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Conventional Approach to Common ENT Problems

Few children escape earache. It is usually due to an infection of the middle ear cavity, when it is known as acute otitis media. This is a frequent problem in young children and a common reason for parents requesting a house call from the doctor when their offspring are crying and distressed in the small hours of the morning, pulling at their ear and exhibiting a moderately high temperature. During daylight hours, children may not respond to their parents’ conversation because of loss of hearing, and sometimes the eardrum may even burst producing a discharge of fluid from the ear canal. Although this looks alarming as well as messy, it serves to relieve the pressure on the eardrum and represents nature’s way of relieving the problem.

Other sources of earache include inflammation of the skin within the ear canal itself. This is known as otitis externa and may be due to infection, or to inflammation such as that caused by constant moisture, seen in people who swim frequently or who do not dry their ears after showering. Pain may also follow infection with the shingles virus, or even be referred pain from other structures in the head such as the teeth or tonsils. Conventional treatment relies on pain relief in the form of paracetamol, aspirin or ibuprofen (although aspirin is not recommended for children under 12), and antibiotics where infection is present. Resistance to the inappropriate over prescribing of antibiotics is to be welcomed but where the delicate structures within the ear are significantly inflamed and where there is a risk of permanent hearing loss if treatment is delayed, broad-spectrum antibiotics are still strongly recommended. Whenever middle ear infections are diagnosed, a follow-up appointment should always be made to ensure that the situation has fully resolved. If there should be fluid or pus present behind the eardrum despite treatment with antibiotics and antihista­mines, an operation known as a myringotomy may be necessary to allow the escape of such material, and sometimes a tiny hollow dumb-bell shaped device called a grommet is inserted into the hole made in the eardrum to dry out the middle ear cavity over a period of months so that hearing may be preserved long term. Growing interest in allergy as a possible cause of chronic middle ear infections (glue ear) is encouraging many patients to experiment with supplements and dietary restriction in an attempt to avoid recurrent problems.

Nasal Congestion

Nasal congestion is also common and results from swelling of the sensitive lining of the nose, the mucous membrane. When it swells, it tends to leak more fluid so that a thick nasal mucus is produced which further gets in the way of breathing. Causes range from the common cold to allergies like hay fever, deviation of the nasal septum and previous injury right through to chronic sinusitis and nasal polyps. These are pear-shaped growths emanating from the mucous membrane itself.

The traditional approach to treating nasal congestion is to identify the underlying cause and either to avoid the trigger factor or treat the resulting symptoms. Steam inhalations can loosen nasal mucus so it can be expelled through vigorous nose blowing, and decongestant sprays and drops can shrink the mucous membrane, opening up the airway and reducing the leakage of fluid. However, these should not be used for more than a maximum of 2 weeks at any time because ultimately the blood vessels become resistant to their action, and permanent exacerbation of the symptoms may result.

If short-term measures such as these have failed, investigation by the doctor to identify sinusitis, polyps or persistent allergy is required. There is no doubt that avoiding the inhalation of cigarette smoke, keeping out of the way of environmental pollution and reducing the number of house dust mites in the household would solve a large number of problems. If chronic sinusitis and polyps are discovered, surgical procedures to drain fluid from the sinuses and to strip away chronically swollen mucous membrane in the sinuses or nasal cavities can be performed.

Tonsils and Adenoids

Although these glands, situated as they are at the back of the throat and nose, tend to be regarded as something of a nuisance, they are actually one of the body’s first lines of defence against invading micro-organisms. As such they have an important function. As they do battle with viruses and bacteria, they swell and become inflamed, causing pain and discomfort. Removing them without good reason through a surgical procedure exposes the individual to the risk of general anaesthesia, will not prevent future sore throats and only means that the second line of defence against infection, namely the glands each side of the neck, are called on to respond instead. Consequently any operation on the tonsils and adenoids is now restricted to those situations where to leave them would be detrimental to health.

Children suffer most up to the age of about 7 when their immune system becomes more fully mature and able to deal with invading bacteria and viruses and when their growth rate is such that their nose and throat passages become wider and less vulnerable to obstructive symptoms. The conventional approach to tonsillitis and adenoid enlargement is to assess the frequency and severity of infections in the child as well as the degree of time lost from school and any interference with sleep. When the child is frequently ill with high temperature, very inflamed glands, difficulty swallowing, weight loss and nasal obstruction as a result of tonsillar and adenoidal enlargement, an operation to remove these structures is seriously considered. In most cases, however, sore throats are due to viral infections which will not respond to antibiotics and which are of short duration anyway. The GP is expertly placed to advise patients accordingly on the best course of action in their individual circumstances.

Tinnitus

This refers to a hissing, ringing or whistling sound in the ear when no external noise actually exists. For reasons not fully understood, the hearing nerve transmits signals to the brain which interprets the messages as background noise. There is often some hearing loss which accompanies the tinnitus and this may be associated with exposure to loud noise in the past or to disorders of the inner, middle or outer ear or even to the side effects of certain drugs such as aspirin or quinine. Many people can experience tinnitus to some degree if they listen hard enough to the sound of silence, but in some people the tinnitus is extreme and they suffer such distress they may even be driven to contemplate suicide. The conventional approach to treatment is unsatisfactory to say the least as no cure is possible and sufferers are merely advised to block out the noise by overriding it with other sounds such as from the radio or hi-fi. Some ear, nose and throat specialists, however, recommend a tinnitus ‘masker’, very much like headphones, which transmits a random mixture of sounds from a broad range of frequencies to drown out the abnormally generated sound from within the ear itself.

Deafness

There are many forms of deafness and many of them result from problems either in the nerve of hearing itself or in the structures that transmit sound from the outside through the ear cavities to the sensory apparatus of hearing itself, deep within the skull. Infection, injury, deterioration due to age and congenital problems may all prove to be the underlying cause. The conventional approach to deafness is first of all to reach a diagnosis and then to treat it accordingly.

Children who are born deaf will clearly have special needs and will need to undergo the long and difficult process of learning to communicate effectively with those around them. Children who become deaf as a result of chronic middle ear infection (glue ear) may require an operation known as a myr­ingotomy to drain fluid from the middle ear cavity and dry out the cells lining it. Where wax in the outer ear is a problem it may be syringed away with warm water by your GP or the practice nurse. Perforated eardrum as a result of loud noise or rapid changes in air pressure may either heal spontaneously or require a surgical procedure known as a tympanoplasty to cover the defect. In cases of deafness due to otosclerosis, where the tiny bones within the middle ear cavity fail to move normally in relation to one another in response to external sound, a stapedectomy operation to insert an artificial stapes bone is effective.

Hearing aids are recommended where it is necessary to increase the volume of sound reaching the inner ear, and for this purpose they contain an amplifier and an earphone that fits into the outer ear. Modern digital hearing aids are so tiny that they fit into the ear canal themselves and are hardly visible to other people. They can improve hearing loss dramatically by enhancing certain frequencies of sound while cutting out others. When the central apparatus for hearing within the skull is severely damaged, a new operation known as a cochlear implant is now being performed which creates new hope for people who are profoundly deaf, even those who have been deaf from birth.