child may complain of headache or pain behind or in front of the ear a few days prior to the onset of Bell’s palsy.
• Swelling or drooping on one side of the face.
• Drooling, excessive, or reduced production of saliva.
• An inability to blink or completely close one eye.
• The child has either excessive tears or marked dryness and inability to make tears in one eye.
• Sounds seem louder than they really are.
• The child is experiencing sensitivity to light.
• Episodes of dizziness.

Treatments for Facial Paralysis:

If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like herpes zoster (Ramsay Hunt Syndrome) may be used. The prognosis for children with facial paralysis is generally very good. The extent of nerve damage determines the extent of recovery. With or without treatment, studies indicate that most pediatric patients with the disorder begin to get better within two weeks after the initial onset of symptoms and recover completely within three to six months. Adults may find residual symptoms remaining for an indefinite period of time.

What happens during the diagnosis?

After an examination, the otolaryngologist- head and neck surgeon may conduct a hearing test to determine if the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism. Additional tests in the physician’s office include a balance test and a tear test, to measure the eye’s ability to produce tears. Eye drops may be necessary to prevent drying of the surface of the eye cornea. In some circumstances, the physician may recommend a CT (computerized tomography) or MRI (magnetic resonance imaging) test to determine if there is infection, tumor, bone fracture, or other abnormality in the area of the facial nerve. An additional diagnostic tool is the Electro neuronography (ENOG), which stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.

Insight into causes and prevention

• What is dizziness?
• What causes dizziness?
• How will my dizziness be treated?
• and more…

Feeling unsteady or dizzy can be caused by many factors such as poor circulation, inner ear disease, medication usage, injury, infection, allergies, and/or neurological disease. Dizziness is treatable, but it is important for your doctor to help you determine the cause so that the correct treatment is implemented. While each person will be affected differently, symptoms that warrant a visit to the doctor include a high fever, severe headache, convulsions, ongoing vomiting, chest pain, heart palpitations, shortness of breath, inability to move an arm or leg, a change in vision or speech, or hearing loss.

What is dizziness?

Dizziness can be described in many ways, such as feeling lightheaded, unsteady, giddy, or feeling a floating sensation. Vertigo is a specific type of dizziness experienced as an illusion of movement of one’s self or the environment. Some experience dizziness in the form of motion sickness, a nauseating feeling brought on by the motion of riding in an airplane, a roller coaster, or a boat. Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium. Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:

• The inner ear (also called the labyrinth), which monitors the directions of motion, such as turning, rolling, forward-backward, side-to-side, and up-and-down motions.
• The eyes, which monitor where the body is in space (i.e., upside down, right side up, etc.) and also directions of motion.
• The pressure receptors in the joints of the lower extremities and the spine, which tell what part of the body is down and touching the ground.
• The muscle and joint sensory receptors (also called proprioception) tell what parts of the body are moving.
• The central nervous system (the brain and spinal cord), which processes all the information from the four other systems to maintain balance and equilibrium.

The symptoms of motion sickness and dizziness appear when the central nervous system receives conflicting messages from the other four systems.

What causes dizziness?

Circulation: If your brain does not get enough blood flow, you feel lightheaded. Almost everyone has experienced this on occasion when standing up quickly from a lying-down position. But some people have light-headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac (heart) function, hypoglycemia (low blood sugar), or anemia (low iron).

Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension.

If the inner ear fails to receive enough blood flow, the more specific type of dizziness—vertigo—occurs. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear.

Neurological diseases: A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis, tumors, etc. These are uncommon causes, but your doctor may perform certain tests to evaluate these.
Anxiety: Anxiety can be a cause of dizziness and lightheadedness. Unconscious overbreathing (hyperventilation) can be experienced as overt panic, or just mild dizziness with tingling in the hands, feet, or face. Instruction on correct breathing technique may be required.
Vertigo: An unpleasant sensation of the world rotating, usually associated with nausea and vomiting. Vertigo usually is due to an issue with the inner ear. The common causes of vertigo are (in order):

• Benign Positional Vertigo: Vertigo is experienced after a change in head position such as lying down, turning in bed, looking up, or stooping. It lasts about 30 seconds and ceases when the head is still. It is due to a dislodged otololith crystal entering one of the semicircular balance canals. It can last for days, weeks, or months. The Epley “repositioning” treatment by an otolaryngologist is usually curative. BPV is the commonest cause of dizziness after (even a mild) head injury.
• Meniere’s disease: An inner ear disorder with attacks of vertigo (lasting hours), nausea, or vomiting, and tinnitus (loud noise) in the ear, which often feels blocked or full. There is usually a decrease in hearing as well.
• Migraine: Some individuals with a prior classical migraine headache history can experience vertigo attacks similar to Meniere’s disease. Usually there is an accompanying headache, but can also occur without the headache.
• Infection: Viruses can attack the inner ear, but usually its nerve connections to the brain, causing acute vertigo (lasting days) without hearing loss (termed vestibular neuronitis). However, a bacterial infection such as mastoiditis that extends into the inner ear can completely destroy both the hearing and equilibrium function of that ear, called labyrinthitis.
• Injury: A skull fracture that damages the inner ear produces a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks and slowly improve as the other (normal) side takes over. BPV commonly occurs after head injury.
• Allergy: Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, dander, etc.) to which they are allergic.

When should I seek medical attention?

Call 911 or go to an emergency room if you experience:

• Dizziness after a head injury,
• fever over 101°F, headache, or very stiff neck,
• convulsions or ongoing vomiting,
• chest pain, heart palpitations, shortness of breath, weakness, a severe headache, inability to move an arm or leg, change in vision or speech, or
• fainting and/or loss of consciousness

Consult your doctor if you:

• have never experienced dizziness before,
• experience a difference in symptoms you have had in the past,
• suspect that medication is causing your symptoms, or
• experience hearing loss.

How will my dizziness be treated?

The doctor will ask you to describe your dizziness and answer questions about your general health. Along with these questions, your doctor will examine your ears, nose, and throat. Some routine tests will be performed to check your blood pressure, nerve and balance function, and hearing. Possible additional tests may include a CT or MRI scan of your head, special tests of eye motion after warm or cold water or air is used to stimulate the inner ear (ENG—electronystagmography or VNG—videonystagmography), and in some cases, blood tests or a cardiology (heart) evaluation. Balance testing may also include rotational chair testing and posturography. Your doctor will determine the best treatment based on your symptoms and the cause of them. Treatments may include medications and balance exercises.

Prevention tips

• Avoid rapid changes in position
• Avoid rapid head motion (especially turning or twisting)
• Eliminate or decrease use of products that impair circulation, e.g., tobacco, alcohol, caffeine, and salt
• Minimize stress and avoid substances to which you are allergic
• Get enough fluids
• Treat infections, including ear infections, colds, flu, sinus congestion, and other respiratory infections

If you are subject to motion sickness:

• Do not read while traveling
• Avoid sitting in the rear seat
• Do not sit in a seat facing backward
• Do not watch or talk to another traveler who is having motion sickness
• Avoid strong odors and spicy or greasy foods immediately before and during your travel
• Talk to your doctor about medications

Remember: Most cases of dizziness and motion sickness are mild and self-treatable. But severe cases and those that become progressively worse deserve the attention of a doctor with specialized skills in diseases of the ear, nose, throat, equilibrium, and neurological systems.

Insight into procedures

• Why consider facial plastic surgery?
• What kinds of problems are treated?
• and more…

Facial expressions are a way to interact with others. How we look has an impact on how others perceive us, so most of us are concerned about our face’s appearance.

Some would like to change certain things about their face. Others are born with facial abnormalities such as a cleft lip, a birthmark, or other birth defects. Many of us notice the effects of aging, sun damage, or previous facial trauma. Fortunately, many of these conditions can be corrected through surgical procedures performed by a surgeon.

Why consider facial plastic surgery?

The range of conditions that otolaryngologists diagnose and treat are widely varied and can involve the whole face, nose, lips, ears, and neck. Facial plastic surgery treats a specific component of these conditions and can be divided into two types-reconstructive and cosmetic. Reconstructive plastic surgery is performed for patients with conditions that may be present from birth, such as birthmarks on the face, cleft lip and palate, protruding ears, and a crooked smile. Other conditions that are the result of accidents, trauma, burns, or previous surgery are also corrected with this type of surgery. In addition, some reconstructive procedures are required to treat existing diseases like skin cancer. Cosmetic facial plastic surgery is surgery performed to enhance visual appearance of the facial structures. Typical procedures include facelifts, eye lifts, rhinoplasty, and liposuction. An otolaryngologist surgeon is well trained to address all of these problems.

What training is necessary?

An otolaryngologist can receive up to 15 years of college and post-graduate training in plastic surgery, concentrating on procedures that reconstruct the elements of the face.

Post-graduate training includes a year of general surgery, four years of residency in otolaryngology (disorders of the ears, nose, and throat), and may also include one to two years in a fellowship dedicated to facial plastic surgery.

After passing a rigorous set of exams given by the American Board of Otolaryngology, otolaryngologists may become board-certified in the specialty of Otolaryngology-Head and Neck Surgery. Because they study the complex anatomy, physiology, and pathology of the entire head and neck, these specialists (sometimes called ENTs) are uniquely qualified to perform the procedures that affect the whole face.

What kinds of problems are treated?

The following are examples of procedures:

Rhinoplasty/Septoplasty-Surgery of the external and internal nose in which cartilage and bone are restructured and reshaped to improve the appearance and function of the nose.

Blepharoplasty-Surgery of the upper and/or lower eyelids to improve the function and/or look of the eyes.

Rhytidectomy-Surgery of the skin of the face and neck to tighten the skin and remove excess wrinkles.

Browlift-Surgery to improve forehead wrinkles and droopy eyebrows.

Liposuction-Surgery to remove excess fat under the chin or in the neck.

Facial implants-Surgery to make certain structures of the face (cheek, lips, chin) more prominent and well defined.

Otoplasty-Surgery to reshape the cartilage of the ears so they protrude less.

Skin surface procedures-Surgery using lasers, chemical peels, or derma-abrasion to improve the smoothness of the skin.

Facial reconstruction-Surgery to reconstruct defects in facial skin as a result of prior surgery, injury, or disease. This includes reconstruction of defects resulting from cancer surgery, scar revision, repair of lacerations to the face from prior trauma, removal of birth marks, and correction of congenital abnormalities of the skull, palate, or lips.

Non-surgical procedures-Techniques such as chemical peels, microdermabrasion, and injectables. Injectables are medications that can be placed under the skin to improv the appearance of the face, such as botox, collagen, Restylane, and other fillers.

How do I find a surgeon?

The Academy can recommend a board-certified otolaryngologist in your area who has a specific interest in facial plastic surgery. A reputable surgeon will take a thorough patient history and advise you on the best procedure for you. Patients should also be cautious not to be swayed by doctors who have the latest equipment, but should instead focus on finding the provider who possesses the skills, expertise, and experience necessary to choose the right treatment method for each individual.

What should you know prior to facial plastic surgery?

Your surgeon should discuss the procedure, risks, and recovery with you. Knowing what to expect will put you more at ease. You should ask how many of the particular type of procedures the surgeon has performed, and how often. You should also know what sort of preparation plans you need to make, how long the procedure will take, and any associated risks. Your surgeon should advise you about any medications you should avoid before your surgery.

Some risks might include: nausea, numbness, bleeding, blood clots, infection, and adverse reactions to the anesthesia. Additionally, if you smoke, you should avoid doing so for two weeks before your surgery in order to optimize healing following your procedure.

You will also want to understand all associated costs and payment options before undergoing any procedure. Insurance will usually cover reconstructive plastic surgery, but check with your provider. If you will be paying for the procedure, find out what payment options are available and if there is a payment plan.

What will recovery be like?

Most plastic surgery will not require a long hospital stay. Depending on the extent of your surgery, some procedures can be completed on an outpatient basis, meaning you would not require a hospital stay. Other procedures may require a hospital stay overnight or for a day or two. Either way, before you are released from the hospital, your surgeon will discuss with you any special care to take while you’re recovering at home. You will be provided with gauze and other types of dressings to tend to your incision area. Permanent sutures and surgical staples will be removed in the office about a week after the procedure. Your surgeon should also explain any special diet you should follow, medications you should take or avoid, and any restriction on activities.

Following your surgery, generally, you should:

• Avoid aerobic exercise for two weeks.
• Refrain from weight lifting and contact sports for one month.
• Talk with your surgeon about medication to manage pain and swelling.
• Avoid aspirin because it can cause bleeding and make bruising worse.

Most patients feel comfortable returning to work one to two weeks following their surgery, when swelling and bruising are reduced and their appearance has improved.

Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.

Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it’s your response that can make the difference between a temporary inconvenience and permanent injury.

When Someone Gets Hurt:

What First Aid Supplies Should You Have on Hand in Case of An Emergency?

• Sterile cloth or pads
• Scissors
• Ice pack
• Tape
• Sterile bandages
• Cotton tipped swabs
• Hydrogen peroxide
• Nose drops
• Antibiotic ointment
• Eye pads
• Cotton balls
• Butterfly bandages

Ask “Are you all right?” Determine whether the injured person is breathing and knows who and where they are.

Be certain the person can see, hear and maintain balance. Watch for subtle changes in behavior or speech, such as slurring or stuttering. Any abnormal response requires medical attention.

Note weakness or loss of movement in the forehead, eyelids, cheeks and mouth.

Look at the eyes to make sure they move in the same direction and that both pupils are the same size.

If any doubts exist, seek immediate medical attention.

When Medical Attention Is Required, What Can You Do?

• Call for medical assistance (911).
• Do not move the victim, or remove helmets or protective gear.
• Do not give food, drink or medication until the extent of the injury has been determined.
• Remember HIV…be very careful around body fluids. In an emergency protect your hands with plastic bags.
• Apply pressure to bleeding wounds with a clean cloth or pad, unless the eye or eyelid is affected or a loose bone can be felt in a head injury. In these cases, do not apply pressure but gently cover the wound with a clean cloth.
• Apply ice or a cold pack to areas that have suffered a blow (such as a bump on the head) to help control swelling and pain.
• Remember to advise your doctor if the patient has HIV or hepatitis.

Facial Fractures

Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:

• Swelling and bruising, such as a black eye
• Pain or numbness in the face, cheeks or lips
• Double or blurred vision
• Nosebleeds
• Changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face; and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some require medical attention.

You should get immediate medical care when you have:

• Deep skin cuts
• Obvious deformity or fracture
• Loss of facial movement
• Persistent bleeding
• Change in vision
• Problems breathing and/or swallowing
• Alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen is important during the healing process to prevent pigment changes. Scars that look too obvious after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:

• Breathing difficulties
• Deformity of the nose
• Persistent bleeding
• Cuts

Bleeding

Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.

Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist-head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later.

Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose may last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist — head and neck surgeon. Injuries may involve specific structures within the neck, such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.

Prevention Of Facial Sports Injuries

The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:

• Be sure the playing areas are large enough that players will not run into walls or other obstructions.
• Cover unremoveable goal posts and other structures with thick, protective padding.
• Carefully check equipment to be sure it is functioning properly.
• Require protective equipment – such as helmets and padding for football, bicycling and rollerblading; face masks, head and mouth guards for baseball; ear protectors for wrestlers; and eyeglass guards or goggles for racquetball and snowmobiling are just a few.
• Prepare athletes with warm-up exercises before engaging in intense team activity.
• In the case of sports involving fast-moving vehicles, for example, snowmobiles or dirt bikes – check the path of travel, making sure there are no obstructing fences, wires or other obstacles.
• Enlist adequate adult supervision for all children’s competitive sports.

What is facial trauma?

The term facial trauma means any injury to the face or upper jaw bone. Facial traumas include injuries to the skin, underlying skeleton, neck, nose and sinuses, eye socket, or teeth and other parts of the mouth. Sometimes these types of injuries are called maxillofacial injury. Facial trauma is often recognized by swelling or lacerations (breaks in the skin). Signs of broken bones include bruising around the eyes, widening of the distance between the eyes, movement of the upper jaw when the head is stabilized, abnormal sensations on the face, and bleeding from the nose, mouth, or ear.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, 5 percent have suffered facial fractures. In children under three years old, the primary cause of these fractures is falls. In children more than five years old, the primary cause for facial trauma is motor vehicle accidents. Fortunately, the correct use of seat belts, boosters, and car seats can dramatically reduce the risk of facial trauma in children.

A number of activities put children at risk for facial injury, such as contact sports, cheerleading, gymnastics, and cycling. Proper supervision and appropriate protective gear should always be employed during these activities. But when accidents do happen, children’s facial injuries require special attention, as a child’s future growth plays a big role in treatment for facial trauma. So one of the most important issues for a caregiver is to follow a physician’s treatment plan as closely as possible until your child is fully recovered.

Why is facial trauma different in children than adults?

Facial trauma can range between minor injury to disfigurement that lasts a lifetime. The face is critical in communicating with others, so it is important to get the best treatment possible. Pediatric facial trauma differs from adult injury because the face is not fully formed and future growth will be a factor in how the child heals and recovers. Certain types of trauma may cause a delay in growth or further complicate recovery. Difficult cases require doctors or a team of doctors with special skills to make a repair that will grow with your child.

Types of facial trauma

New technology, such as advanced CT scans that can provide three-dimensional anatomic detail, has improved physicians’ ability to evaluate and manage facial trauma. In some cases, immediate surgery is needed to realign fractures before they heal incorrectly. Other injuries will have better outcomes if repairs are done after cuts and swelling have improved. Research has shown that even when an injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physician’s care.

Soft tissue injuries

Injuries such as cuts (lacerations) may occur on the soft tissue of the face. In combination with suturing the wound, the provider should take care to inspect and treat any injures to the facial nerves, glands, or ducts. In younger children, many lacerations require sedation or general anesthesia to achieve the best repair.

Bone injuries

When facial bone fractures occur, the treatment is similar to that of a fracture in other parts of the body. Some injuries may not need treatment, and others may require stabilization and fixation using wires, plates, and screws. Factors influencing these treatment decisions are the location of the fracture, the severity of the fracture, and the age and general health of the patient. It is important during treatment of facial fractures to be careful that the patient’s facial appearance is minimally affected.

Injuries to the teeth and surrounding dental structures style

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Because of the specific needs of the dental structures, certain actions and precautions should be taken if a child has received an injury to his or her teeth or surrounding dental structures.

• If a tooth is “knocked out” it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better the chance it will survive, so the patient should see a dentist or oral surgeon as soon as possible.
• Never attempt to “wipe the tooth off” since remnants of the ligament which hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.

References:

Stewart MG, Chen AY. Factors predictive of poor compliance with follow-up after Facial trauma: A prospective study. Otolaryngol Head Neck Surg 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetrating neck trauma in children: An urban hospital’s experience. Otolaryngol Head Neck Surg 2000: 123: 439-43

What is cleft lip and cleft palate?

We all start out life with a cleft lip and palate. During normal fetal development between the 6th and 11th week of pregnancy, the clefts in the lip and palate fuse together. In babies born with cleft lip or cleft palate, one or both of these splits failed to fuse.

A “cleft” means a split or separation; the palate is the “roof” of the mouth. A cleft palate or lip then is a split in the oral (mouth) structure. Physicians call clefting a “craniofacial anomaly.” A child can be born with both a cleft lip and cleft palate or a cleft in just one area. Oral clefts are one of the most common birth defects.

Clefts in the lip can range from a tiny notch in the upper lip to a split that extends into the nose. A cleft palate can range from a small malformation that results in minimal problems to a large separation of the palate that interferes with eating, speaking, and even breathing. Clefts are often referred to as unilateral, a split on one side, or bilateral, one split on each side. There are three primary types of clefts:

• Cleft lip/palate refers to the condition when both the palate and lip are cleft. About one in 1,000 babies are born with cleft lip/palate.
• About 50 percent of all clefts
• More common in Asians and certain groups of American Indians
• Occurs less frequently in African Americans
• Up to 13 percent of cases present with other birth defects
• Occurs more often in male children
• Isolated cleft palate is the term used when a cleft occurs only in the palate. About one in 2,000 babies are born with this type of cleft (the incidence of submucous cleft palate, a type of isolated cleft palate, is one in 1,200).
• About 30 percent of all clefts
• All racial groups have similar risk
• Occurs more often in female children
• Isolated cleft lip refers to a cleft in the lip only accounting for 20 percent of all clefts.

What causes clefts?

No one knows exactly what causes clefts, but most believe they are caused by one or more of three main factors: an inherited characteristic (gene) from one or both parents, environment (poor early pregnancy health or exposure to toxins such as alcohol or cocaine), and genetic syndromes. A syndrome is an abnormality in genes on chromosomes that result in malformations or deformities that form a recognizable pattern. Cleft lip/palate is a part of more than 400 syndromes including Waardenburg, Pierre Robin, and Down syndromes. Approximately 30 percent of cleft deformities are associated with a syndrome, so a thorough medical evaluation and genetic counseling is recommended for cleft patients.

How is a cleft diagnosed?

Clefting of the lip and palate is usually visible during the baby’s first examination. One exception is a submucous cleft where the palate is cleft, but remains covered by smooth, unbroken lining of the mouth. A child with cleft lip or palate is often referred to a multidisciplinary team of experts for treatment. The team may include: an otolaryngologist (ear, nose, and throat specialist), plastic surgeon, oral surgeon, speech pathologist, pediatric dentist, orthodontist, audiologist, geneticist, pediatrician, nutritionist, and psychologist/social worker.

How are clefts treated?

Treatment of clefts is highly individual, depending on the overall health of the child and the severity and location of the cleft(s). Multiple surgeries and long-term follow-up are often necessary. Because clefts can interfere with physical, language and psychological development, treatment is recommended as early as possible. Surgery to repair a cleft lip is usually done between 10 and 12 weeks of age. A cleft palate is repaired through a procedure called palatoplasy, which is done between nine and 18 months. Additional surgeries are often needed to achieve the best results. In addition to surgery, the child may receive follow-up care from members of the multidisciplinary team on issues of speech, hearing, growth, dental, and psychological development.

What are the complications of clefts?

The complications of cleft lip and cleft palate can vary greatly depending on the degree and location of the cleft. They can include all or some or all of the following:

Breathing: When the palate and jaw are malformed, breathing becomes difficult. Treatments include surgery and oral appliances.

Feeding: Problems with feeding are more common in cleft children. A nutritionist and speech therapist that specializes in swallowing may be helpful. Special feeding devices are also available.

Ear infections and hearing loss: Any malformation of the upper airway can affect the function of the Eustachian tube and increase the possibility of persistent fluid in the middle ear, which is a primary cause of repeat ear infections. Hearing loss can be a consequence of repeat ear infections and persistent middle ear fluid. Tubes can be inserted in the ear by an otolaryngologist to alleviate fluid build-up and restore hearing.

Speech and language delays: Normal development of the lips and palate are essential for a child to properly form sounds and speak clearly. Cleft surgery repairs these structures; speech therapy helps with language development.

Dental problems: Sometimes a cleft involves the gums and jaw, affecting the proper growth of teeth and alignment of the jaw. A pediatric dentist or orthodontist can assist with this problem.

Tumors or growths in the head and neck region may be divided into those that are benign (not cancerous) and malignant (i.e., cancer). Fortunately, most growths in the head and neck region in children are considered to be benign. These benign growths can be related to infection, inflammation, fluid collections, swellings, or neoplasms (tumors) that are non life-threatening. The malignant growths, on the other hand, may be life-threatening and cause other problems related to their growth and spread. Even the malignant growths in the head and neck are usually treatable.

Benign Tumors

It is very common for children to have enlarged tonsils and adenoids. These are almost always from an infection or inflammation. It is very rare that children develop a cancer, lymphoma, or sarcoma of these areas. When the tonsils, adenoids, or other areas of the mouth or throat remain enlarged or are enlarged on only one side, it is important to have an evaluation by a specialist in ear, nose and throat or otolaryngology-head and neck surgery.

The lymph nodes of the neck region may become enlarged during childhood. Most of the time, this is reactive in nature and related to inflammation or infection. However, if the lymph nodes remain enlarged for a period of time without going away, it is important to have an otolaryngologist-head and neck surgeon evaluate the problem.

Other benign growths in the face and neck include cysts (fluid collection) such as branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, and dermoid cysts. These often require removal due to their continued growth and potential for infection. Growths of blood vessels often are seen in the face and neck and these are often referred to as hemangiomas, vascular malformations, lymphatic and arteriovenous malformations (AVM). Some of these may require removal or treatment depending upon the type and location.

Sinus and Nose Growths

Although most children have nose bleeds and occasional allergies and sinus infection, sometimes tumors of the nose and sinus present with similar symptoms. It is generally recommended that a child with continuous sinus problems or nose bleeds be evaluated by an otolaryngologist-head and neck surgeon to be sure it is not a tumor or other treatable condition.

Non-epithelial neoplasms constitute the majority of sinonasal (sinus) tumors in children and adolescents. Among these, rhabdomyosarcoma (RMS) or undifferentiated sarcoma and non-Hodgkin lymphoma account for the majority of cases. Among head and neck RMS 14 percent arise from the nasal cavity and 10 percent from the paranasal sinuses. Nasopharyngeal carcinoma accounts for one third of the nasopharyngeal neoplasms in children. As is the case in adult patients, it is associated with Epstein-Barr virus (EBV) infection as demonstrated by EBV DNA presence in malignant cells. Less frequently, Ewing’s sarcoma/PNET can present in this location. These tumors have also been described as secondary malignancies following treatment of retinoblastoma and other neoplasms. Esthesioneuroblastoma is a rare sinonasal tumor historically related to Ewing/PNET, although more recently comparative genomic hybridization analysis disputes this relation. Other less common sinonasal tumors presenting in children include hemangioma and hemagiopericitoma, fibroma and fibrosarcoma, malignant fibrous histiocytoma, and desmoid fibromatosis.

Salivary Gland Tumors

There are three paired sets of salivary glands in the head and neck region. These include the ones in front of the ears (parotid), below the jaw (submandibular), and underneath the tongue (sublingual). Additionally, there are numerous very small salivary glands throughout the mouth and throat. Although tumors can arise in these areas, they are rare. Thus, any child with a growth in these areas should be seen by an otolaryngologist-head and neck surgeon.

Thyroid Tumors

The thyroid gland is found in the front of the lower part of the neck just above the chest area but below the Adam’s apple on both sides. Although tumors can arise in this area, they are rare. Thus, any child with a growth in this area should be seen by an otolaryngologist-head and neck surgeon.

Insight into preventing injuries caused by falls

• Why are falls more likely during the senior years?
• How does lifestyle management affect fall prevention?
• and more…

Today’s society is more active than ever, but inevitably every year more than two million Americans fall and sustain serious injury, costing the healthcare system in excess of $3 billion dollars. Hidden costs affecting the individual include pain, disability, lawsuits, loss of independence, deterioration in well-being, and the impact on other family members. Nonetheless, falls are predictable and preventable, even for older adults.

Why are falls more likely during the senior years?

Falls and the resulting injuries are among the most serious health issues affecting the elderly population. The increased risk for falls in the elderly can be attributed, in general, to the body’s deterioration due to inactivity and a slow deterioration of the central nervous system (CNS). For example, the sensory cells in the ears’ balance system gradually decrease in number and cannot be replaced. The nerves that carry sensory information to the brain lose fiber and nerve cells, leading to problems with the function of complex brain interconnections. In addition, nerve endings lose their ability to produce the chemicals responsible for the transmission of information. This process accelerates after age 50.

Many systemic diseases can affect the CNS and sense organs and therefore increase the likelihood of instability and the risk of falling. In addition, muscle strength gradually decreases with age and joint tendons and ligaments lose their flexibility, resulting in limited range of motion. The combined effects of bone and joint disease and inactivity can result in a body that can no longer carry out complex motion commands initiated by the brain. Atherosclerotic cardiovascular disease (hardening of the arteries) is another disease process that can affect balance. It is accelerated by high blood pressure, smoking, and diabetes. Although artery hardening gradually increases during middle age, there is a point at which a slight additional decrease in blood flow causes serious vascular impairment, such as stroke.

Head injuries, sometimes caused by falls, can damage the sense organs in the inner ears, or the brain itself. Therefore, physical activity is very important for injury recovery to the sensory systems. The general debility of aging can negatively affect recovery if it results in a decreased level of activity. Often, injuries to the knees, hips, and back do not completely heal, leaving some limitation of motion.

Arthritis can cause permanent crippling, nonreversible, effects on the bones and joints of the hips, knees, and ankles, and osteoporosis can lead to bone weakness. Together, these ailments can dramatically increase the probability of serious injury from a fall or cause a spontaneous fracture that might lead to a fall.

How can medications affect my sensory functions?

In this time of specialization, it is possible for a patient to receive from several physicians prescriptions that might have additive side effects on the brain and sensory function. Therefore, patients should keep a complete list of all their medications and dosages, and make this list available to each physician they consult. Coordination of all medications through a single primary care physician would help avoid adverse drug reactions to the brain and sensory functions. The list should include:

• Over-the-counter medications, such as antihistamines, sleeping medications, analgesics, and cough suppressants.
• Medications used to treat high blood pressure, heart disease, allergy, insomnia, stomach acidity, and depression.
• Medications listing alcohol as an ingredient, since it affects movement and judgment and adversely interacts with many medications.

How can I recover from an injury caused by a fall?

Rehabilitation

• A thorough and complete evaluation of sensory, CNS, muscle/joint, and balance functions should be performed. This includes a search for causes of dizziness, such as inner ear diseases; an evaluation of the inner ear balance system, which might be adversely affected by certain drugs (such as a class of antibiotics known as aminoglycocides); trauma; and the aging process.
• Tests of higher mental function are important, since falling can be a sign of serious mental deterioration.
• A careful review of all medications (both prescription and over-the-counter) is very important. If medication for anxiety or depression is used, switching from a long-acting drug to one that is more quickly passed from the body seems to decrease the risk of falling.

All correctable problems should be treated. That includes visual correction with proper eyeglasses, improvement of hearing by hearing aids, adjustment or elimination of medications, and treatment of any other disease which could impair balance.

Rehabilitation includes increasing the range of motion, as well as physical strength. A very important part of rehabilitation is overcoming the fear of falling, thus avoiding further injury. Walkers and canes can aid stability, while simple changes in the home, such as installing hand-holds in bathrooms or along walls, could decrease the likelihood of falling and increase confidence. But keep in mind, drastically changing a familiar environment often hampers recovery. As soon as possible, rehabilitation should include family members and home support groups. Rapid return to physical activity and social interaction with family and community can often stop the vicious spiral into inactivity, reclusiveness, and progressive deterioration that falls and injuries cause.

How does lifestyle management affect fall prevention?

As many of the problems responsible for falling develop during early and middle age, initial efforts to prevent injuries should begin at a younger age. Many of the changes in muscle, bone, and the central nervous system are not inevitable results of aging, but are brought on by inactive lifestyles and self-inflicted damage from smoking, poor diet, and lack of exercise. Although hardening of the arteries is occasionally hereditary, in most cases it can be reduced by diets low in cholesterol and saturated fatty acids, as well as regular physical exercise.

Tips to prevent falls among seniors

Health

• Have hearing and vision check-ups regularly. If hearing and vision are impaired, important cues that help maintain balance can be lost.
• Get up slowly. A momentary drop in blood pressure can cause dizziness when standing up too quickly.
• Use a cane or walker to help maintain balance on uneven ground or slippery surfaces. Wear sturdy, low-heeled shoes with wide, nonslip soles.
• Exercise to improve your strength, muscle tone, and coordination. Walking is a good form of exercise.

Home

• Remove raised doorway thresholds in all rooms. Rearrange furniture to keep electrical cords and furniture out of walking paths. Fasten area rugs to the floor with tape or tacks.
• Never stand on a chair. Use nonskid floor wax and wipe up spills immediately.
• Be sure stairways have sturdy hand rails.
• Install grab handles and nonskid mats inside and outside your shower and tub.
• Use shower chairs and bath benches to minimize the risk of falling.

Put a light switch by the bedroom door and by your bed so you don’t have to walk across the room to turn on a light. Night lights in your bedrooms, halls, and bathroom are a good idea.

Can Over-the-Counter Medications Help?

Why Do We Suffer From Nasal And Sinus Discomfort?

The body’s nasal and sinus membranes have similar responses to viruses, allergic insults, and common bacterial infections. Membranes become swollen and congested. This congestion causes pain and pressure; mucus production increases during inflammation, resulting in a drippy, runny nose. These secretions may thicken over time, may slow in their drainage, and may predispose to future bacterial infection of the sinuses.

Congestion of the nasal membranes may even block the eustachian tube leading to the ear, resulting in a feeling of blockage in the ear or fluid behind the eardrum. Additionally, nasal airway congestion causes the individual to breathe through the mouth.

Each year, more than 37 million Americans suffer from sinusitis, which typically includes nasal congestion, thick yellow-green nasal discharge, facial pain, and pressure. Many do not understand the nature of their illness or what produces their symptoms. Consequently, before visiting a physician, they seek relief for their nasal and sinus discomfort by taking non-prescription or over-the-counter (OTC) medications.

What Is The Role Of OTC Medication For Sinus Pain?

There are many different OTC medications available to relieve the common complaints of sinus pain and pressure, allergy problems, and nasal congestion. Most of these medications are combination products that associate either a pain reliever such as acetaminophen with a decongestant or an antihistamine. Knowledge of these products and of the probable cause of symptoms will help the consumer to decide which product is best suited to relieve the common symptoms associated with nasal or sinus inflammation.

OTC nasal medications are designed to reduce symptoms produced by the inflammation of nasal membranes and sinuses. The goals of OTC medications are to: (1) reopen to nasal passages; (2) reduce nasal congestion; (3) relieve pain and pressure symptoms; and (4) reduce potential for complications. The medications come in several forms.

Nasal Saline Sprays: Non-Medicated Nasal Sprays

Nasal saline is an invaluable addition to the list of over-the-counter medications. It is ideal for all types of nasal problems. The added moisture produced by the saline reduces thick secretions and assists in the removal of infectious agents. There is no risk of becoming “addicted” to nasal saline. It should be applied as a mist to the nose up to six times per day. Nasal saline can also be made at home: contact your otolaryngologist for details.

Nasal Decongestant Sprays: Medicated Nasal Sprays

Afrin nasal spray, Neo-Synephrine, Otrivin, Dristan nasal spray, and other brands decongest the swollen nasal membranes. They clear nasal passages almost immediately and are useful in treating the initial stages of a common cold or viral infection. Nasal decongestant sprays are safe to use, especially appropriate for preventing eustachian tube problems when flying, and to halt progression of sinus infections following colds. However, they should only be utilized for 3-5 days because prolonged use leads to rebound congestion or “getting hooked on nasal sprays.” The patient with nasal swelling caused by seasonal allergy problems should use a cromolyn sodium nasal spray. The spray must be used frequently (four times a day) during allergy season to prevent the release of histamine from the tissues, which starts the allergic reaction. It works best before symptoms become established by stabilizing the nasal membranes and has few side effects.

Decongestant Medications

Pressure and congestion are common symptoms of nasal passage swelling. Decongestant medications are OTC products that relieve nasal swelling, pressure, and congestion but do not treat the cause of the inflammation. They reduce blood flow to the nasal membranes leading to improved airflow, less breathing through the mouth, decreased pressure in the sinuses and head, and subsequently less discomfort. Decongestants do not relieve drippy noses. Their side effects may include light headedness or giddiness and increased blood pressure and heart rate. (Patients with high blood pressure or heart problems should consult a physician before use.) In addition, other medications may interact with oral decongestants causing side effects. Both of these are available as single products or in combination with a pain reliever or an antihistamine. They are labeled as “non-drowsy” due to a side effect of stimulation of the nervous system.

Decongestant-Combination Products

Some medications are combined to reduce the number of pills. Tylenol® Sinus or Advil Cold and Sinus® exemplify products that join a pain reliever (acetaminophen or ibuprophen) with a decongestant (pseudoephedrine). These products relieve both sinus and cold/flu symptoms yet retain all the attributes of the individual drug including side effects.

Antihistamine Medications

Antihistamines combat allergic problems leading to nasal congestion. OTC antihistamines such as diphenhydramine (Benadryl®), or clemastine (Tavist®) may be used for relieving allergic symptoms of itching, sneezing, and nasal congestion. They relieve the drainage associated with the allergic inflammation but not obstruction or congestion. Antihistamines have a potential for sedation causing grogginess and dryness after use. Newer nonsedating antihistamines are available.

Antihistamine-Decongestant Combination Products

Antihistamines and decongestant products are often combined to relieve multiple symptoms of congestion and drainage and reduce the side effects of both products. Antihistamines produce sedation; decongestants are added to make them “non-drowsy.” The combined allergy product then relieves congestion and a runny nose.

Insight into recognizing symptoms for early detection

• Early detection of head and neck cancer
• Symptoms of head and neck cancer
• and more…

This year, more than 55,000 Americans will develop cancer of the head and neck (most of which is preventable); nearly 13,000 of them will die from it.

Early detection of head and neck cancer

Tobacco use is the most preventable cause of these deaths. In the United States, up to 200,000 people die each year from smoking-related illnesses. The good news is that this figure has decreased due to the increasing number of Americans who have quit smoking. The bad news is that some of these smokers switched to smokeless or spit tobacco, assuming it is a safe alternative. This is untrue. By doing so, they are only changing the site of the cancer risk from their lungs to their mouths. While lung cancer cases are decreasing, cancers in the head and neck appear to be increasing, but they are curable if caught early. Fortunately, most head and neck cancers produce early symptoms. You should know the potential warning signs so you can alert your doctor as soon as possible. Remember—successful treatment of head and neck cancer depends on early detection. Knowing and recognizing its signs can save your life.

Symptoms of head and neck cancer

A lump in the neck. Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas and blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change in the voice. Most cancers in the larynx cause some changes in voice. An otolaryngologist is a head and neck specialist who can examine your vocal cords easily and painlessly. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse or notice voice changes for more than two weeks, see your doctor.

A growth in the mouth. Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after a week should be evaluated by a physician. Your dentist or doctor can determine if a biopsy (tissue sample test) is needed and can refer you to a head and neck surgeon who can perform this procedure.

Bringing up blood. This is often caused by something other than cancer. However, tumors in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician.

Swallowing problems. Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods—and sometimes liquids—difficult. The food may “stick” at a certain point and then either go through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by a physician. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a scope) will be performed to find the cause.

Changes in the skin. The most common head and neck cancer is basal cell cancer of the skin. Fortunately, this is rarely serious if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, but can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that enlarges slowly, producing a central “dimple” and eventually an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show color changes. Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers, and if caught early and properly treated, usually are not dangerous. If there is a sore on the lip, lower face, or ear that does not heal, consult a physician. Malignant melanoma typically produces a blue-black or black discoloration of the skin. However, any mole that changes size, color, or begins to bleed may mean trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist or other physician.

Persistent earache. Constant pain in or around the ear when you swallow can be a sign of infection or tumor growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness, or a lump in the neck. These symptoms should be evaluated by an otolaryngologist.

Identifying high risk of head and neck cancer

As many as 90 percent of head and neck cancers arise after prolonged exposure to specific risk factors. Use of tobacco (cigarettes, cigars, chewing tobacco, or snuff) and alcoholic beverages are the most common cause of cancers of the mouth, throat, voice box, and tongue. In adults who do not smoke or drink, cancer of the throat can occur as a result of infection with the human papilloma virus (HPV). Prolonged exposure to sunlight is linked with cancer of the lip and is also established as a major cause of skin cancer.

What you should do. All of the symptoms and signs described here can occur with no cancer present. In fact, many times complaints of this type are due to some other condition. But you can’t tell without an examination. So if they do occur, see your doctor to be sure.

Remember—when found early, most cancers in the head and neck can be cured with few side effects. Cure rates for these cancers could be greatly improved if people would seek medical advice as soon as possible. Play it safe. If you detect warning signs of head and neck cancer, see your doctor immediately.  And practice health habits which help prevent these diseases.

Not every headache is the consequence of sinus and nasal passage problems. For example, many patients visit an ear, nose, and throat specialist to seek treatment for a sinus headache and learn they actually have a migraine or tension headache. The confusion is common, a migraine can cause irritation of the trigeminal or fifth cranial nerve (with branches in the forehead, cheeks and jaw). This may produce pain at the lower-end branches of the nerve, in or near the sinus cavity.

Symptoms Of Sinusitis

Pain in the sinus area does not automatically mean that you have a sinus disorder. On the other hand, sinus and nasal passages can become inflamed leading to a headache. Headache is one of the key symptoms of patients diagnosed with acute or chronic sinusitis. In addition to a headache, sinusitis patients often complain of:

• Pain and pressure around the eyes, across the cheeks and the forehead
• Achy feeling in the upper teeth
• Fever and chills
• Facial swelling
• Nasal stuffiness
• Yellow or green discharge

However, it is important to note that there are some cases of headaches related to chronic sinusitis without other upper respiratory symptoms. This suggests that an examination for sinusitis be considered when treatment for a migraine or other headache disorder is unsuccessful.

Treatment For A Sinus Headache

Sinus headaches are associated with a swelling of the membranes lining the sinuses (spaces adjacent to the nasal passages). Pain occurs in the affected region – the result of air, pus, and mucus being trapped within the obstructed sinuses. The discomfort often occurs under the eye and in the upper teeth (disguised as a headache or toothache). Sinus headaches tend to worsen as you bend forward or lie down. The key to relieving the symptoms is to reduce sinus swelling and inflammation and facilitate mucous drainage from the sinuses.

There are several at-home steps that help prevent sinus headache or alleviate its pain. They include:

Breathe moist air: Relief for a sinus headache can be achieved by humidifying the dry air environment. This can be done by using a steam vaporizer or cool-mist humidifier, steam from a basin of hot water, or steam from a hot shower.

Alternate hot and cold compresses: Place a hot compress across your sinuses for three minutes, and then a cold compress for 30 seconds. Repeat this procedure three times per treatment, two to six times a day.

Nasal irrigation: Some believe that when nasal irrigation or rinse is performed, mucus, allergy creating particles and irritants such as pollens, dust particles, pollutants and bacteria are washed away, reducing the inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better and will reduce the symptoms. Nasal irrigation helps shrink the sinus membranes and thus increases drainage. There are several over-the-counter nasal rinse products available. Consult your ear, nose, and throat specialist for directions on making a home nasal rinse or irrigation solution.

Over-the-counter medications: Some over-the-counter (OTC) drugs are highly effective in reducing sinus headache pain. The primary ingredient in most OTC pain relievers is aspirin, acetaminophen, ibuprofen, naproxen, or a combination of them. The best way to choose a pain reliever is by determining which of these ingredients works best for you.

Decongestants: Sinus pressure headaches caused by allergies are usually treated with decongestants and antihistamines. In difficult cases, nasal steroid sprays may be recommended.

Alternative medicine: Chinese herbalists use Magnolia Flower as a remedy for clogged sinus and nasal passages. In conjunction with other herbs, such as angelica, mint, and chrysanthemum, it is often recommended for upper respiratory tract infections and sinus headaches, although its effectiveness for these problems has not been scientifically confirmed.

If none of these preventative measures or treatments is effective, a visit to an ear, nose, and throat specialist may be warranted. During the examination, a CT scan of the sinuses may be ordered to determine the extent of blockage caused by chronic sinusitis. If no chronic sinusitis were found, treatment might then include allergy testing and desensitization (allergy shots). Acute sinusitis is treated with antibiotics and decongestants. If antibiotics fail to relieve the chronic sinusitis and accompanying headaches, endoscopic or image-guided surgery may be the recommended treatment.

Insight into complications and treatment

• What is a thyroid disorder?
• What treatment may be recommended?
• What is thyroid surgery?
• and more…

Your thyroid gland is one of the endocrine glands that makes hormones to regulate physiological functions in your body, like metabolism (heart rate, sweating, energy consumed). Other endocrine glands include the pituitary, adrenal, and parathyroid glands and specialized cells within the pancreas.

The thyroid gland is located in the middle of the lower neck, below the larynx (voice box) and wraps around the front half of the trachea (windpipe). It is shaped like a bow tie, just above the collarbones, having two halves (lobes) joined by a small tissue bar (isthmus.). You can’t always feel a normal thyroid gland.

What is a thyroid disorder?

Diseases of the thyroid gland are very common, affecting millions of Americans. The most common thyroid problems are:

• An overactive gland, called hyperthyroidism (e.g., Graves’ disease, toxic adenoma or toxic nodular goiter)
• An underactive gland, called hypothyroidism (e.g., Hashimoto’s thyroiditis)
• Thyroid enlargement due to overactivity (as in Graves’ disease) or from under-activity (as in hypothyroidism). An enlarged thyroid gland is often called a “goiter.”

Patients with a family history of thyroid cancer or who had radiation therapy to the head or neck as children for acne, adenoids, or other reasons are more prone to develop thyroid malignancy.

If you develop significant swelling in your neck or difficulty breathing or swallowing, you should call your surgeon or be seen in the emergency room.

What treatment may be recommended?

Depending on the nature of your condition, treatment may include the following:

Hypothyroidism treatment: Thyroid hormone replacement pills
Hyperthyroidism treatment:

• Medication to block the effects of excessive production of thyroid hormone
• Radioactive iodine to destroy the thyroid gland
• Surgical removal of the thyroid gland

Goiters (lumps):

If you experience this condition, your doctor will propose a treatment plan based on the examination and your test results. He may recommend:

• An imaging study to determine the size, location, and characteristics of any nodules within the gland. Types of imaging studies include CT or CAT scans, ultrasound, or MRIs.
• A fine-needle aspiration biopsy—a safe, relatively painless procedure. With this procedure, a hypodermic needle is passed into the lump, and tissue fluid samples containing cells are taken. Several passes with the needle may be required. Sometimes ultrasound is used to guide the needle into the nodule. There is little pain afterward and very few complications from the procedure. This test gives the doctor more information on the nature of the lump in your thyroid gland and may help to differentiate a benign from a malignant or cancerous thyroid mass.
• Thyroid surgery may be required when:
  
  • the fine needle aspiration is reported as suspicious or suggestive of cancer
  • imaging shows that nodules have worrisome characteristics or that nodules are getting bigger
  • the trachea (windpipe) or esophagus are compressed because both lobes are very large

Historically, some thyroid nodules, including some that are malignant, have shown a reduction in size with the administration of thyroid hormone. However, this treatment, known as medical “suppression” therapy, has proven to be an unreliable treatment method.

What is thyroid surgery?

Thyroid surgery is an operation to remove part or all of the thyroid gland. It is performed in the hospital, and general anesthesia is usually required. Typically, the operation removes the lobe of the thyroid gland containing the lump and possibly the isthmus. A frozen section (immediate microscopic reading) may be used to determine if the rest of the thyroid gland should be removed during the same surgery.

Sometimes, based on the result of the frozen section, the surgeon may decide not to remove any additional thyroid tissue, or proceed to remove the entire thyroid gland, and/or other tissue in the neck. This decision is usually made in the operating room by the surgeon, based on findings at the time of surgery. Your surgeon will discuss these options with you preoperatively.

As an alternative, your surgeon may choose to remove only one lobe and await the final pathology report before deciding if the remaining lobe needs to be removed. There also may be times when the definite microscopic answer cannot be determined until several days after surgery. If a malignancy is identified in this way, your surgeon may recommend that the remaining lobe of the thyroid be removed at a second procedure. If you have specific questions about thyroid surgery, ask your otolaryngologist to answer them in detail.

What happens after thyroid surgery?

During the first 24 hours:

After surgery, you may have a drain (tiny piece of plastic tubing), which prevents fluid and blood from building up in the wound. This is removed after the fluid accumulation has stabilized, usually within 24 hours after surgery. Most patients are discharged later the same day or the next day. Complications are rare but may include:

• Bleeding
• Bleeding under the skin that rarely can cause shortness of breath requiring immediate medical evaluation
• A hoarse voice
• Difficulty swallowing
• Numbness of the skin on the neck
• Vocal cord paralysis
• Low blood calcium

At home:

Following the procedure, if it is determined that you need to take any medication, your surgeon will discuss this with you prior to your discharge. Medications may include:

• Thyroid hormone replacement
• Calcium and/or vitamin D replacement

Some symptoms may not become evident for two or three days after surgery. If you experience any of the following, call your surgeon or seek medical attention:

• Numbness and tingling around the lips and hands
• Increasing pain
• Fever
• Swelling
• Wound discharge
• Shortness of breath

If a malignancy is identified, thyroid replacement medication may be withheld for several weeks. This allows a radioactive scan to better detect any remaining microscopic thyroid tissue, or spread of malignant cells to lymph nodes or other sites in the body.

How is a diagnosis made?

The diagnosis of a thyroid function abnormality or a thyroid mass is made by taking a medical history and a physical examination. In addition, blood tests and imaging studies or fine-needle aspiration may be required. As part of the exam, your doctor will examine your neck and ask you to lift up your chin to make your thyroid gland more prominent. You may be asked to swallow during the examination, which helps to feel the thyroid and any mass in it. Tests your doctor may order include:

• Evaluation of the larynx/vocal cords with a mirror or a fiberoptic telescope
• An ultrasound examination of your neck and thyroid
• Blood tests of thyroid function
• A radioactive thyroid scan
• A fine-needle aspiration biopsy
• A chest X-ray
• A CT or MRI scan

Insight into causes and treatments

• How does the Temporo-Mandibular Joint work?
• What causes TMJ pain?
• How is TMJ pain treated?
• and more…

Open your jaw all the way and shut it. This simple movement would not be possible without the Temporo-Mandibular Joint (TMJ). It connects the temporal bone (the bone that forms the side of the skull) and the mandible (the lower jaw). Even though it is only a small disc of cartilage, it separates the bones so that the mandible may slide easily whenever you talk, swallow, chew, kiss, etc. Therefore, damage to this complex, triangular structure in front of your ear, can cause considerable discomfort.

Where is the Temporo-Mandibular Joint?

You can locate this joint by putting your finger on the triangular structure in front of your ear. Then move your finger just slightly forward and press firmly while you open your jaw all the way and close it. You can also feel the joint motion in your ear canal.

How does the Temporo-Mandibular Joint work?

When you bite down hard, you put force on the object between your teeth and on the Temporo-Mandibular Joint. In terms of physics, the jaw is the lever and the TMJ is the fulcrum. Actually, more force is applied (per square foot) to the joint surface than to whatever is between your teeth because the cartilage between the bones provides a smooth surface, over which the joint can freely slide with minimal friction.

Therefore, the forces of chewing can be distributed over a wider surface in the joint space and minimize the risk of injury. In addition, several muscles contribute to opening and closing the jaw and aid in the function of the TMJ.

What causes TMJ pain?

In most patients, pain associated with the TMJ is a result of displacement of the cartilage disc that causes pressure and stretching of the associated sensory nerves. The popping or clicking occurs when the disk snaps into place when the jaw moves. In addition, the chewing muscles may spasm, not function efficiently, and cause pain and tenderness.

What causes damage to the TMJ?

• Major and minor trauma to the jaw
• Teeth grinding
• Excessive gum chewing
• Stress and other psychological factors
• Improper bite or malpositioned jaws
• Arthritis

What are the symptoms?

• Ear pain
• Sore jaw muscles
• Temple/cheek pain
• Jaw popping/clicking
• Locking of the jaw
• Difficulty in opening the mouth fully
• Frequent head/neck aches

The pain may be sharp and searing, occurring each time you swallow, yawn, talk, or chew, or it may be dull and constant. It hurts over the joint, immediately in front of the ear, but pain can also radiate elsewhere. It often causes spasms in the adjacent muscles that are attached to the bones of the skull, face, and jaws. Then, pain can be felt at the side of the head (the temple), the cheek, the lower jaw, and the teeth.

A very common focus of pain is in the ear. Many patients come to the ear specialist quite convinced their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the doctor will consider the possibility that the pain comes from TMJ.

There are a few other symptoms besides pain that TMJ can cause. It can make popping, clicking, or grinding sounds when the jaws are opened widely. Or the jaw locks wide open (dislocated). At the other extreme, TMJ can prevent the jaws from fully opening. Some people get ringing in their ears from TMJ.

How is TMJ pain treated?

Because TMJ symptoms often develop in the head and neck, otolaryngologists are appropriately qualified to diagnose TMJ problems. Proper diagnosis of TMJ begins with a detailed history and physical, including careful assessment of the teeth occlusion and function of the jaw joints and muscles. An early diagnosis will likely respond to simple, self-remedies:

• Rest the muscles and joints by eating soft foods.
• Do not chew gum.
• Avoid clenching or tensing.
• Relax muscles with moist heat (1/2 hour at least twice daily).

In cases of joint injury, apply ice packs soon after the injury to reduce swelling. Relaxation techniques and stress reduction, patient education, non-steroidal anti-inflammatory drugs, muscle relaxants or other medications may also offer relief.

Other treatments for advanced cases may include fabrication of an occlusal splint to prevent wear and tear on the joint, improving the alignment of the upper and lower teeth, and surgery. After diagnosis, your otolaryngologist may suggest further consultation with your dentist and oral surgeon to facilitate effective management of TMJ pain.

As many as 20 percent of high school boys and two percent of high school girls continue to use smokeless tobacco, according to the Centers for Disease Control and Prevention. Despite public education campaigns sponsored by medical societies, organized baseball, and individuals, 12 to 14 million American users, one third are under age 21, and more than half of those developed the habit before they were 13. Peer pressure is just one of the reasons for starting the habit. Serious users often graduate from brands that deliver less nicotine to stronger ones. With each use, you need a little more of the drug to get the same feeling.

There has been some progress. The organizer of America’s fastest growing sport, National Association for Stock Car Auto Racing (NASCAR) has dropped its long-time affiliation with Winston tobacco. NASCAR president Mike Helton says a total tobacco ban is “an issue that’s on our radar for next year.”

And there have been setbacks in the fight against smoking tobacco. New marketing campaigns that feature flavored smokeless products have won over new young users. Journalistic coverage of Dr. Brad Rodu and his support of smokeless tobacco as a substitute for cigarettes has diluted the Academy’s “No Smokeless Tobacco Use” message that has been an official campaign for this Academy since 1989. In a November 10, 2005 study; “New Cigarette Brands with Flavors That Appeal to Youth: Tobacco Marketing Strategies; Health Affairs, November/December 2005, Volume 24, number 6, funded by the American Legacy Foundation and the National Cancer Institute noted that candy flavors were also added to smokeless tobacco products, cigars and cigarette rolling papers. “

Gregory Connolly, senior author of the study and a professor of the practice of public health at the Harvard School of Pubic Health noted, “Tobacco companies are using candy-like flavors and high tech delivery devices to turn a blowtorch into a flavored popsicle, misleading millions of youngsters to try a deadly product. Although the study focuses primarily on cigarettes, it noted that the addiction to smokeless tobacco or “chew” is as strong if not stronger than to cigarettes. Additional research has shown that there continues to be substantial evidence that smokeless tobacco is deadly. A December 18, 2003 study by Patricia Richter, Ph.D and Francis Spierto, Ph.D, two CDC researchers released by the Center for the Advancement of Health reported that the most popular brands of smokeless tobacco contain the highest amounts of nicotine that can be readily absorbed by the body. According to Richter, “Consumers need to know that smokeless tobacco products, including loose-leaf and moist snuff, are not safe alternatives to smoking,” Richter says. “The amount of nicotine absorbed per dose from using smokeless tobacco is greater than the amount of nicotine absorbed from smoking one cigarette.

Kicking Tobacco Means Kicking It All

In November 11, 2005 Reuters story, “Oral Tocacco Not Safe Sbustiute for Smoking,” Dr. Stephen Hecht and colleagues from the University of Minnesota Cancer Center in Minneapolis related data from their current research that compared the levels of cancer-causing nitrosamines in popular smokeless tobacco products and medicinal nicotine products such as the nicotine patch, nicotine gum, and nicotine lozenges.

The results “clearly showed that the levels of cancer-causing nitrosamines are far higher in smokeless tobacco products than they are in medicinal nicotine products,” Hecht said during a press briefing. While smokeless tobacco has “demonstrably less carcinogens and toxins than cigarette smoke,” said Hecht, smokeless tobacco still has “remarkably high levels of carcinogenic tobacco-specific nitrosamines — levels that are 100 to 1,000 times higher than in any other consumer product that is designed for oral consumption.” In a separate study, the team evaluated carcinogen biomarker levels in individuals using these products. They had 54 users of popular US smokeless tobacco products use their usual brand for two weeks and then had them switch to either Swedish snus or a nicotine patch for four weeks.

The team found that carcinogen levels in urine were statistically significantly lower after the switch from US-made smokeless tobacco brands to snus or to the nicotine patch. When comparing snus users to patch users, levels of cancer- causing compounds were significantly lower in patch users, indicating that medicinal nicotine is safer than snus, Hecht said. These results conflict with some prior studies that suggested that smokeless tobacco including moist snuff may be a less harmful habit than cigarette smoking because many of the carcinogens in cigarette smoke are either reduced or absent in smokeless tobacco. The bottom line, Dr.Hecht said, is that “smokeless tobacco products are dangerous.”

“The evidence suggests,” he continued, “that smokeless products are in fact a cause of oral cancer and pancreatic cancer in humans. The current evidence does not support smokeless tobacco as a substitute for cigarette smoking.”

Laryngeal cancer is not as well known by the general public as some other types of cancer, yet it is not a rare disease. The American Cancer Society estimates that in 2005 almost 10,000 new cases of laryngeal cancer will be diagnosed, and close to 3,800 people will die from laryngeal cancer in the United States. Even for survivors, the consequences of laryngeal cancer can be severe with respect to voice, breathing, or swallowing. It is fundamentally a preventable disease though, since the primary risk factors for laryngeal cancer are associated with modifiable behaviors.

Risk Factors Associated With Laryngeal Cancer

Development of laryngeal cancer is a process that involves many factors, but approximately 90 percent of head and neck cancers occur after exposure to known carcinogens (cancer causing substances). Chief among these factors is tobacco. Over 90 percent of laryngeal cancers are a type of cancer called squamous cell carcinoma (SCCA), and over 95 percent of patients with laryngeal SCCA are smokers. Smoking contributes to cancer development by causing mutations or changes in genes, impairing clearance of carcinogens from the respiratory tract, and decreasing the body’s immune response.

Tobacco use is measured in pack-years, where one pack per day for one year is considered one pack-year. Two pack-years is defined as either one pack per day for two years, or two packs per day for one year (Longer terms of pack years are determined using a similar ratio.) Depending upon the number of pack-years smoked, studies have reported that smokers are about 5 to 35 times more likely to develop laryngeal cancer than non-smokers. It does seem that the duration of tobacco exposure is probably more important overall to cancer causing effect, than the intensity of the exposure.

Alcohol is another important risk factor for laryngeal cancer, and acts as a promoter of the cancer causing process. The major clinical significance of alcohol is that it potentiates the effects of tobacco. Magnitude of this effect is between an additive and a multiplicative one. That is, people who smoke and drink alcohol have a combined risk that is greater than the sum of the individual risks. The American Cancer Society recommends that those who drink alcoholic beverages should limit the amount of alcohol they consume, with one drink per day considered a limited alcohol exposure.

Other risk factors for laryngeal cancer include certain viruses, such as human papilloma virus (HPV), and likely acid reflux. Vitamin A and beta-carotene may play a protective role.

Signs and Symptoms of Laryngeal Cancer

Signs and symptoms of laryngeal cancer include: progressive or persistent hoarseness, difficulty swallowing, persistent sore throat or pain with swallowing, difficulty breathing, pain in the ear, or a lump in the neck. Anyone with these signs or symptoms should be evaluated by an Otolaryngologist (Ear, Nose and Throat Doctor). This is particularly important for people with risk factors for laryngeal cancer.

Treatment of Laryngeal Cancer

The primary treatment options for laryngeal cancer include surgery, radiation therapy, chemotherapy, or a combination of these treatments. Remember that this is a preventable disease in the vast majority of cases, because the main risk factors are associated with modifiable behaviors. Do not smoke and do not abuse alcohol!

Tumors or growths in the head and neck region may be divided into those that are benign (not cancerous) and malignant (i.e., cancer). Fortunately, most growths in the head and neck region in children are considered to be benign. These benign growths can be related to infection, inflammation, fluid collections, swellings, or neoplasms (tumors) that are non life-threatening. The malignant growths, on the other hand, may be life-threatening and cause other problems related to their growth and spread. Even the malignant growths in the head and neck are usually treatable.

Benign Tumors

It is very common for children to have enlarged tonsils and adenoids. These are almost always from an infection or inflammation. It is very rare that children develop a cancer, lymphoma, or sarcoma of these areas. When the tonsils, adenoids, or other areas of the mouth or throat remain enlarged or are enlarged on only one side, it is important to have an evaluation by a specialist in ear, nose and throat or otolaryngology-head and neck surgery.

The lymph nodes of the neck region may become enlarged during childhood. Most of the time, this is reactive in nature and related to inflammation or infection. However, if the lymph nodes remain enlarged for a period of time without going away, it is important to have an otolaryngologist-head and neck surgeon evaluate the problem.

Other benign growths in the face and neck include cysts (fluid collection) such as branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, and dermoid cysts. These often require removal due to their continued growth and potential for infection. Growths of blood vessels often are seen in the face and neck and these are often referred to as hemangiomas, vascular malformations, lymphatic and arteriovenous malformations (AVM). Some of these may require removal or treatment depending upon the type and location.

Sinus and Nose Growths

Although most children have nose bleeds and occasional allergies and sinus infection, sometimes tumors of the nose and sinus present with similar symptoms. It is generally recommended that a child with continuous sinus problems or nose bleeds be evaluated by an otolaryngologist-head and neck surgeon to be sure it is not a tumor or other treatable condition.

Non-epithelial neoplasms constitute the majority of sinonasal (sinus) tumors in children and adolescents. Among these, rhabdomyosarcoma (RMS) or undifferentiated sarcoma and non-Hodgkin lymphoma account for the majority of cases. Among head and neck RMS 14 percent arise from the nasal cavity and 10 percent from the paranasal sinuses. Nasopharyngeal carcinoma accounts for one third of the nasopharyngeal neoplasms in children. As is the case in adult patients, it is associated with Epstein-Barr virus (EBV) infection as demonstrated by EBV DNA presence in malignant cells. Less frequently, Ewing’s sarcoma/PNET can present in this location. These tumors have also been described as secondary malignancies following treatment of retinoblastoma and other neoplasms. Esthesioneuroblastoma is a rare sinonasal tumor historically related to Ewing/PNET, although more recently comparative genomic hybridization analysis disputes this relation. Other less common sinonasal tumors presenting in children include hemangioma and hemagiopericitoma, fibroma and fibrosarcoma, malignant fibrous histiocytoma, and desmoid fibromatosis.

Salivary Gland Tumors

There are three paired sets of salivary glands in the head and neck region. These include the ones in front of the ears (parotid), below the jaw (submandibular), and underneath the tongue (sublingual). Additionally, there are numerous very small salivary glands throughout the mouth and throat. Although tumors can arise in these areas, they are rare. Thus, any child with a growth in these areas should be seen by an otolaryngologist-head and neck surgeon.

Thyroid Tumors

The thyroid gland is found in the front of the lower part of the neck just above the chest area but below the Adam’s apple on both sides. Although tumors can arise in this area, they are rare. Thus, any child with a growth in this area should be seen by an otolaryngologist-head and neck surgeon.

The thyroid is a butterfly shaped gland located at the base of the throat. It has two lobes separated in the middle by a strip of tissue (the isthmus). The thyroid itself secretes three main hormones: (1) Thyroxine contains iodine, needed for growth and metabolism; (2) Triiodothyronine, similar in function to Thyroxine, effects body size, tissues growth, and function: and (3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Thyroid cancer is the third most common tumor malignancy in children. It occurs six times more often in females than males and shares several characteristics with adult thyroid cancer patients. Surgery is the preferred treatment for this cancer and although the procedure is often uncomplicated, one of the risks of thyroid surgery involves vocal cord paralysis. Consequently, an otolaryngologist-head and neck surgeon should be consulted.

Types of thyroid cancer in children:

Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly.

Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels causing the cancer to spread to other parts of the body, making the disease difficult to control.

Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with multiple endocrine neoplasia type 2 (MEN2), an inherited genetic form of the cancer.

Anaplastic: This is the fastest growing of the thyroid cancers, with extremely abnormal cells that grow and spread rapidly, especially locally in the head and neck region. This form of cancer usually is found in older patients.

Symptoms:

The symptoms of this disease vary. Your child may have a lump in the neck, continuous swollen lymph nodes, a tight or full feeling in the neck, and/or trouble with breathing or swallowing, hoarseness.

Diagnosis:

If any of these symptoms occur, consult your child’s physician for a diagnosis. The diagnosis could consist of a head and neck examination to determine if unusual lumps are present; a blood test to indicate how the thyroid is functioning; a sonography, which uses high-frequency sound waves and a computer to create an image of the thyroid gland; a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do no absorb iodine in the normal way; fine needle biopsy, removal for study of a small part of the tumor; and surgery, where a procedure known as a thyroid lobectomy, necessitates removal of the lobe of the thyroid gland that contains the tumor, for analysis.

Treatments for thyroid cancer:

If the tumor is found to be malignant then surgery is used to remove as much of the tumor as possible either by lobectomy or subtotal thyroidectomy (removal of at least one thyroid lobe and up to a near-total removal of the thyroid gland). If necessary, the otolaryngologist- head and neck surgeon may remove the entire thyroid, in a procedure called a total thyroidectomy. Surgery may be followed by radioactive iodine therapy which destroys cancer cells that are left after surgery and help prevent the disease from returning Thyroid hormone therapy may need to be administered throughout your child’s life when he/she has had surgery to remove the thyroid followed by radioactive iodine treatment to replace normal hormones and slow the growth of cancer cells. If cancer has spread to other parts of the body, chemotherapy, the treatment of disease by means of chemical substances or drugs, may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. In general, treatment outcomes for this type of cancer in children tend to be excellent. The best outcome is achieved with teenage girls, papillary type cancer, and a tumor localized to the thyroid gland.

Source: National Cancer Institute “Populationbased Outcomes for Pediatric Thyroid Carcinoma,” by Nina L. Shapiro MD, and Neil Bhattacharyya MD, Laryngoscope. 2005 Feb;115(2):337-40.

Rhabdomyosarcoma is a type of a sarcoma, which means a cancer of the bone, soft tissues, or connective tissue. This cancer can occur anywhere in the body but is most often found in the head and neck region, followed by the organs associated with reproduction and urination, and the arms or legs.

More than 90 percent of rhabdomyosarcomas are diagnosed in people under 25 years old; about 60 percent of these cases are diagnosed in children under the age of 10. In the United States, rhabdomyosarcoma strikes approximately five in every one million children each year.

The cause of rhabdomyosarcoma is unknown. Some children with certain birth defects are at increased risk, and some families have a gene mutation that elevates risk. However, the vast majority of children with rhabdomyosarcoma do not have any known risk factors.

Rhabdomyosarcoma Symptoms Depend on Where the Tumor Develops:

The otolaryngologist-head and neck surgeon is the medical specialist that will identify the symptoms of this cancer in the head and neck region. Specifically, when rhabdomyosarcoma affects the eye or eyelid, the result can be a bulging eye, a swollen eyelid or paralysis of the eye muscles. In the sinuses, rhabdomyosarcoma can cause a stuffy nose, and sometimes a nasal discharge that contains pus or blood. In other locations in the head and neck, the most common symptom of a rhabdomyosarcoma near the surface is a painless lump or swelling that gradually gets larger.

When rhabdomyosarcomas develops in the urogenital tract, the consequence can be tumors causing difficulty in urination, blood in the urine, constipation, a lump or mass inside the vagina, vaginal discharge that contains blood and mucus, or a painless enlargement of one side of the scrotum. Rhabdomyosarcoma appears as a lump or swelling, with or without pain, tenderness and redness. In physically active children, the swelling is sometimes mistaken for an injury related to sports or childhood play.

Call your doctor promptly if your child develops any of these symptoms.

What to Expect When you See the Doctor:

After reviewing your child’s symptoms, your doctor will examine your child. Depending on the results of this exam, your doctor may order a regular X-ray as the first test. Computed tomography (CT) scans and magnetic resonance imaging (MRI) might also be needed. If a tumor is found on any of these tests, a small piece of tissue is removed and examined in a laboratory (biopsy).

If the lab tests show signs of a cancerous tumor, your doctor will refer you to a medical center that has the facilities, personnel, and experience to treat childhood cancer. There your child will have more tests to check whether the cancer has spread to the lungs, bones, or elsewhere.

Diagnosis

Once childhood rhabdomyosarcoma is found, more tests will be done to find out if the cancer cells have spread to other parts of the body. This is called staging. Your doctor needs to know how far the cancer has spread to plan treatment.

Treatments:

A rhabdomyosarcoma will continue to grow until it is treated. Without proper treatment, this cancer eventually may spread to the lungs, bone marrow, bones, or lymph nodes. There are treatments for all patients with childhood rhabdomyosarcoma. Three types of treatment are used, most often in combination with each other:

– Surgery

– Chemotherapy (using drugs to kill cancer cells)

– Radiation therapy (using highenergy X-rays or other high-energy rays to kill cancer cells)

Prognosis:

More than 70 percent of children with localized rhabdomyosarcoma enjoy long-term survival. Survival rates depend on initial tumor size, location, appearance under the microscope, how much of the tumor can be removed with surgery, and whether the disease has spread to other parts of the body.

Insight into recognizing symptoms for early detection

• Early detection of head and neck cancer
• Symptoms of head and neck cancer
• and more…

More than 55,000 Americans will develop cancer of the head and neck (most of which is preventable) this year; nearly 13,000 of them will die from it.

Early detection of head and neck cancer

Tobacco use is the most preventable cause of these deaths. In the United States, up to 200,000 people die each year from smoking-related illnesses. The good news is that this figure has decreased due to the increasing number of Americans who have quit smoking. The bad news is that some of these smokers switched to smokeless or spit tobacco, assuming it is a safe alternative. This is untrue. By doing this, they are only changing the site of the cancer risk from their lungs to their mouth. While lung cancer cases are down, cancers in the head and neck appear to be increasing. Cancer of the head and neck is curable if caught early. Fortunately, most head and neck cancers produce early symptoms. You should know the potential warning signs so you can alert your doctor as soon as possible. Remember-successful treatment of head and neck cancer depends on early detection. Knowing and recognizing the signs of head and neck cancer can save your life.

Symptoms of head and neck cancer

A lump in the neck …Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas and blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change in the voice …Most cancers in the larynx cause some changes in voice. An otolaryngologist is a head and neck specialist who can examine your vocal cords easily and painlessly. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse or notice voice changes for more than two weeks, see your doctor.

A growth in the mouth …Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These sores and swellings may be painless unless they become infected. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, be concerned. Your dentist or doctor can determine if a biopsy (tissue sample test) is needed and can refer you to a head and neck surgeon who can perform this procedure.

Bringing up blood …This is often caused by something other than cancer. However, tumors in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician.

Swallowing problems …Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods difficult. Sometimes liquids can also be troublesome. The food may “stick” at a certain point and then either go through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by a physician. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a scope) will be performed to find the cause.

Changes in the skin …The most common head and neck cancer is basal cell cancer of the skin. Fortunately, this is rarely serious if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, but can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that enlarges slowly, producing a central “dimple” and eventually an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show color changes. Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers and, if caught early and properly treated, usually are not dangerous. If there is a sore on the lip, lower face, or ear that does not heal, consult a physician. Malignant melanoma classically produces dense blue-black or black discolorations of the skin. However, any mole that changes size, color, or begins to bleed may mean trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist or other physician.

Persistent earache …Constant pain in or around the ear when you swallow can be a sign of infection or tumor growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness or a lump in the neck. These symptoms should be evaluated by an otolaryngologist.

Identifying high risk of head and neck cancer

As many as 90 percent of head and neck cancers arise after prolonged exposure to specific factors. Use of tobacco (cigarettes, cigars, chewing tobacco, or snuff) and alcoholic beverages are closely linked with cancers of the mouth, throat, voice box, and tongue. In adults who do not smoke or drink, cancer of the mouth and throat is nearly nonexistent. Prolonged exposure to sunlight is linked with cancer of the lip and is also established as a major cause of skin cancer.

What you should do …All of the symptoms and signs described here can occur with no cancer present. In fact, many times complaints of this type are due to some other condition. But you can’t tell without an examination. So, if they do occur, see your doctor to be sure.

Remember: When found early, most cancers in the head and neck can be cured with little difficulty. Cure rates for these cancers could be greatly improved if people would seek medical advice as soon as possible. Play it safe. If you detect warning signs of head and neck cancer, see your doctor immediately.

Be safe: See your doctor early and practice health habits which help prevent these diseases.

Access to quality healthcare for children is forwarded by the availability of good healthcare information. With this year’s release of a new surgeon general’s report on secondhand smoke, the following information should beshared with patients.

New Warning on Secondhand Smoke

The Surgeon General released new evidence this year-July 2006-supporting the fact that secondhand smoke, smoke from a burning cigarette and the smoke exhaled by the smoker, represents a dangerous health hazard.

The new report states that there is no risk-free level of secondhand smoke exposure. Although secondhand smoke is dangerous to everyone, fetuses, infants, and children are at most risk. Even brief exposures can be harmful to children. This is because secondhand smoke can damage developing organs, such as the lungs and brain.

Infants and Children Effects and Exposure

Babies of mothers who smoked and those exposed to smoke are more likely to die from Sudden Infant Death Syndrome (SIDS) than babies who are not exposed to smoke.

Babies of mothers who smoked and those exposed to smoke after birth have weaker lungs and thereby increased risk of more health problems.

Children with asthma exposed to secondhand smoke experience more frequent and severe attacks.

Children exposed to secondhand smoke are at increased risk for ear infections and are more likely to need an operation to insert ear tubes for drainage.

Youth and Teens Effects and Exposure

Secondhand smoke exposure causes respiratory symptoms, including cough, phlegm, wheeze, and breathlessness, among school-aged children.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Statistics

More than 4,000 different chemicals have been identified in secondhand smoke and at least 43 of these chemicals cause cancer.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children less than five years of age live in homes with at least one adult smoker.

28 percent of high schoolers are exposed to secondhand smoke in their own homes.

A recent study found that 34 percent of teens begin smoking as a result of tobacco company promotional activities.

Among middle school students who were current smokers, 71 percent reported never being asked to show proof of age when buying cigarettes in a store, and 66 percent were not refused purchase because of their age.

Checklist for Protection Against Secondhand Smoke:

Young children

Remember that you are a powerful role model. If you don’t smoke, your children are less likely to smoke.

Make your home and car smoke-free spaces. Put up no-smoking stickers and signs in your home.

Make sure you and your kids aren’t exposed to second-hand smoke at daycare, school, or friends’ homes.

Support businesses and activities that are smoke-free. Let other businesses owners know that you can’t support their businesses until they become 100 percent smoke-free too.

If you can’t find a smoke-free restaurant and must go to one that allows some smoking, ask to sit in the nonsmoking section.

If your asthma or COPD is triggered by smoke, don’t risk it-stay away from any place that allows smoking.

Support laws that restrict smoking.

Youth and Teens

Parents

Talk to your children about smoking; they’ll be less likely to smoke than if you ignore the problem.

Support tobacco education in the schools and ban all smoking on school grounds, on school buses, and at school-sponsored events for students, school personnel, and visitors.

Ask that schools enforce the policy and consistently administer penalties for violations and that this is communicated in written and oral form to students, staff, and visitors.

Vote for public smoking restrictions as an important component of the social environment that supports healthy behavior, reducing the number of opportunities to smoke, and making smoking less socially acceptable.

Support tax increases on tobacco products so young people cannot afford them.

Teens

If your friends smoke, ask them in a caring way to quit or at least not to smoke around you.

Peers, siblings, and friends are powerful influences on you and others. Understand that the most common situation for first trying a cigarette is with a friend who already smokes.

Families

Work together to uphold restrictions on tobacco advertising and promotions.

Sources and Resources

The Health Consequences of Involuntary Exposure to Tobacco Smoke: Children are Hurt by Secondhand Smoke. A Report of the Surgeon General, U.S. Department of Health and Human Services, 2006; Available at: https://www.hhs.gov/surgeongeneral/reports-and-publications/index.html.

CDC. Tobacco Use, Access & Exposure to Tobacco Among Middle & High School Students, US 2004 MMWR. Vol. 54(12) April 2005.

American Legacy Foundation. 2004 National Youth Tobacco Survey. 2005

CDC. Cigarette Use Among High School Students – United States, 1991-2003. Morbidity and Mortality Weekly Report 2004; 53(23): 499-502.

King C, Siegel M. The Master Settlement Agreement with the Tobacco Industry and Cigarette Advertising in Magazines. New England Journal of Medicine 2001; 345: 504-511.

Insight into detection, prevention, and treatment

• What is skin cancer?
• How is skin cancer diagnosed?
• Am I at risk for skin cancer?
• and more…

The skin is the largest organ in our body. It provides protection against heat, cold, light, and infection. The skin is made up of two major layers (epidermis and dermis) as well as various types of cells. The top (or outer) layer of the skin-the epidermis-is composed of three types of cells: flat, scaly cells on the surface called squamous cells; round cells called basal cells; and melanocytes, cells that provide skin its color and protect against skin damage. The inner layer of the skin-the dermis-is the layer that contains the nerves, blood vessels, and sweat glands.

What is skin cancer?

Skin cancer is a disease in which cancerous (malignant) cells are found in the outer layers of your skin. There are several types of cancer that originate in the skin. The most common types are basal cell carcinoma (70 percent of all skin cancers) and squamous cell carcinoma (20 percent). These types are classified as nonmelanoma skin cancer. Melanoma (5 percent of all skin cancers) is the third type of skin cancer. It is less common than basal cell or squamous cell skin cancer, but potentially much more serious. Other types of skin cancer are rare.

Basal cell carcinoma is the most common type of skin cancer. It typically appears as a small raised bump that has a pearly appearance. It is most commonly seen on areas of the skin that have received excessive sun exposure. These cancers may spread to the skin around the cancer but rarely spread to other parts of the body.

Squamous cell carcinoma is also seen on the areas of the body that have been exposed to excessive sun (nose, lower lip, hands, and forehead). Often this cancer appears as a firm red bump or ulceration of the skin that does not heal. Squamous cell carcinomas can spread to lymph nodes in the area.

Melanoma is a skin cancer (malignancy) that arises from the melanocytes in the skin. Melanocytes are the cells that give color to our skin. These cancers typically arise as pigmented (colored) lesions in the skin with an irregular shape, irregular border, and multiple colors. It is the most harmful of all the skin cancers, because it can spread to other sites in the body. Fortunately, most melanomas have a very high cure rate when identified and treated early.

What causes skin cancer?

Most skin cancers occur on sun-exposed areas of our skin, and there is a lot of scientific evidence to support UV radiation as a causative factor in most types of skin cancer. Family history is also important, particularly in melanoma. The lighter your skin type, the more susceptible you are to UV damage and to skin cancer.

How is skin cancer diagnosed?

The vast majority of skin cancers can be cured if diagnosed and treated early. Aside from protecting your skin from sun damage, it is important to recognize the early signs of skin cancer.

• Skin sores that do not heal,
• Bumps or nodules in the skin that are enlarging, and
• Changes in existing moles (size, texture, color).

If you notice any of the factors listed above, see your doctor right away. If you have a spot or lump on your skin, your doctor may remove the growth and examine the tissue under the microscope. This is called a biopsy. A biopsy can usually be done in the doctor’s office and usually involves numbing the skin with a local anesthetic. Examination of the biopsy under the microscope will tell the doctor if the skin lesion is a cancer (malignancy).

How is skin cancer treated?

There are varieties of treatments available, including surgery, radiation therapy, and chemotherapy, to treat skin cancer. Treatment for skin cancer depends on the type and size of cancer, your age, and your overall health.

Surgery is the most common form of treatment. It generally consists of an office or outpatient procedure to remove the lesion and check edges to make sure all the cancer was removed. In many cases, the site is then repaired with simple stitches. In larger skin cancers, your doctor may take some skin from another body site to cover the wound and promote healing. This is termed skin grafting. In more advanced cases of skin cancer, radiation therapy or chemotherapy (drugs that kill cancer cells) may be used with surgery to improve cure rates.

Am I at risk for skin cancer?

People with any of the factors listed below have a higher risk of developing skin cancer and should be particularly careful about sun exposure.

• Long-term sun exposure
• Fair skin (typically blonde or red hair with freckles)
• Place of residence (increased risk in southern climates)
• Presence of moles, particularly if there are irregular edges, uneven coloring, or an increase in the size
• of the mole
• Family history of skin cancer, particularly melanoma
• Use of indoor tanning devices
• Severe sunburns as a child
• Nonhealing ulcers or nodules in the skin.

How can I lower my risk of skin cancer?

The single most important thing you can do to lower your risk of skin cancer is to avoid direct sun exposure. Sunlight produces ultraviolet (UV) radiation that can directly damage the cells (DNA) of our skin. People who work outdoors are at the highest risk of developing a skin cancer. The sun’s rays are the most powerful between 10 am and 2 pm, so you must be particularly careful during those hours. If you must be out during the day, wear clothing that covers as much of your skin as possible, including a wide-brimmed hat to block the sun from your face, scalp, neck, and ears.

The use of a sunscreen can provide protection against UV radiation. When selecting a sunscreen, choose one with a Sun Protection Factor (SPF) of 15 or more. For people who live in the Southern U.S., a SPF of 30 or greater should be used during summer and when prolonged exposure is anticipated. Sunscreen should be applied before exposure and when the skin is dry. If you will be sweating or swimming, most sunscreens will need to be reapplied. Sunscreen products do not completely block the damaging rays, but they do allow you to be in the sun longer without getting sunburn.

It is also critical to recognize early signs of skin trouble. The best time to do self-examination is after a shower in front of a full-length mirror. Note any moles, birthmarks, and blemishes. Be on the alert for sores that do not heal or new nodules on the skin. Any mole that changes in size, color, or texture should be carefully examined. If you notice anything new or unusual, see your physician right away. If you have a strong family history of skin cancer, particularly melanoma, an annual examination by a physician skilled at diagnosing skin cancer is recommended. Catching skin cancer early can save your life.

Ultraviolet index: What you need to know

The new Ultraviolet (UV) index provides important information to help you plan your outdoor activities and avoid overexposure to the damaging rays of the sun. Developed by the National Weather Service and the Environmental Protection Agency, the UV index is issued daily as a national service.

The UV index gives the next day’s amount of exposure to UV rays. The index predicts UV levels on a 0 to 10+ scale (see chart).

Always take precautions against overexposure, and take special care when the UV index predicts exposure levels of moderate to above (5 to 10+).

Index number Exposure level

Insight into its physical and mental effects

• What chemicals are in smokeless tobacco?
• Who uses smokeless tobacco?
• Tips for quitting
• and more…

Three percent of American adults are smokeless tobacco users. They run the same risks of gum disease, heart disease, and addiction as cigarette users, but an even greater risk of oral cancer. Each year about 30,000 Americans are diagnosed with oral and pharyngeal cancers, and more than 8,000 people die of these diseases. Despite the health risks associated with tobacco use, consumers continue to demand the product. In 2001, the five largest tobacco manufacturers spent $236.7 million on smokeless tobacco advertising and promotion.

What is smokeless tobacco?

There are two forms of smokeless tobacco: chewing tobacco and snuff. Chewing tobacco is usually sold as leaf tobacco (packaged in a pouch) or plug tobacco (in brick form). Both are placed between the cheek and gum. Users keep chewing tobacco in their mouths for several hours to get a continuous high from the nicotine in the tobacco.

Snuff is a powdered tobacco (usually sold in cans) that is put between the lower lip and the gum. It is also referred to as “dipping.” Just a pinch is all that’s needed to release the nicotine, which is then swiftly absorbed into the bloodstream, resulting in a quick high.

The chemicals contained in chew or snuff are poisonous and addictive. Every time smokeless tobacco is used, the body adjusts to the amount of tobacco needed to get a high. Consequently, the next time tobacco is used, the body will need a little more tobacco to get the same feeling. Holding an average-sized dip or chew in the mouth for 30 minutes gives the user as much nicotine as smoking four cigarettes.

Is smokeless tobacco less harmful than cigarettes?

In 1986, the U.S. Surgeon General declared that the use of smokeless tobacco “is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous conditions and can lead to nicotine addiction and dependence.” Also since 1991, the National Cancer Institute has recommended that the public avoid the use of all tobacco products due to their high levels of nitrosamines.

In a recent study, cancer researchers found that oral tobacco products including lozenges and moist snuff are not a good alternative to smoking, since the levels of cancer-causing nitrosamines in smokeless tobacco and lozenges are very high. Some smokeless products contain the highest amounts of nicotine that can be readily absorbed by the body.

What are the ingredients in smokeless tobacco?

• Polonium 210 (nuclear waste)
• N-Nitrosamines (cancer-causing)
• Formaldehyde (embalming fluid)
• Nicotine (addictive drug)
• Cadmium (used in batteries and nuclear reactor shields)
• Cyanide ( poisonous compound)
• Arsenic (poinsonous metallic element)
• Benzene (used in insecticides and motor fuels)
• Lead (nerve poison)

Who are the most common smokeless tobacco users?

According to the 2000 National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration, young adults between the ages of 18-25 are the most common smokeless tobacco users. This trend may be influenced by innovative marketing tactics targeted at a younger audience.

Smokeless tobacco manufacturers are marketing flavored smokeless tobacco. A 2005 American Legacy Foundation and National Cancer Institute study noted, “Tobacco companies are using candy-like flavors and high tech delivery devices to turn a blowtorch into a flavored popsicle, misleading millions of youngsters to try a deadly product.”

What are the physical and mental effects of smokeless tobacco use?

Cancer. Smokeless tobacco is a cancer-causing agent or carcinogen. Cancers are most likely to develop at the site where tobacco is held in the mouth, but it may also include the lips, tongue, cheek, and throat.

Leukoplakia. Smokeless tobacco users may develop a condition in which white spots form on the gums, inside of the cheeks and sometimes tongue. It can be caused by the irritation from the tobacco juice. The disorder can be considered pre-cancerous. Therefore, if a white patch does not heal within one week, a doctor should be consulted.

Heart disease. The stimulating effects of nicotine, an organic compound made out of carbon, hydrogen, nitrogen, and sometimes oxygen, increase the heart rate and blood pressure and may trigger irregular heart beats.

Gum and tooth disease. Smokeless tobacco permanently discolors teeth, causes halitosis (bad breath), and may contribute to tooth loss. Smokeless tobacco contains a lot of sugar which forms and acid that may eat away the tooth enamel causing cavities and mouth sores. Also, its direct and repeated contact with the gums may cause them to recede.

Social effects. Bad breath, discolored teeth.

What are some early warning signs of oral cancer?

• A sore that bleeds easily and does not heal
• A lump or thickening anywhere in the mouth or neck
• Soreness or swelling that does not go away
• A red or white patch that does not go away
• Trouble chewing, swallowing, or moving the tongue or jaw

Tips to quit using smokeless tobacco for a lifetime

Write down a list of reasons to quit. For example:

• Don’t want to risk getting cancer.
• Family members find it offensive.
• Don’t like having bad breath after chewing and dipping.
• Don’t want stained teeth or no teeth.
• Don’t like being addicted to nicotine.
• Want to start leading a healthier life.

Pick a quit date and throw out all chewing tobacco and snuff. Remember daily of the decision to stop chewing tobacco. Ask friends and family to help stay committed to the decision to quit by giving support and encouragement. Find alternatives to smokeless tobacco, such as sugarless gum, pumpkin or sunflower seeds, apple slices, raisins, or dried fruit. Engage in recreational activities to keep the mind off of smokeless tobacco. Develop a personalized plan that works best; set realistic goals. Reward successes.

Your child with a hearing loss can succeed – in school, in work, and in life! It is important to keep this as your focus, whatever your child’s age or degree of hearing loss. While you will have the support of many professionals, ultimately you as parents will make many decisions about what is in the best interest of your child. As with all children, there is no magic formula for raising a child with a hearing loss. It helps to maintain a positive attitude, educate yourself about hearing loss, seek out the best resources, and take an active role in your child’s education. Most of all, keep in mind that your child is a child first, and a child with a hearing loss second.

This online booklet is written for parents of children of all ages and all degrees of hearing loss. With so much to cover, the information presented here is only a brief overview, supplemented with a variety of reference and resource materials so you can follow up on subjects more thoroughly. In addition, you are encouraged to join the Alexander Graham Bell Association for the Deaf and Hard of Hearing for access to a huge variety of resources, including educational programs for you and your child, a large inventory of books and other publications, video tapes, conferences, and a national support network.

Will your child have a “normal” life? While some mild-moderate losses can be surgically or medically corrected, most hearing loss is a permanent condition. Thus, your child’s life will have its challenges. However, these challenges sometimes turn into advantages. For example, the ability to work hard and concentrate more, coupled with the routines of audiologic and language therapy, frequently produces children who are self-disciplined and focused. Moreover, the outcomes for children with hearing loss have greatly improved in the last two decades due to major advances in technology and emphasis on programs of early detection and early intervention.

Emotional Impact of the Diagnosis: Parents can benefit from counseling and support after the diagnosis of hearing loss. Grief, anger, fear and denial are natural responses for hearing parents to feel when they find out their child has a hearing loss. Their expected “normal” child has a problem and this problem is going to present many challenges. We convey love through our words and tone of voice as well as through hugs and kisses. We soothe a child through the sound of our voice, or by singing a lullaby. We teach children that the objects in their room, their toys, their food, and the people around them all have names. We show children how to pronounce words by our example. We discipline and warn children of danger through words as well as actions. How are we going to do this now?

Deaf parents of deaf children are not necessarily prone to grief because they are already familiar with living in a world without sound. Deaf parents may feel more comfortable with a child who is deaf, because this seems natural. But this isn’t the case for most hearing parents, who probably know little or nothing about hearing loss and who may never have known a child with a hearing loss. Many deaf parents will teach their child sign language as naturally as hearing parents unconsciously teach their child to speak. But hearing parents must commit themselves to the goal of helping their child listen and speak in order to participate fully in a hearing world, or the equally arduous task of becoming fluent in sign language and learning about Deaf culture.

Grief is a common emotion and an honest expression of disappointment and fear of the unknown. Grief that is not acknowledged or dealt with can lead to denial of a child’s problem, which in turn can lead to procrastination in taking constructive action. Unacknowledged grief can lead to unfocused and displaced anger on the part of parents which can last a lifetime. Acknowledging grief, painful as it may be, will clear away anger and denial, allowing parents to most effectively nurture their child.

About 40,000 people in the United States develop facial paralysis each year with children comprising a small percentage of that population. There are more than 50 known causes of facial paralysis but the most common in children is “Bell’s palsy,” the cause of which is not certain. This disorder effects one side of the facial muscles due to dysfunction of the seventh cranial nerve, usually thought to stem from a viral infection; Bell’s palsy is found in 20 out of 100,000 Americans, with the incidence increasing with each decade of life.

What causes Bell’s palsy?

In Bell’s palsy, facial paralysis results from damage (e.g., possibly from viral infection) to the facial nerve. Adults and children will either wake up to find they have facial paralysis or palsy, or have symptoms such as a dry eye or tingling around their lips that progress to Bell’s palsy during that same day. Occasionally symptoms may take a few days to progress to facial weakness or paralysis. Physical trauma to the head and neck region at birth and during childhood may cause facial paralysis. Other causes are:

• Chicken pox: Chicken pox and shingles are both caused by a single virus of the herpes family known as varicella-zoster virus (VZV). Varicella is the primary infection that causes chickenpox; Herpes zoster is the reactivation of the virus that causes shingles. Research studies suggest that Bell’s palsy may be due to a reactivation of herpes simplex virus (HSV). Between 75 percent and 90 percent of chickenpox cases occur in children under 10 years of age. According to a 2001 study, about 10 percent of children between ages five and nine and about two percent of 10 to 14 year olds get chicken pox each year.
• Infectious mononucleosis: This condition, with a peak incidence in the 15- 17 age group, can be caused by several different viruses. The leading causes are the Epstein-Barr virus and cytomegalovirus, both members of the herpes virus family. The infection is transmitted by saliva, sexual contact, respiratory droplets, and blood transfusions.
• Lyme disease: Lyme disease is an infection that’s spread by Ixodes ticks (black-legged or deer ticks in the eastern United States, and western black-legged ticks in the west). The second stage of Lyme disease usually appears two to three months after the tick bite, and may include facial palsy or paralysis among other symptoms.

What are the symptoms of Bell’s palsy in children?

Not all children react the same to this disorder. However, recorded symptoms include:

• The child may complain of headache or pain behind or in front of the ear a few days prior to the onset of Bell’s palsy.
• Swelling or drooping on one side of the face.
• Drooling, excessive, or reduced production of saliva.
• An inability to blink or completely close one eye.
• The child has either excessive tears or marked dryness and inability to make tears in one eye.
• Sounds seem louder than they really are.
• The child is experiencing sensitivity to light.
• Episodes of dizziness.

Treatments for Facial Paralysis:

If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like herpes zoster (Ramsay Hunt Syndrome) may be used. The prognosis for children with facial paralysis is generally very good. The extent of nerve damage determines the extent of recovery. With or without treatment, studies indicate that most pediatric patients with the disorder begin to get better within two weeks after the initial onset of symptoms and recover completely within three to six months. Adults may find residual symptoms remaining for an indefinite period of time.

What happens during the diagnosis?

After an examination, the otolaryngologist- head and neck surgeon may conduct a hearing test to determine if the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism. Additional tests in the physician’s office include a balance test and a tear test, to measure the eye’s ability to produce tears. Eye drops may be necessary to prevent drying of the surface of the eye cornea. In some circumstances, the physician may recommend a CT (computerized tomography) or MRI (magnetic resonance imaging) test to determine if there is infection, tumor, bone fracture, or other abnormality in the area of the facial nerve. An additional diagnostic tool is the Electro neuronography (ENOG), which stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.

Sources:

National Institute of Neurological Disorders and Stroke

Bell’s Palsy Research Foundation

eNotes.com

Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.

Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it’s your response that can make the difference between a temporary inconvenience and permanent injury.

When Someone Gets Hurt:

What First Aid Supplies Should You Have on Hand in Case of An Emergency?

• Sterile cloth or pads
• Scissors
• Ice pack
• Tape
• Sterile bandages
• Cotton tipped swabs
• Hydrogen peroxide
• Nose drops
• Antibiotic ointment
• Eye pads
• Cotton balls
• Butterfly bandages

Ask “Are you all right?” Determine whether the injured person is breathing and knows who and where they are.

Be certain the person can see, hear and maintain balance. Watch for subtle changes in behavior or speech, such as slurring or stuttering. Any abnormal response requires medical attention.

Note weakness or loss of movement in the forehead, eyelids, cheeks and mouth.

Look at the eyes to make sure they move in the same direction and that both pupils are the same size.

If any doubts exist, seek immediate medical attention.

When Medical Attention Is Required, What Can You Do?

• Call for medical assistance (911).
• Do not move the victim, or remove helmets or protective gear.
• Do not give food, drink or medication until the extent of the injury has been determined.
• Remember HIV…be very careful around body fluids. In an emergency protect your hands with plastic
• bags.
• Apply pressure to bleeding wounds with a clean cloth or pad, unless the eye or eyelid is affected or a
• loose bone can be felt in a head injury. In these cases, do not apply pressure but gently cover the
• wound with a clean cloth.
• Apply ice or a cold pack to areas that have suffered a blow (such as a bump on the head) to help
• control swelling and pain.
• Remember to advise your doctor if the patient has HIV or hepatitis.

Facial Fractures

Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:

• Swelling and bruising, such as a black eye
• Pain or numbness in the face, cheeks or lips
• Double or blurred vision
• Nosebleeds

· Changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face; and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some require medical attention.

You should get immediate medical care when you have:

• Deep skin cuts
• Obvious deformity or fracture
• Loss of facial movement
• Persistent bleeding
• Change in vision
• Problems breathing and/or swallowing
• Alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen is important during the healing process to prevent pigment changes. Scars that look too obvious after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:

• Breathing difficulties
• Deformity of the nose
• Persistent bleeding
• Cuts
• Bleeding

Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.

Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist-head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later.

Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose may last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist — head and neck surgeon. Injuries may involve specific structures within the neck, such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.

Prevention Of Facial Sports Injuries

The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:

• Be sure the playing areas are large enough that players will not run into walls or other obstructions.
• Cover unremoveable goal posts and other structures with thick, protective padding.
• Carefully check equipment to be sure it is functioning properly.
• Require protective equipment – such as helmets and padding for football, bicycling and rollerblading; face masks, head and mouth guards for baseball; ear protectors for wrestlers; and eyeglass guards or goggles for racquetball and snowmobiling are just a few.
• Prepare athletes with warm-up exercises before engaging in intense team activity.
• In the case of sports involving fast-moving vehicles, for example, snowmobiles or dirt bikes – check the path of travel, making sure there are no obstructing fences, wires or other obstacles.
• Enlist adequate adult supervision for all children’s competitive sports.

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food—and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

When should my child see a doctor?

If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician.

Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?

The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens.

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days.

How is allergic rhinitis treated?

The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures.

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks.

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.

Why Is Early Childhood Hearing Screening Important For Your Child?

Approximately two to four of every 1,000 children in the United States are born deaf or hard-of-hearing, making hearing loss the most common birth disorder. Many studies have shown that early diagnosis of hearing loss is crucial to the development of speech, language, cognitive, and psychosocial abilities. Treatment is most successful if hearing loss is identified early, preferably within the first month of life. Still, one in every four children born with serious hearing loss does not receive a diagnosis until age three or older.

When Should A Child’s Hearing Be Tested?

The first opportunity to test a child’s hearing is in the hospital shortly after birth. If your child’s hearing is not screened before leaving the hospital, it is recommended that screening be done within the first month of life. Should test results indicate a possible hearing loss, seek further evaluation as soon as possible; preferably within the first three to six months of life.

Is Early Hearing Screening Mandatory?

In recent years, health organizations across the country, including the AmericanAcademy of Otolaryngology – Head and Neck Surgery, have worked to highlight the importance of screening all newborns for hearing loss. These efforts are working. In 2003, more than 85 percent of all newborns in the United States were screened for hearing loss. In fact, some 39 states have passed legislation requiring some form of hearing screening of newborns before they leave the hospital. This still leaves more than a million babies who are not screened for hearing loss before leaving the hospital.

How Is Screening Done?

Two tests are used to screen infants and newborns for hearing loss. They are:

Otoacoustic emissions (OAE) involves placement of a sponge earphone in the ear canal to measure whether the ear can respond properly to sound. In normal-hearing children, a measurable “echo” should be produced when sound is emitted through the earphone. If no echo is measured, it could indicate a hearing loss.

Auditory brain stem response (ABR) is a more complex test. Earphones are placed on the ears and electrodes are placed on the head and ears. Sound is emitted through the earphones while the electrodes measure how your child’s brain responds to the sound.

If either test indicates a potential hearing loss, your physician may suggest a follow-up evaluation by an otolaryngologist.

Signs Of Hearing Loss In Children

Hearing loss can also occur later childhood, after a newborn leaves the hospital. In these cases, parents, grandparents, and other caregivers are often the first to notice that something may be wrong with a young child’s hearing. Even if your child’s hearing was tested as a newborn, you should continue to watch for signs of hearing loss including:

• Not reacting in any way to unexpected loud noises,
• Not being awakened by loud noises,
• Not turning his/her head in the direction of your voice,
• Not being able to follow or understand directions,
• Poor language development, or
• Speaking loudly or not using age-appropriate language skills.
• If your child exhibits any of these signs, report them to your doctor.

What Happens If My Child Has A Hearing Loss?

Hearing loss in children can be temporary or permanent. It is important to have hearing loss evaluated by a physician who can rule out medical problems that may be causing the hearing loss, such as otitis media (ear infection), excessive earwax congenital malformations, or a genetic hearing loss.

If it is determined that your child’s hearing loss is permanent, hearing aids may be recommended to amplify the sound reaching your child’s ear. Ear surgery may be able to restore or significantly improve hearing in some instances. For those with certain types of profound hearing loss who do not benefit sufficiently from hearing aids, a cochlear implant may be considered. Unlike a hearing aid, a cochlear implant bypasses damaged parts of the auditory system and directly stimulates the hearing nerve and allows the child to hear louder and clearer sound.

You will need to decide whether or not your deaf child will communicate primarily with oral speech and/or sign language, and seek early intervention to prevent language delays. Research indicates that habilitation of hearing loss by age six months will prevent subsequent language delays. Other communication strategies such as auditory verbal therapy, lip reading, and cued speech may also be used in conjunction with a hearing aid or cochlear implant, or independently.

What is facial trauma?

The term facial trauma means any injury to the face or upper jaw bone. Facial traumas include injuries to the skin covering, underlying skeleton, neck, nasal (sinuses), orbital socket, or oral lining, as well as the teeth and dental structures. Sometimes these types of injuries are called maxillofacial injury. Facial trauma is often recognized by lacerations (breaks in the skin); bruising around the eyes, widening of the distance between the eyes (which may indicate injury to the bones between the eye sockets); movement of the upper jaw when the head is stabilized (which may indicate a fracture in this area); and abnormal sensations on the cheek.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, five percent have suffered facial fractures. In children less than three years old, the primary cause of these fractures is falls. In children more than five years old the primary cause for facial trauma is motor vehicle accidents.

Our fast paced world of ultra sports and increasing violence puts children at risk for facial injury. But, children’s facial injuries require special attention. A child’s future growth plays a big role in treatment for facial trauma. So, one of the most important issues as a care giver is to follow a physician’s treatment plan as closely as you can until your child is fully recovered.

Why is facial trauma different in children than adults?

Facial trauma can range between minor injury to disfigurement that lasts a lifetime. The face is critical in communicating with others, so it is important to get the best treatment possible. Pediatric facial trauma differs from adult injury because the face is not fully formed and future growth will be a factor in how the child heals and recovers. Certain types of trauma may cause a delay in the growth or further complicate recovery. Difficult cases require physicians with great skill to make a repair that will grow with your child.

Types of facial trauma

New technology, such as CT scans, have improved physicians ability to evaluate and manage facial trauma. In some cases, immediate surgery is needed to realign fractures before they heal incorrectly. Other injuries will have better outcomes if repairs are done after cuts and swelling have improved. A new study has shown that even when injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physicians care.

Soft tissue injuries

Injuries such as cuts (lacerations) may occur on the soft tissue of the face. In combination with suturing the wound, the provider should take care to inspect and treat any injures to the facial nerves, glands, or ducts.

Bone injuries

When a fracture of the bones in the face occurs, the treatment process is similar to that of a fracture in other parts of the body. Factors that affect how the fracture should be dealt with are the location of the fracture, the severity of the fracture, and the age and general health of the patient. It is important during treatment of facial fractures to be careful that the patient’s facial appearance is minimally affected.

Injuries to the teeth and surrounding dental structures style

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Because of the specific needs of the dental structures, certain actions and precautions should be taken if a child has received an injury to his or her teeth or surrounding dental structures.

• If a tooth is “knocked out”, it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better chance it will survive. Therefore, the patient should see a dentist or oral surgeon as soon as possible.
• Never attempt to “wipe the tooth off” since remnants of the ligament which hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.

References:

Stewart MG, Chen AY. Factors predictive of poor compliance with follow-up after Facial trauma: A prospective study. Otolaryn Head and Neck Surg 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetratin neck trauma in children: an urban hospital’s experience. Otolaryn Head and Neck Surg 2000: 123: 439-43

What you should know

• The CDC and FDA, in partnership with state health departments, have recently completed an investigation that found children with cochlear implants have a higher chance of getting bacterial meningitis than children without cochlear implants. Some children who are candidates for cochlear implants may have factors that increase their risk of meningitis even before they get a cochlear implant. However, this investigation was not designed to determine the risk of meningitis in children who are candidates for cochlear implants but don’t have them.
• Because people with cochlear implants are at increased risk for meningitis, CDC recommends that people with cochlear implants follow recommendations for pneumococcal vaccinations that apply to members of other groups at increased risk. Recommendations for the timing and type of pneumococcal vaccination vary with age and vaccination history and should be discussed with a health care provider.
• Recommendations for people with cochlear implants aged two years and older include the following:
  
  • Children who have cochlear implants, are aged 2 years and older, and have completed the pneumococcal conjugate vaccine (Prevnar ®) series should receive one dose of the pneumococcal polysaccharide vaccine (Pneumovax ® 23). If they have just received pneumococcal conjugate vaccine, they should wait at least two months before receiving pneumococcal polysaccharide vaccine.
  • Children who have cochlear implants are between 24 and 59 months of age, and have never received either pneumococcal conjugate vaccine or pneumococcal polysaccharide vaccine should receive two doses of pneumococcal conjugate vaccine two or more months apart and then receive one dose of pneumococcal polysaccharide vaccine at least two months later.
  • Persons who are aged 5 years and older with cochlear implants should receive one dose of pneumococcal polysaccharide vaccine.

Additional facts

• Worldwide, there are over 90 known reports of people getting meningitis after getting a cochlear implant. This is out of approximately 60,000 people who have cochlear implants.

• Meningitis is an infection. The infection is in the fluid that surrounds the brain and spinal cord. There are two main types of meningitis, viral and bacterial. Bacterial meningitis is the most serious type. It is the type that has been reported in people with cochlear implants. Depending on the cause of the meningitis, the symptoms, treatment, and outcomes differ.

• Bacterial meningitis can be caused by several different kinds of bacteria. Four vaccines protect against most of these bacteria. The vaccines are:
  
  • 7-valent pneumococcal conjugate (Prevnar®) (PCV-7)
  • 23-valent pneumococcal polysaccharide (Pneumovax® 23) (PPV-23)
  • Haemophilus influenzae type b conjugate (Hib)
  • Quadrivalent A,C,Y,W-135 meningococcal polysaccharide (Menomune®).

Meningitis in people with cochlear implants is most commonly caused by the bacteria Streptococcus pneumoniae (pneumococcus). Children with cochlear implants are more likely to get pneumococcal meningitis than children without cochlear implants. None of the children in the investigation had meningococcal meningitis caused by Neisseria meningitidis. There is no evidence that children with cochlear implants are more likely to get meningococcal meningitis than children without cochlear implants.

Sleep apnea is known to affect 1 to 3 percent of children, but because there may be many unreported cases, could actually affect more. Sleep apnea can affect your child’s sleep and behavior and if left untreated can lead to more serious problems. Because sleep apnea can be difficult to diagnose, it is important to monitor your child for the symptoms and have a doctor see her if she exhibits any.

What is sleep apnea?

Obstructive sleep apnea occurs when breathing is disrupted during sleep. This occurs when the airway is blocked, resulting in choking that causes a slower heart rate and increased blood pressure, alerting your child’s brain and causing him to wake up.

What are the symptoms?

The first sign that your child may have sleep apnea is loud snoring that occurs regularly. You may also notice behavioral changes. Due to a lack of sleep, he or she may be more cranky, have more or less energy, and have difficulty concentrating in school.

How is sleep apnea diagnosed?

If you notice that your child has any of those symptoms, have him or her checked by an otolaryngologist- head and neck surgeon, who can use a sleep test to determine sleep apnea. For the test, electrodes are attached to the head to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and can be performed in a sleep laboratory or at home.

Results can vary, so it is important to have the otolaryngologist determine whether your child needs treatment. Often, in mild cases, treatment will be delayed while you are asked to monitor your child and let the doctor know if the symptoms worsen. In severe cases, the doctor will determine the appropriate treatment.

What are the dangers if sleep apnea is left untreated?

Because sleep apnea can lead to more serious problems, it is important that it be properly treated. When left untreated, sleep apnea can cause:

• snoring
• sleep deprivation
• increased bed wetting
• slowed growth
• attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)
• breathing difficulty
• heart trouble

What causes sleep apnea?

In children, sleep apnea can occur for several physical reasons, including enlarged tonsils and adenoids, and abnormalities of the jaw bone and tongue. These factors cause the airway to be blocked, resulting in vibration of the tonsils, or snoring. Overweight children are at increased risk for sleep apnea. Of the 37 percent of children who are considered overweight, 25 percent of them likely have sleeping difficulties that may include sleep apnea. This is because extra fat around the neck and throat block the airway, making it difficult for these children to sleep soundly. Studies have shown that after three months of exercise, the number of children at risk for sleep apnea dropped by 50 percent.

How is sleep apnea treated?

Because enlarged tonsils and adenoids are a common cause of sleep apnea in children, routine treatment often involves an adenotonsillectomy, an operation to remove the tonsils and adenoids. This is a routine operation with a 90 percent success rate. Studies published in Otolaryngology-Head and Neck Surgery (October 2005) and presented at the Academy’s 2006 annual meeting in Toronto showed that when children with sleep apnea were tested one to five months after their surgery, they showed extreme improvement in their sleep and behavior, and that these improvements remained nearly a year and a half later.

Who is in day care?

The 2000 census reported that of among the nation’s 19.6 million preschoolers, grandparents took care of 21 percent, 17 percent were cared for by their father (while their mother was employed or in school); 12 percent were in day care centers; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in nursery schools or preschools. More than one-third of preschoolers (7.2 million) had no regular child-care arrangement and presumably were under maternal care.

Day care establishments are defined as those primarily engaged in care of infants or children, or in providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary function or major element. Some may or may not have substantial educational programs, and some may care for older children when they are not in school.

What are your child’s risks of being exposed to a contagious illness at a day care center?

Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centers do pose some degree of an increased health risk for children, because of the exposure to other children who may be sick.

When your child is in a day care center, the risk is greatest for viral upper respiratory infection (affecting the nose, throat, mouth, voice box) and the common cold, ear infections, and diarrhea. Some studies have tried to link asthma to day care. Other studies suggest that being exposed to all the germs in day care actually IMPROVES your child’s immune system.

Studies suggest that the average child will get eight to ten colds per year, lasting ten – 14 days each, and occurring primarily in the winter months. This means that if a child gets two colds from March to September, and eight colds from September to March, each lasting two weeks, the child will be sick more than over half of the winter.

At the same time, children in a day care environment, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media annually. This is four times the incidence of children staying at home.

When should your child remain at home instead of day care or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

When your child has a temperature higher than 100 degrees, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home.
Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?

The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:

• Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.
• Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:
  
  • Look for otitis (inflammation) in the ear. This is an indicator of future ear infections.
  • Review with you any allergies your child may have. This will assist in determining if the diet offered at the day care center may be harmful to your child.
  • Examine the child’s tonsils for infection and size. Enlarged tonsils could indicate that your child may not be getting a healthy sleep at night, resulting in a tired condition during the day.

Alert the day care center manager when your child is ill, and include the nature of the illness.

Day care has become a necessity for millions of families. Monitoring the health of your own child is key to preventing unnecessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

Your child has been diagnosed with allergic rhinitis, a physiological response to specific allergens such as pet dander or ragweed. The symptoms are fairly simple — a runny nose (rhinitis), watery eyes, and some periodic sneezing. The best solution is to administer over-the-counter antihistamine, and the problem will resolve on its own ….right?

Not really – the interrelated structures of the ears, nose, and throat can cause certain medical problems which trigger additional disorders – all with the possibility of serious consequences.

Simple hay fever can lead to long term problems in swallowing, sleeping, hearing, and breathing. Let’s see what else can happen to a child with a case of hay fever.

Ear infections:

One of children’s most common medical problems is otitis media, or middle ear infection. These infections are especially common in early childhood. They are even more common when children suffer from allergic rhinitis (hay fever) as well. Allergic inflammation can cause swelling in the nose and around the opening of the Eustachian tube (ear canal). This swelling has the potential to interfere with drainage of the middle ear. When bacteria laden discharge clogs the tube, infection is more likely.

Sore throats:

The hay fever allergens may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats, and husky voice. Although more common in older people and in dry inland climates, thick, dry mucus can also irritate the throat and be hard to clear. Air conditioning, winter heating, and dehydration can aggravate the condition. Paradoxically, antihistamines will do so as well. Some newer antihistamines do not produce dryness.

Snoring:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis (hay fever) and perennial (year-round) allergic rhinitis. This allergic condition may have a debilitating effect on the nasal turbinates, the small, shelf-like, bony structures covered by mucous membranes (mucosa). The turbinates protrude into the nasal airway and help to warm, humidify, and cleanse air before it reaches the lungs. When exposed to allergens, the mucosa can become inflamed. The blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose. This inflammation, or rhinitis, can cause chronic nasal obstruction that affects individuals during the day and night.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

Pediatric sinusitis:

Allergic rhinitis can cause enough inflammation to obstruct the openings to the sinuses. Consequently, a bacterial sinus infection occurs. The disease is similar for children and adults. Children may or may not complain of pain. However, in acute sinusitis, they will often have pain and typically have fever and a purulent nasal discharge. In chronic sinusitis, pain and fever are not evident. Some children may have mood or behavior changes. Most will have a purulent, runny nose and nasal congestion even to the point where they must mouth breathe. The infected sinus drains around the Eustachian tube, and therefore many of the children will also have a middle ear infection.

Seasonal allergic rhinitis may resolve after a short period. Administration of the proper over-the-counter antihistamines may alleviate the symptoms. However, if your child suffers from perennial (year round) allergic rhinitis, an examination by specialist will assist in preventing other ear, nose, and throat problems from occurring.

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease or GERD.

Sometimes, acidic stomach contents will reflux all the way up to the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES), and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up. This is essentially LPR because the stomach contents are refluxing into the back of the throat. However, in most infants, it is a normal occurrence caused by the immaturity of both the upper and lower esophageal sphincters, the shorter distance from the stomach to the throat, and the greater amount of time infants spend in the horizontal position. Only infants who have associated airway (breathing) or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a “lump” or something “stuck” in the throat, which does not go away despite multiple swallowing attempts to clear the “lump.” Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This event is known as “laryngospasm.”

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist such as an otolaryngologist. Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

• Chronic cough
• Hoarseness
• Noisy breathing (stridor)
• Croup
• Reactive airway disease (asthma)
• Sleep disordered breathing (SDB)
• Frank spit up
• Feeding difficulty
• Turning blue (cyanosis)
• Aspiration
• Pauses in breathing (apnea)
• Apparent life threatening event (ALTE)
• Failure to thrive (a severe deficiency in growth such that an infant or child is less than five percentile compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction causing recurrent ear infections, or persistent middle ear fluid, and even symptoms of “sinusitis.” The direct relationship between LPR and the latter mentioned problems are currently under research investigation.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician a referral to see an otolaryngologist for evaluation. An otolaryngologist may perform a flexible fiberoptic nasopharyngoscopy/laryngoscopy, which involves sliding a 2 mm scope through the infant or child’s nostril, to look directly at the voice box and related structures or a 24 hour pH monitoring of the esophagus. He or she may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box and related structures (direct laryngoscopy), a full endoscopic look at the trachea and bronchi (bronchoscopy), and an endoscopic look at the esophagus (esophagoscopy) with a possible biopsy of the esophagus to determine if esophagitis is present. LPR in infants and children remains a diagnosis of clinical judgment based on history given by the parents, the physical exam, and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment of LPR is based on successful treatment of GER. In infants and children, basic recommendations may include smaller and more frequent feedings and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications including H2 blockers or proton pump inhibitors may be necessary. Similar to adults, those who fail medical treatment, or have diagnostic evaluations demonstrating anatomical abnormalities may require surgical intervention such as a fundoplication.

The National Institute on Deafness and Other Communication Disorders reports that approximately 28 million Americans have lost some or all of their hearing, including 17 in 1,000 children under age 18. There are three types of hearing loss:

Conductive hearing loss:

This occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones of the middle ear. Conductive hearing loss usually involves a reduction in sound level, or the ability to hear faint sounds. This type of hearing loss can be caused by middle ear infection, impacted earwax, or a benign tumor. This type of hearing loss can often be medically or surgically corrected.

Sensorineural hearing loss:

This hearing loss, caused by damage to the inner ear or to the nerve pathways from the inner ear to the brain, is permanent and cannot be medically or surgically corrected. Sensorineural hearing loss not only involves a reduction in sound level, or ability to hear faint sounds, but also affects speech understanding, or ability to hear clearly. Causes of this disorder include drugs that are toxic to the auditory system, and genetic syndromes. Sensorineural hearing loss may also occur as a result of noise exposure, viruses, head trauma, aging, and tumors.

Mixed hearing loss:

Hearing loss can be both conductive and sensorineural. For example, there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. When this occurs, the hearing loss is referred to as a mixed hearing loss.

Incidence of this disorder increases with age. For example, approximately 314 in 1,000 people over age 65 have hearing loss and 40 to 50 percent of people 75 and older have a hearing loss.

Although 10 million Americans suffer irreversible noise-induced hearing loss, with 30 million more exposed to dangerous noise levels each day, very little has been reported on children’s risk for this type of impairment .

This may soon change. Preteens are attending music concerts with increasing regularity. Additionally, the portable MP3 player, successor to transistor radios and the walkman, is a portable device that can provide up to 15,000 songs through headphones.

Should MP3 player use be limited?

Ear specialists say a whisper is 30 decibels and that a normal conversation is 60 decibels. The sound from an iPod Shuffle has been measured at 115 decibels. A survey sponsored by the Australian government found that about 25 percent of people using portable stereos had daily noise exposures high enough to cause hearing damage. And further research from the United Kingdom determined that young people, ages 18 to 24, were more likely than other adults to exceed safe listening limits.

Researchers at Boston Children’s Hospital determined that listening to a portable music player with headphones at 60 percent of its potential volume for one hour a day is relatively safe.

Why earplugs are important at concerts

Parents should be aware that various medical studies have found sound levels at rock concerts often to be significantly higher than 85 dBA, with some reports suggesting that sound intensity may reach 90 dBA to as high as 122 dBA.

To experience 85 dBA, listen to an electric shaver or a busy urban street. Experts agree that continued exposure to noise above 85 dBA over time will cause hearing loss. Clearly, if levels are maintained at values greater than 85 dBA for long periods of time, this may lead to a significant noise exposure and frequent concertgoers may experience some potentially irreversible hearing loss from this experience.

A research study, “Incidence of Spontaneous Hearing Threshold Shifts during Modern Concert Performances,” from the University of Minnesota Medical Center in Minneapolis examined sound intensity throughout a well-known concert venue and the effectiveness of earplugs.

The findings, presented at the 2005 annual meeting stated that sound pressure levels appeared equally hazardous in all parts of the concert hall, regardless of the type of music played. Accordingly, you should use earplugs at every type of musical concert, regardless of your vicinity to the stage.

A good rule of thumb: When a child accompanies a parent to any activity or location with excessive noise, ear protection should be worn by the entire family.

Dust, mites, pet dander, and ragweed are not the only allergic threats to your child. Food allergies and sensitivities may cause a wide range of adverse reactions to the skin, respiratory system, stomach, and other physiological functions of the body.

Determining what foods are the cause of an allergic reaction is key to treatment. Before you identify the culinary culprit you must consider what type of food allergy your child has. There are two types of food allergies. They are classified as:

• Fixed food allergies: A fixed food allergy may be very apparent, such as the child whose lips swell and throat itches immediately in response to eating peanuts. The cause for this type of food allergy is similar to that of inhalant allergies, so the diagnosis is more easily reached. Blood testing (i.e., RAST test) is typically used to verify fixed food allergies. Approximately five to 15 percent of food allergies are of the fixed variety.
• Cyclic food allergies: These allergies are far more common but less understood. Delayed food allergy symptoms can take up to three days to appear. This type of reaction is associated with the body’s immunoglobin G (IgG) or antibodies. Unlike fixed food allergies, this allergic response is cyclical in nature. As an example, a child may be IgG sensitive to milk. Consequently, symptoms might appear if the child increases the intake and/or frequency of milk consumption.

Both children and adults are susceptible to food allergies. The bad news for children is that they often have more skin reactions to foods, such as eczema, than do adults. But the good news for the young patient is that a child often outgrows his or her food sensitivities, even those that are positive on a RAST test, over time. Food allergies may fade, and then inhalant (e.g, dust, ragweed) allergies may begin to manifest.

Diagnosing and treating the cyclic food allergy

If your child is experiencing allergic reactions to food of unknown origin, you should ask yourself, “Are there any foods that my child craves or any food that I avoid offering?” These foods may be the ones that are causing difficulties for the young patient.

Your physician may also suggest the Elimination and Challenge Diet. This dietary test consists of the following steps:

1. Keep a detailed food diary tracking what was eaten (including ingredients), when it was eaten, medications taken, and any symptoms which developed. Be honest! Some well-meaning parents or caregivers often create a food diary to look healthier than it typically is. Your child can receive the best diagnosis if the diet records are accurate, timed precisely, and truthful. The diet diary can be evaluated by an ear, nose, and throat specialist to identify one or several food items that may be the culprits.

2. Conduct an unblinded elimination and challenge diet at home based upon your physician’s assessment of your child’s diet diary. It is best if you carefully maintain a new diet diary for your child during the period of elimination and challenge. During this elimination and challenge diet, your child must abstain from one, and only one, of the possible food culprits at a time for a period of four days. This can be difficult to carry out if the food is very common, such eggs or cereal, so you need to pay strict attention to your child’s diet during the elimination phase. Any “cheating” will invalidate the results.

3. On the fifth day, you will be asked to feed your child the suspected culprit food item. This is the challenge! Provide your child an average-sized portion of the food in question to be eaten in five minutes. In one hour the child should eat another 1/2 portion if no symptoms have developed. Any symptoms that develop are then timed and recorded. With a true cyclic food allergy, you would expect a significant worsening of the symptoms described in the original diet diary, although the challenge symptoms may vary as well. Fixed food allergies should never be deliberately challenged unless under the direct supervision of a physician. For minor, moderate discomfort from the testing, the patient may take: 1) a child’s laxative to decrease the transit time through the digestive system, 2) Alka Seltzer Gold, 3) Buffered Vitamin C (one gram).

If the Elimination and Challenge Diet confirms a cyclic food allergy, then you will be asked to abstain from feeding your child this food for a period of three to six months. After this time you can slowly reintroduce the food on a rotary basis; it is not to be eaten more frequently than every four days (once or twice a week).

Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and other upper aerodigestive regions. In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at age four months. But an infant’s improved neuromuscular control and the ability to sit up will lead to a spontaneous resolute ion of significant GER in more than half of infants by age ten months and four out of five at age 18 months.

Researchers have found that 10 percent of infants (younger than 12 months) with GER develop significant complications. The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD). Physically, GERD occurs when a muscular valve at the lower end of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas. It is estimated that some five to eight percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?

GER and EER in children often cause relatively few symptoms until a problem exists (GERD). The most common initial symptom of GERD is heartburn. Heartburn is more common in adults, whereas children have a harder time describing this sensation. They usually will complain of a stomach ache or chest discomfort, particularly after meals.

More frequent or severe GER and EER can cause other problems in the stomach, esophagus, pharynx, larynx, lungs, sinuses, ears and even the teeth. Consequently, other typical symptoms could include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting), stomach aches (dyspepsia), abdominal/chest pain (heartburn), sore throat, hoarseness, apnea, laryngeal and tracheal stenoses, asthma/wheezing, chronic sinusitis, ear infections/fluid, and dental caries. Effortless regurgitation is very suggestive of GER. However recurrent vomiting (which is not the same) does not necessarily mean a child has GER.

Unlike infants, the adolescent child will not necessarily resolve GERD on his or her own. Accordingly, if your child displays the typical symptoms of GERD, a visit to a pediatrician is warranted. However, in some circumstances, the disorder may cause significant ear, nose, and throat disorders. When this occurs, an evaluation by an otolaryngologist is recommended.

How is GERD diagnosed?

Most of the time, the physician can make a diagnosis by interviewing the caregiver and examining the child. There are occasions when testing is recommended. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus. The sensor can detect when acid from the stomach is “refluxed” into the esophagus. This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours. At the conclusion of the test, the results will indicate how often the child “refluxes” acid into his or her esophagus and whether he or she has any symptoms when that occurs.
• Barium swallow or upper GI series: The child is fed barium, a white, chalky, liquid. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowings of the upper intestinal tract.
• Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a special camera. This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration). It may also be helpful in determining how long milk sits in the stomach.
• Endoscopy with biopsies: This most comprehensive test involves the passing down of a flexible endoscope with lights and lenses through the mouth into the esophagus, stomach, and duodenum. This allows the doctor to get a directly look at the esophagus, stomach, and duodenum and see if there is any irritation or inflammation present. In some children with gastroesophageal reflux, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis). Endoscopy in children usually requires a general anesthetic.

Fiberoptic Laryngoscopy: A small lighted scope is placed in the nose and the pharynx to evaluate for inflammation.

What treatments for GERD are available?

Treatment of reflux in infants is intended to lessen symptoms, not to relieve the underlying problem, as this will often resolve on its own with time. A useful simple treatment is to thicken a baby’s milk or formula with rice cereal, making it less likely to be refluxed.

Several steps can be taken to assist the older child with GERD:

• Lifestyle changes: Raise the head of the child’s bed about 30 degrees while they sleep and have the child eat smaller, more frequent meals instead of large amounts of food at one sitting. Avoid having the child eat right before they go to bed or lie down; instead, let two or three hours pass. Try a walk or warm bath or even a few minutes on the toilet. Some researchers believe that certain lifestyle changes such as losing weight or dressing in loose clothing my assist in alleviating GERD. Even chewing sugarless gum may help.
• Dietary changes: Avoid chocolate, carbonated drinks, caffeine, tomato products, peppermint, and other acidic foods as citrus juices. Fried foods and spicy foods are also known to aggravate symptoms. Pay attention to what your child eats and be alert for individual problems.
• Medical Treatment: Most of the medications prescribed to treat GERD either break down or lessen intestinal gas, decrease or neutralize stomach acid, or improve intestinal coordination. Your physician will prescribe the most appropriate medication for your child.
• Surgical Treatment: It is rare for children with GERD to require surgery. For the few children who do require surgery, the most commonly performed operation is called Nissen fundoplication. With this procedure, the top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts preventing reflux.

Tumors or growths in the head and neck region may be divided into those that are benign (not cancerous) and malignant (i.e., cancer). Fortunately, most growths in the head and neck region in children are considered to be benign. These benign growths can be related to infection, inflammation, fluid collections, swellings, or neoplasms (tumors) that are non life-threatening. The malignant growths, on the other hand, may be life-threatening and cause other problems related to their growth and spread. Even the malignant growths in the head and neck are usually treatable.

Benign Tumors

It is very common for children to have enlarged tonsils and adenoids. These are almost always from an infection or inflammation. It is very rare that children develop a cancer, lymphoma, or sarcoma of these areas. When the tonsils, adenoids, or other areas of the mouth or throat remain enlarged or are enlarged on only one side, it is important to have an evaluation by a specialist in ear, nose and throat or otolaryngology-head and neck surgery.

The lymph nodes of the neck region may become enlarged during childhood. Most of the time, this is reactive in nature and related to inflammation or infection. However, if the lymph nodes remain enlarged for a period of time without going away, it is important to have an otolaryngologist-head and neck surgeon evaluate the problem.

Other benign growths in the face and neck include cysts (fluid collection) such as branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, and dermoid cysts. These often require removal due to their continued growth and potential for infection. Growths of blood vessels often are seen in the face and neck and these are often referred to as hemangiomas, vascular malformations, lymphatic and arteriovenous malformations (AVM). Some of these may require removal or treatment depending upon the type and location.

Sinus and Nose Growths

Although most children have nose bleeds and occasional allergies and sinus infection, sometimes tumors of the nose and sinus present with similar symptoms. It is generally recommended that a child with continuous sinus problems or nose bleeds be evaluated by an otolaryngologist-head and neck surgeon to be sure it is not a tumor or other treatable condition.

Non-epithelial neoplasms constitute the majority of sinonasal (sinus) tumors in children and adolescents. Among these, rhabdomyosarcoma (RMS) or undifferentiated sarcoma and non-Hodgkin lymphoma account for the majority of cases. Among head and neck RMS 14 percent arise from the nasal cavity and 10 percent from the paranasal sinuses. Nasopharyngeal carcinoma accounts for one third of the nasopharyngeal neoplasms in children. As is the case in adult patients, it is associated with Epstein-Barr virus (EBV) infection as demonstrated by EBV DNA presence in malignant cells. Less frequently, Ewing’s sarcoma/PNET can present in this location. These tumors have also been described as secondary malignancies following treatment of retinoblastoma and other neoplasms. Esthesioneuroblastoma is a rare sinonasal tumor historically related to Ewing/PNET, although more recently comparative genomic hybridization analysis disputes this relation. Other less common sinonasal tumors presenting in children include hemangioma and hemagiopericitoma, fibroma and fibrosarcoma, malignant fibrous histiocytoma, and desmoid fibromatosis.

Salivary Gland Tumors

There are three paired sets of salivary glands in the head and neck region. These include the ones in front of the ears (parotid), below the jaw (submandibular), and underneath the tongue (sublingual). Additionally, there are numerous very small salivary glands throughout the mouth and throat. Although tumors can arise in these areas, they are rare. Thus, any child with a growth in these areas should be seen by an otolaryngologist-head and neck surgeon.

Thyroid Tumors

The thyroid gland is found in the front of the lower part of the neck just above the chest area but below the Adam’s apple on both sides. Although tumors can arise in this area, they are rare. Thus, any child with a growth in this area should be seen by an otolaryngologist-head and neck surgeon.

Today in the United States, studies estimate that 34 percent of U.S. adults are overweight and an additional 31 percent (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13 percent of Americans were obese, and in 1980 15 percent were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15 percent of 6- to 11-year-olds and more than 15 percent of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight?”

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

• Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
• Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
• Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. “Morbid” is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II Diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea, and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem, and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose, and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose, and throat conditions that are common in obese children, such as:

Sleep apnea:

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea-hypopnea is slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea-obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated.” Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections:

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity, and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies:

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose, and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that:

Morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care, and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells, and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

To understand earaches you must first know about the Eustachian tube, a narrow channel connecting the inside of the ear to the back of the throat, just above the soft palate. The tube allows drainage — preventing fluid in the middle ear from building up and bursting the thin ear drum. In a healthy ear, the fluid drains down the tube, assisted by tiny hair cells, and is swallowed.

The tube maintains middle ear pressure equal to the air outside the ear, enabling free eardrum movement. Normally, the tube is collapsed most of the time in order to protect the middle ear from the many germs residing in the nose and mouth. Infection occurs when the Eustachian tube fails to do its job. When the tube becomes partially blocked, fluid accumulates in the middle ear, trapping bacteria already present, which then multiply. Additionally, as the air in the middle ear space escapes into the bloodstream, a partial vacuum is formed that absorbs more bacteria from the nose and mouth into the ear.

Why do children have more ear infections than adults?

Children have Eustachian tubes that are shorter, more horizontal, and straighter than those of adults. These factors make the journey for the bacteria quick and relatively easy. A child’s tube is also floppier, with a smaller opening that easily clogs.

Inflammation of the middle ear is known as “otitis media.” When infection occurs, the condition is called “acute otitis media.” Acute otitis media occurs when a cold, allergy or upper respiratory infection, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube.

When fluid forms in the middle ear, the condition is known as “otitis media with effusion,” which can occur with or without infection. This fluid can remain in the ear for weeks to many months. When infected fluid persists or repeatedly returns, this is sometimes called “chronic middle ear infection.” If not treated, chronic ear infections have potentially serious consequences such as temporary or permanent hearing loss.

How are recurrent acute otitis media and otitis media with effusion treated?

Some child care advocates suggest doing nothing or administering antibiotics to treat the infection. More than 30 million prescriptions are written each year for ear infections, accounting for 25 percent of all antibiotics prescribed in the United States. However, antibiotics are not effective against viral ear infections (30 to 50 percent of such disorders), may cause uncomfortable side effects such as upset stomach, and can contribute to antibiotic resistance. Medical researchers believe that 25 percent of all pneumococcus strains, the most common bacterial cause of ear infections, are resistant to penicillin, and ten to 20 percent are resistant to amoxicillin.

Is surgery effective against recurrent otitis media and otitis media with effusion?

In some cases, surgery may be the only effective treatment for chronic ear infections. Some physicians recommend the use of laser myringotomy, using a laser to create a tiny hole in the eardrum. The treatment is done in the doctor’s office using topical anesthesia (ear drops). Laser myringotomy works by providing several weeks of ventilation for the middle ear. Proponents suggest this can reduce the many courses of antibiotic treatment for severe ear infections and eliminates the need for surgical insertion of tubes with general anesthesia.

Before the procedure:

Prior to the procedure, the otolaryngologist will examine the patient for a description of the tympanic membrane (eardrum) and the middle ear space. An audiometry may be performed to assess patient hearing. A tympanometry will be performed that tests compliance of the tympanic membrane at various levels of air pressure. This test provides a measurement of the extent of middle ear effusion, Eustachian tube function, and otitis media.

The procedure: During the procedure, a small incision is made in the ear drum, the fluid is suctioned out, and a tube is placed. In young children, this is usually done under a light, general anesthesia; older patients may have the procedure performed under local anesthesia. There are over 50 different tube designs, all in different shapes, color, and composition. In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time. Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.

After the procedure : Immediately after the procedure, the surgeon will examine the patient for persistent or profuse bleeding or discharge. After one month, the tube placement will be reviewed, and the patient’s hearing may be tested. Later, the physician will assess the tube’s effectiveness in alleviating the ear infection.

What is the most common surgical treatment for ear infections?

The most common surgical procedure administered to children under general anesthesia is myringotomy with insertion of tympanostomy tubes (TT). A tube is inserted in the middle ear to allow continuous drainage of fluid. The procedure is recommended for treatment of: chronic otitis media with effusion (lasting longer than three months), recurrent acute otitis media (more than three episodes in six months or more than four episodes in 12 months), severe acute otitis media, otitis media with effusion and a hearing loss greater than 30 dB, non-responsiveness to antibiotics, and impending mastoiditis or intra-cranial complication due to otitis media.

If the patient is age six or younger, it is recommended that tubes remain in place for up to two years. Most tubes will fall out without assistance. Otherwise, the specialist will determine when the tubes should be removed.

Your ENT physician will recommend the most effective treatment for your child’s ear infection.

Tinnitus is a condition where the patient experiences ringing or other head noises that are not produced by an external source. This disorder can occur in one or both ears, range in pitch from a low roar to a high squeal, and may be continuous or sporadic. This often debilitating condition has been linked to ear injuries, circulatory system problems, noise-induced hearing loss, wax build-up in the ear canal, medications harmful to the ear, ear or sinus infections, misaligned jaw joints, head and neck trauma, Ménière’s disease, and an abnormal growth of bone of the middle ear. In rare cases, slow-growing tumors on auditory, vestibular, or facial nerves can cause tinnitus as well as deafness, facial paralysis, and balance problems. The American Tinnitus Association estimates that more than 50 million Americans have tinnitus problems to some degree, with approximately 12 million people have symptoms severe enough to seek medical care.

This condition is not uncommon in the pediatric population. Although tinnitus in children is as common as in the adult population, children generally do not complain spontaneously of having tinnitus. Researchers believe that the child with tinnitus considers the noise in the ear to be a normal event, as it has usually been present for a long period of time. A second explanation of this discrepancy lies in the fact that the child may not distinguish between the psychological impact of the tinnitus and its medical significance.

Continuous tinnitus can be annoying and distracting, and in severe cases it can cause psychological distress and interfere with your child’s ability to lead a normal life. The good news is that most children with tinnitus seem to eventually outgrow the symptom. It is unusual to see a child carry the problem into adulthood.

If you think your child has tinnitus:

You should first arrange an appointment with your family physician or pediatrician. If the child does not have a specific problem with the ears such as middle ear inflammation with thick discharge then it may be necessary to have your child referred to an otolaryngologist or ear, nose, and throat specialist.

What treatment your child may be offered.

Most people, including children, who are diagnosed with tinnitus find that there is no specific problem underlying their tinnitus. Consequently, there is no specific medicine or operation to ‘cure’ tinnitus. However, experts suggest that the following steps be taken with the child diagnosed with tinnitus:

(1) Reassure the child: Explain that this condition is common and they are not alone. Ask your physician to describe the condition to the child in terms and images that they can understand.

(2) Explain that he/she may feel less distressed by their tinnitus in the future: Many children find it helpful to have their tinnitus explained carefully to them and to know about ways to manage it. This is partly due to a medical concept known as “neural plasticity,”resulting in children’s brains being more able to change their response to all kinds of stimulation. If it is carefully managed, childhood tinnitus may not be a serious problem.

(3) Use sound generators or provide background noise: Sound therapy has been used to treat adults with tinnitus for some time, and can also be used with children. Sound therapy aims to make tinnitus less noticeable. If tinnitus occurs on a regular basis, then the child’s nervous system can, with soundtherapy, adapt to the condition. The sound can be environmental, such as a fan or quiet background music.

(4) Have hearing-impaired children wear hearing aids: A child with tinnitus and a hearing loss may find that hearing aids can help improve the tinnitus. Hearing aids do this by picking up sounds your child may not normally hear, which in turn will help their brain filter out their tinnitus. It may also help them by taking the strain out of listening. Straining to hear can make your child’s brain focus on the tinnitus noises.

(5) Helping your child to sleep with debilitating tinnitus: Severe tinnitus may lead to sleep difficulties for the young patient. Ask your otolaryngologist the best strategy to adopt when the child cannot sleep.

Finally, help your child to relax. Some children believe their tinnitus gets worse when they are under stress. Discuss appropriate stress relieving techniques with your pediatrician or family physician.

The thyroid is a butterfly shaped gland located at the base of the throat. It has two lobes separated in the middle by a strip of tissue (the isthmus). The thyroid itself secretes three main hormones: (1) Thyroxine contains iodine, needed for growth and metabolism; (2) Triiodothyronine, similar in function to Thyroxine, effects body size, tissues growth, and function: and (3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Thyroid cancer is the third most common tumor malignancy in children. It occurs six times more often in females than males and shares several characteristics with adult thyroid cancer patients. Surgery is the preferred treatment for this cancer and although the procedure is often uncomplicated, one of the risks of thyroid surgery involves vocal cord paralysis. Consequently, an otolaryngologist-head and neck surgeon should be consulted.

Types of thyroid cancer in children:

Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly.

Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels causing the cancer to spread to other parts of the body, making the disease difficult to control.

Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with multiple endocrine neoplasia type 2 (MEN2), an inherited genetic form of the cancer.

Anaplastic: This is the fastest growing of the thyroid cancers, with extremely abnormal cells that grow and spread rapidly, especially locally in the head and neck region. This form of cancer usually is found in older patients.

Symptoms:

The symptoms of this disease vary. Your child may have a lump in the neck, continuous swollen lymph nodes, a tight or full feeling in the neck, and/or trouble with breathing or swallowing, hoarseness.

Diagnosis:

If any of these symptoms occur, consult your child’s physician for a diagnosis. The diagnosis could consist of a head and neck examination to determine if unusual lumps are present; a blood test to indicate how the thyroid is functioning; a sonography, which uses high-frequency sound waves and a computer to create an image of the thyroid gland; a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do no absorb iodine in the normal way; fine needle biopsy, removal for study of a small part of the tumor; and surgery, where a procedure known as a thyroid lobectomy, necessitates removal of the lobe of the thyroid gland that contains the tumor, for analysis.

Treatments for thyroid cancer:

If the tumor is found to be malignant then surgery is used to remove as much of the tumor as possible either by lobectomy or subtotal thyroidectomy (removal of at least one thyroid lobe and up to a near-total removal of the thyroid gland). If necessary, the otolaryngologist- head and neck surgeon may remove the entire thyroid, in a procedure called a total thyroidectomy. Surgery may be followed by radioactive iodine therapy which destroys cancer cells that are left after surgery and help prevent the disease from returning Thyroid hormone therapy may need to be administered throughout your child’s life when he/she has had surgery to remove the thyroid followed by radioactive iodine treatment to replace normal hormones and slow the growth of cancer cells. If cancer has spread to other parts of the body, chemotherapy, the treatment of disease by means of chemical substances or drugs, may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. In general, treatment outcomes for this type of cancer in children tend to be excellent. The best outcome is achieved with teenage girls, papillary type cancer, and a tumor localized to the thyroid gland.

Source: National Cancer Institute “Populationbased Outcomes for Pediatric Thyroid Carcinoma,” by Nina L. Shapiro MD, and Neil Bhattacharyya MD, Laryngoscope. 2005 Feb;115(2):337-40.

Insight into effects and prevention

• What is secondhand smoke?
• Who is at risk?
• and more…

Secondhand smoke is a combination of the smoke from a burning cigarette and the smoke exhaled by a smoker. Also known as environmental tobacco smoke (ETS), it can be recognized easily by its distinctive odor. ETS contaminates the air and is retained in clothing, curtains and furniture. Many people find ETS unpleasant, annoying, and irritating to the eyes and nose. More importantly, it represents a dangerous health hazard. Over 4,000 different chemicals have been identified in ETS, and at least 43 of these chemicals cause cancer.

Is exposure to ETS common?

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children under five years of age live in homes with at least one adult smoker.

Smoke’s effect on…

The fetus and newborn

Maternal, fetal, and placental blood flow change when pregnant women smoke, although the long-term health effects of these changes are not known. Some studies suggest that smoking during pregnancy causes birth defects such as cleft lip or palate. Smoking mothers produce less milk, and their babies have a lower birth weight. Maternal smoking also is associated with neonatal death from Sudden Infant Death Syndrome, the major cause of death in infants between one month and one year of age.

Children’s lungs and respiratory tracts

Exposure to ETS decreases lung efficiency and impairs lung function in children of all ages. It increases both the frequency and severity of childhood asthma. Secondhand smoke can aggravate sinusitis, rhinitis, cystic fibrosis, and chronic respiratory problems such as cough and postnasal drip. It also increases the number of children’s colds and sore throats. In children under two years of age, ETS exposure increases the likelihood of bronchitis and pneumonia. In fact, a 1992 study by the Environmental Protection Agency says ETS causes 150 – 300 thousand lower respiratory tract infections each year in infants and children under 18 months of age. These illnesses result in as many as 15 thousand hospitalizations. Children of parents who smoke half a pack a day or more are at nearly double the risk of hospitalization for a respiratory illness.

The ears

Exposure to ETS increases both the number of ear infections a child will experience, and the duration of the illness. Inhaled smoke irritates the eustachian tube, which connects the back of the nose with the middle ear. This causes swelling and obstruction which interferes with pressure equalization in the middle ear, leading to pain, fluid and infection. Ear infections are the most common cause of children’s hearing loss. When they do not respond to medical treatment, the surgical insertion of tubes into the ears is often required.

The brain

Children of mothers who smoked during pregnancy are more likely to suffer behavioral problems such as hyperactivity than children of non-smoking mothers. Modest impairment in school performance and intellectual achievement have also been demonstrated.

Who is at risk?

Although ETS is dangerous to everyone, fetuses, infants and children are at most risk. This is because ETS can damage developing organs, such as the lungs and brain.

Secondhand smoke causes cancer

You have just read how ETS harms the development of your child, but did you know that your risk of developing cancer from ETS is about 100 times greater than from outdoor cancer-causing pollutants? Did you know that ETS causes more than 3,000 non-smokers to die of lung cancer each year? While these facts are quite alarming for everyone, you can stop your child’s exposure to secondhand smoke right now.

What can you do?

• Stop smoking, if you do smoke. Consult your physician for help, if needed. There are many new pharmaceutical products available to help you quit.
• If you have household members who smoke, help them stop. If it is not possible to stop their smoking, ask them, and visitors, to smoke outside of your home.
• Do not allow smoking in your car.
• Be certain that your children’s schools and day care facilities are smoke free.

Your child’s sinuses are not fully developed until age 20. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Unlike in adults, pediatric sinusitis is difficult to diagnose because symptoms can be subtle and the causes complex.

How Do I Know When My Child Has Sinusitis?

The following symptoms may indicate a sinus infection in your child:

• a “cold” lasting more than 10 to 14 days, sometimes with a low-grade fever
• thick yellow-green nasal drainage
• post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
• headache, usually in children age six or older
• irritability or fatigue
• swelling around the eyes

Young children have immature immune systems and are more prone to infections of the nose, sinus, and ears, especially in the first several years of life. These are most frequently caused by viral infections (colds), and they may be aggravated by allergies. However, when your child remains ill beyond the usual week to ten days, a serious sinus infection is likely.

You can reduce the risk of sinus infections for your child by reducing exposure to known environmental allergies and pollutants such as tobacco smoke, reducing his/her time at day care, and treating stomach acid reflux disease.

How Will the Doctor Treat Sinusitis?

Acute sinusitis: Most children respond very well to antibiotic therapy. Nasal decongestants or topical nasal sprays may also be prescribed for short-term relief of stuffiness. Nasal saline (saltwater) drops or gentle spray can be helpful in thinning secretions and improving mucous membrane function.

If your child has acute sinusitis, symptoms should improve within the first few days. Even if your child improves dramatically within the first week of treatment, it is important that you continue therapy until all the antibiotics have been taken. Your doctor may decide to treat your child with additional medicines if he/she has allergies or other conditions that make the sinus infection worse.

Chronic sinusitis: If your child suffers from one or more symptoms of sinusitis for at least twelve weeks, he or she may have chronic sinusitis. Chronic sinusitis or recurrent episodes of acute sinusitis numbering more than four to six per year, are indications that you should seek consultation with an ear, nose, and throat (ENT) specialist. The ENT may recommend medical or surgical treatment of the sinuses.

Diagnosis of sinusitis: If your child sees an ENT specialist, the doctor will examine his/her ears, nose, and throat. A thorough history and examination usually leads to the correct diagnosis. Occasionally, special instruments will be used to look into the nose during the office visit. An x-ray called a CT scan may help to determine how your child’s sinuses are formed, where the blockage has occurred, and the reliability of a sinusitis diagnosis.

When Is Surgery Necessary For Sinusitis?

Surgery is considered for the small percentage of children with severe or persistent sinusitis symptoms despite medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your child’s sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your child’s sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections.

Also, your doctor may advise removing adenoid tissue from behind the nose as part of the treatment for sinusitis. Although the adenoid tissue does not directly block the sinuses, infection of the adenoid tissue, called adenoiditis, or obstruction of the back of the nose, can cause many of the symptoms that are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal drip, bad breath, cough, and headache.

Summary

Sinusitis in children is different than sinusitis in adults. Children more often demonstrate a cough, bad breath, crankiness, low energy, and swelling around the eyes along with a thick yellow-green nasal or post-nasal drip. Once the diagnosis of sinusitis has been made, children are successfully treated with antibiotic therapy in most cases. If medical therapy fails, surgical therapy can be used as a safe and effective method of treating sinus disease in children