Online Medicine Resource: EAR NOSE and THROAT PROBLEMS

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TONSILLITIS AND ADENO-TONSILLECTOMY

Tonsillitis is an inflammation of the tonsils in the mouth and will often, but not necessarily, cause a sore throat and fever.

Symptoms may also include pain in the tonsil area and inability to swallow and/or painful swallowing. White spots may also appear on the tonsils.

There are 3 main types of tonsillitis: acute, subacute and chronic.

- Acute tonsillitis can either be bacterial or viral in origin.

- Subacute tonsillitis (which can last between 3 weeks and 3 months) is caused by the bacterium Actinomyces.

- Chronic tonsillitis, which can last for long periods if not treated, is almost always bacterial, and is extremely painful.

Causes

Bacterial tonsillitis may be caused by Group A streptococcal bacteria, resulting in strep throat. Viral tonsillitis may be caused by numerous viruses such as the Epstein-Barr virus (the cause of glandular fever) or the Coxsackie virus.

Sometimes, tonsillitis is caused by a superinfection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina.

Treatment

Treatment consists of painkillers and fluids; if caused by bacteria then antibiotics are also prescribed. Usually penicillin, or erythromycin if the patient is allergic to penicillin. Amoxicillin should not be used, unless bacterial infection has been microbiologically confirmed, because if mononucleosis is mistaken as tonsillitis and amoxicillin is given, a rash might develop and it may be wrongly assumed that the patient has developed an allergy to penicillins. Rest in a warm environment is advisable.

In many cases of tonsillitis, the pain caused by the inflamed tonsils warrants the prescription of topical anesthetics for temporary relief. Viscous lidocaine solutions are often prescribed for this purpose.

One may consider a burst of steroids to help decrease the edema and inflammation thereby easing pain and allowing the patient to swallow liquids sooner.

When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week, however some rare infections may last for up to two weeks.

In chronic cases tonsillectomy (surgical removal of tonsils) may be indicated.

Complications

An abscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis. This is termed a peritonsillar abscess (or quinsy). Rarely the infection may spread beyond the tonsil resulting in inflammation and infection of the internal jugular vein giving rise to a spreading septicaemia infection (Lemierre's syndrome).

In chronic/recurrent cases (generally defined as seven episodes of tonsillitis in the preceding year, five episodes in each of the preceding two years or three episodes in each of the preceding three years)[2][3][4], or in acute cases where the palatine tonsils become so swollen that swallowing is impaired, a tonsillectomy can be performed to remove the tonsils. Patients whose tonsils have been removed are certainly still protected from infection by the rest of their immune system.

Bacteria feeding on mucus which acumulates in pits (referred to as 'crypts') in the tonsils, produce whitish-yellow deposits known as a tonsilloliths. These "tonsil stones" emit a very pungent odor due to the presence of volatile sulphur compounds.

Tonsilloliths (or tonsil stones) which occur in the crypts of the tonsils can only be completely cured by tonsillectomy or by resurfacing the tonsil by laser, but practicing good oral hygiene and use of a water pick may help lessen the symptoms. It is still possible to get tonsiloliths after removal of the tonsils unless a complete tonsillectomy is performed.

Hypertrophy of the tonsils can result in snoring, mouth breathing, disturbed sleep, and obstructive sleep apnea, during which the patient stops breathing and experiences a drop in the oxygen content in the bloodstream. A tonsillectomy can be curative.

In very rare cases, diseases like rheumatic fever or glomerulonephritis can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations.

TINNITUS

Tinnitus is a symptom associated with many forms of hearing loss. It can also be a symptom of other health problems.

Tinnitus can be so severe that it interferes with daily activities. People with severe cases of tinnitus may find it difficult to hear, work, or even sleep.

What causes tinnitus?

Hearing loss. Doctors and scientists have discovered that people with different kinds of hearing loss also have tinnitus.

Loud noise. Too much exposure to loud noise can cause noise-induced hearing loss and tinnitus.

Medicine. More than 200 medicines can cause tinnitus. If you have tinnitus and you take medicine, ask your doctor or pharmacist whether your medicine could be involved.

Other health problems. Allergies, tumours, and problems in the heart and blood vessels, jaws, and neck can cause tinnitus.

What should I do if I have tinnitus?

The most important thing you can do is to go see your doctor. Your doctor can try to determine what is causing your tinnitus. He or she can check to see if it is related to blood pressure, kidney function, diet, or allergies. Your doctor can also determine whether your tinnitus is related to any medicine you are taking.

To learn more about what is causing your tinnitus, your doctor may refer you to an otolaryngologist, an ear, nose, and throat doctor. He or she will examine your ears and your hearing to try to find out why you have tinnitus. Another hearing professional, an audiologist, can measure your hearing. If you need a hearing aid, an audiologist can fit you with one that meets your needs.

How will hearing experts treat my tinnitus?

Although there is no cure for tinnitus, scientists and doctors have discovered several treatments that may give you some relief. Not every treatment works for everyone, so you may need to try several to find the ones that help.

Treatments can include:

Hearing aids. Many people with tinnitus also have a hearing loss. Wearing a hearing aid makes it easier for some people to hear the sounds they need to hear by making them louder. The better you hear other people talking or the music you like, the less you notice your tinnitus.

Maskers. Maskers are small electronic devices that use sound to make tinnitus less noticeable. Maskers do not make tinnitus go away, but they make the ringing or roaring seem softer. For some people, maskers hide their tinnitus so well that they can barely hear it.

Some people sleep better when they use maskers. Listening to static at a low volume on the radio or using bedside maskers can help. These are devices you can put by your bed instead of behind your ear. They can help you ignore your tinnitus and fall asleep.

Medicine or drug therapy. Some medicines may ease tinnitus. If your doctor prescribes medicine to treat your tinnitus, he or she can tell you whether the medicine has any side effects.

Tinnitus retraining therapy. This treatment uses a combination of counselling and maskers. Otolaryngologists and audiologists help you learn how to deal with your tinnitus better. You may also use maskers to make your tinnitus less noticeable. After a while, some people learn how to avoid thinking about their tinnitus. It takes time for this treatment to work, but it can be very helpful.

Counselling. People with tinnitus may become depressed. Talking with a counsellor or people in tinnitus support groups may be helpful.

Relaxing. Learning how to relax is very helpful if the noise in your ears frustrates you. Stress makes tinnitus seem worse. By relaxing, you have a chance to rest and better deal with the sound.

What can I do to help myself?

Think about things that will help you cope. Many people find listening to music very helpful. Focusing on music might help you forget about your tinnitus for a while. It can also help mask the sound. Other people like to listen to recorded nature sounds, like ocean waves, the wind, or even crickets.

Avoid anything that can make your tinnitus worse. This includes smoking, alcohol, and loud noise. If you are a construction worker, an airport worker, or a hunter, or if you are regularly exposed to loud noise at home or at work, wear ear plugs or special earmuffs to protect your hearing and keep your tinnitus from getting worse.

If it is hard for you to hear over your tinnitus, ask your friends and family to face you when they talk so you can see their faces. Seeing their expressions may help you understand them better. Ask people to speak louder, but not shout. Also, tell them they do not have to talk slowly, just more clearly.

STREP THROAT

Strep throat, also called acute streptococcal pharyngitis, is an infection with group A streptococcus bacteria that causes a sore throat.

Scarlet fever (another form of group A strep disease) can follow strep throat. It is usually contagious and lasts for a specific length of time whether or not it is treated.

Symptoms of strep throat

If you have strep throat infection, you will have a red and painful sore throat and may have white patches on your tonsils.

You also may have swollen lymph nodes in your neck, run a fever, and have a headache.

Nausea, vomiting, and abdominal pain can occur but are more common in children than in adults.

Symptoms of scarlet fever

In addition to the symptoms of strep throat, a red rash appears on the sides of your chest and abdomen. It may spread to cover most of your body. This rash appears as tiny, red pinpoints and has a rough texture like sandpaper. When pressed on, the rash loses color or turns white.

There may also be dark red lines in the folds of skin. You may get a bright strawberry-red tongue and flushed (rosy) face, while the area around your mouth remains pale. The skin on the tips of your fingers and toes often peels after you get better. If you have a severe case, you may have a high fever, nausea, and vomiting.

Transmission of strep throat

You can get strep throat and other group A strep infections by direct contact with saliva or nasal discharge from an infected person.

Most people do not get group A strep infections from casual contact with others, but a crowded environment like a dormitory, school, or an institutional setting such as a nursing home can make it easier for the bacteria to spread.

There have also been reports of contaminated food, especially milk and milk products, causing infection.

You can get sick within 3 days after being exposed to the germ. Once infected, you can pass the infection to others for up to 2 to 3 weeks even if you don't have symptoms. After 24 hours of antibiotic treatment, you will no longer spread the germs to others.

Diagnosis of strep throat

Your health care provider will take a throat swab. This will be used for a culture (a type of laboratory test) or a rapid strep test, which only takes 10 to 20 minutes.

If the result of the rapid test is negative, you may get a follow-up culture to confirm the results, which takes 24 to 48 hours. If the culture test is also negative, your health care provider may suspect you do not have strep, but rather another type of infection. The results of these throat cultures will affect what your health care provider decides to be the best treatment.

Most sore throats are caused by viral infections, however, and antibiotics are useless against them.

Treatment for strep throat

If you have a strep infection, your health care provider will prescribe an antibiotic. This will help reduce symptoms, and after 24 hours of taking the medicine, you will no longer be able to spread the infection to others. Treatment will also reduce the chance of complications.

Health experts think penicillin is the best medicine for treating strep throat because it has been proven to be effective, safe, and inexpensive. Your health care provider may have you take pills for 10 days or give you a shot. If you are allergic to penicillin there are other antibiotics your health care provider can give you to clear up the illness.

During treatment, you may start to feel better within 4 days. This can happen even without treatment. Still, it is very important to finish all your medicine to prevent complications.

Children with strep throat are usually treated with amoxicillin.

Complications of strep throat

Untreated group A strep infection can result in rheumatic fever and post-streptococcal glomerulonephritis (PSGN).

Rheumatic fever develops about 18 days after a bout of strep throat and causes joint pain and heart disease. It can be followed months later by Sydenham's chorea, a disorder where the muscles of the torso and arms and legs are marked with dancing and jerky movements.

PSGN is an inflammation of the kidneys that may follow an untreated strep throat but more often comes after a strep skin infection.

Both disorders are rarely seen because of prompt and effective treatment of most cases of strep throat.

SORE THROAT

A sore throat is also known as pharyngitis, a painful inflammation of the pharynx.

The major cause of a sore throat is viral infection (90%). The remainder are caused by bacterial infection. Some cases of pharyngitis are caused by irritation from agents such as pollutants or chemical substances.

Viral sore throats

These comprise about 90% of all infectious cases and can be a feature of many different types of viral infections.

Adenovirus - the most common of the viral causes. Typically the degree of neck lymph node enlargement is modest and the throat often does not appear red, although is very painful.
Orthomyxoviridae which cause influenza - present with rapid onset high temperature, headache and generalised ache. A sore throat may be associated.
Infectious mononucleosis ("glandular fever") caused by the Epstein-Barr virus. This may cause significant lymph gland swelling and an exudative tonsillitis with marked redness and swelling of the throat. The heterophile test can be used if this is suspected.
Herpes simplex virus can cause multiple mouth ulcers.
Measles

Bacterial sore throats

Group A Streptococcus

The most common bacterial agent is streptococcus. Unlike adenovirus, there tends to be greater generalised symptoms and more signs to find. Typically enlarged and tender lymph glands, with bright red inflamed and swollen throat, the patient may have a high temperature, headache, and aching muscles (myalgia) and joints (arthralgia). It may be impossible to distinguish between viral and bacterial causes of sore throat.

Some immune-system meditated complications may occur:

Scarlet fever with its vivid rash, although the milder disease seen after the 1950's suggests that the bacteria may have mutated to less virulent illness and some doctors now call this scarlatina (literally a 'little scarlet fever')
Historically the most important complication was of the generalised inflammatory disorder of rheumatic fever which could later result in Rheumatic heart disease affecting the valves of the heart. Antibiotics may reduce the incidence of this complication to under a third. However the incidence of rheumatic fever in developed-regions of the world remains low even though the use of antibiotics has been declining. This may be a result of a change in the prevalence of various strains of bacteria. In underdeveloped regions, untreated streptococcal infection can still give rise to rheumatic heart disease and may be due to environmental factors, or reflect a genetic predisposition of the patient to the disease.
Post-streptococcal glomerulonephritis is an inflammation of the kidney. It is disputed whether antibiotics might reduce the small risk of this or not.
Very rarely there may occur a secondary infection behind the tonsils which may cause a life-threatening septicaemia (Lemierre's syndrome).

Diphtheria

Diphtheria is a potentially life threatening upper respiratory infection caused by Corynebacterium diphtheriae which has been largely eradicated in developed nations since the introduction of childhood vaccination programs, but is still reported in the Third World and increasingly in some areas in Eastern Europe. Antibiotics are effective in the early stages, but recovery is generally slow.

Treatment

Without treatment most pharyngitis will settle spontaneously within a few days. The main focus of treatment is symptomatic.

Specific treatment of pharyngitis will vary according to the cause.

Antibiotics are only helpful when a bacterial infection is the cause of the sore throat.

Simple analgesics, especially NSAIDs (eg. ibuprofen), are usually effective at relieving a painful throat.

SINUSITIS

Sinusitis is an inflammation of the paranasal sinuses, which may or may not be as a result of infection, from bacterial, fungal, viral, allergic or autoimmune issues.

Newer classifications of sinusitis refer to it as rhinosinusitis, taking into account the thought that inflammation of the sinuses cannot occur without some inflammation of the nose as well (rhinitis).

Classification

By location

There are several paired paranasal sinuses, including the frontal, ethmoid, maxillary and sphenoid sinuses. The ethmoid sinuses can also be further broken down into anterior and posterior, the division of which is defined as the basal lamella of the middle turbinate. In addition to the acuity of disease, discussed below, sinusitis can be classified by the sinus cavity which it affects:

Maxillary sinusitis - can cause pain or pressure in the maxillary (cheek) area (eg. toothache, headache).

Frontal sinusitis - can cause pain or pressure in the frontal sinus cavity (located behind/above eyes), headache.

Ethmoid sinusitis - can cause pain or pressure pain between and/or behind eyes, headache.

Sphenoid sinusitis - can cause pain or pressure behind the eyes, but often refers to the vertex of the head.

Recent theories of the sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the respiratory tract (ie. - the "one airway" theory) and is often linked to asthma. All forms of sinusitis may either result in, or be a part of, a generalized inflammation of the airway so other airway symptoms such as cough may be associated with it. One can get a sinus infection by 'making out' or open mouth kissing.[citation needed]

Acute vs. chronic

Sinusitis can be acute (going on less than four weeks), subacute (4-12 weeks) or chronic (going on for 12 weeks or more).

All three types of sinusitis have similar symptoms, and are thus often difficult to distinguish.

Acute sinusitis

Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin. Virally damaged surface tissues are then colonized by bacteria, most commonly Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Staphylococcus aureus. Other bacterial pathogens include other streptococci species, anaerobic bacteria and, less commonly, gram negative bacteria. Another possible cause of sinusitis can be dental problems that affect the maxillary sinus. Acute episodes of sinusitis can also result from fungal invasion. These infections are most often seen in patients with diabetes or other immune deficiencies (such as AIDS or transplant patients on anti-rejection medications) and can be life threatening.

Chronic sinusitis

Chronic sinusitis is a complicated spectrum of diseases that share chronic inflammation of the sinuses in common. The causes are multifactorial and may include allergy, environmental factors such as dust or pollution, bacterial infection, and/or fungus (either allergic, infective or reactive). Non allergic factors such as Vasomotor rhinitis can also cause chronic sinus problems.

Symptoms include: Nasal congestion; facial pain; headache; fever; general malaise; thick green or yellow discharge; feeling of facial 'fullness' worsening on bending over; aching teeth.

In a small number of cases, chronic maxillary sinusitis can also be brought on by the spreading of bacteria from a dental infection.

A more recent, and still debated, development in chronic sinusitis is the role that fungus may play. Fungus can be found in the nasal cavities and sinuses of most patients with sinusitis, but can also be found in healthy people as well. It remains unclear if fungus is a definite factor in the development of chronic sinusitis and if it is, what the difference may be between those who develop the disease and those who do not.

Diagnosis

Factors which may predispose to developing sinusitis include: allergies; structural problems such as, for example, a deviated septum, small sinus ostia; smoking; nasal polyps; carrying the cystic fibrosis gene (research is still tentative); prior bouts of sinusitis as each instance may result in increased inflammation of the nasal or sinus mucosa and potentially further narrow the openings.

When imaging techniques are required for diagnosis CT scanning is the method of choice. If allergies are suspected, allergy testing may be performed.

Treatment

Therapeutic measures range from the medicinal to the traditional and may include nasal irrigation or jala neti using a warm saline solution, analgesics (such as aspirin, paracetamol (acetaminophen) or ibuprofen), hot drinks including tea and chicken soup, inhaling steam, over-the-counter decongestants and nasal sprays, and getting plenty of rest. If sinusitis doesn't improve within 48 hours, or is causing significant pain, one should see a doctor, who may prescribe antibiotics or nasal steroids. If the recommended doses and duration of antibiotic treatment(s) are ineffective, one should reconsult a doctor; who may suggest further treatment by a specialist.

For chronic or recurring sinusitis, referral to an otolaryngologist is indicated for more specialist assessment and treatment, which may include nasal surgery.

A relatively recent advance in the treatment of sinusitis is a type of surgery called FESS - functional endoscopic sinus surgery, whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces prior open techniques requiring facial or oral incisions and refocuses the technique to the natural openings of the sinuses instead of promoting drainage by gravity, the idea upon which the less effective Caldwell-Luc surgery was based.

Another recently developed treatment is Balloon Sinuplasty. This method, similar to balloon angioplasty used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. Its final role in the treatment of sinus disease is still under debate but appears promising.

Another treatment option is Coblation which is a recent technique for removing and treating tissue performed at a lower temperatures (40C to 70C).

Based on the recent theories on the role that fungus may play in the development of chronic sinusitis, newer medical therapies include topical nasal applications of antifungal agents. Much of the original research indicating fungus took place at the Mayo Clinic and they have since patented this treatment option. Although there are some licensing battles taking place over these drugs as a result of the patent, they are currently available for other uses and therefore can be compounded by pharmacies or even by the patient.

Nasal irrigation and flush promotes sinus cavity health, and patients with chronic sinusitis including symptoms of facial pain, headache, halitosis, cough, anterior rhinorrhea (watery discharge) and nasal congestion found nasal irrigation to be "just as effective at treating these symptoms as the drug therapies." In other studies, "daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis," and is "recommended as an effective adjunctive treatment of chronic sinonasal symptoms."

SALIVARY STONES

Salivary stones are stones (calculi), primarily calcium mineral salts, that form within the salivary ducts. The resulting blockage and inflammation (sialitis) causes immense pain on eating when saliva production increases.

The majority (80%) of salivary stones form in the submandibular gland.

Salivary stones can be surgically removed under local anaesthetic.

Lithotripsy (shockwave treatment) may be an alternative treatment.

OTITIS EXTERNA

What is otitis externa?

Otitis externa (Swimmer's ear) is an infection of the ear and/or outer ear canal. It can cause the ear to itch or become red and inflamed so that head movement or touching of the ear is very painful. There may also be pus that drains from the ear.

What causes otitis externa?

Otitis externa is often caused by infection with a germ called Pseudomonas aeruginosa. This germ is common in the environment (soil, water) and is microscopic so that it can't be seen with the naked eye. Although all age groups are affected by Otitis externa, it is more common in children and young adults and can be extremely painful.

How is otitis externa spread?

Having contaminated water get in the ear can give people Otitis externa. Otitis externa usually occurs within a few days of getting contaminated water or placing contaminated objects in the ear.

Is there a difference between a childhood middle ear infection and otitis externa?

Yes. Otitis externa is not the same as the common childhood middle ear infection. If you can wiggle the outer ear without pain or discomfort then your ear infection is probably not Otitis externa.

Can otitis externa be prevented?

Yes. Here are four Healthy Swimming tips for protection against Otitis externa:

Dry your ears after swimming. If it is difficult to get water out of your ear, apply a few drops of an alcohol-based ear product into the ear. Ask a pharmacist at your local drug store for this product.

Ask your pool manager about the chlorine and pH testing programme at your pool. Pools and hot tubs with good chlorine and pH control are unlikely to spread Otitis externa.

Pay attention to signage and avoid swimming in locations that have been closed because of pollution.

Avoid putting objects in the ear (e.g. fingers, cotton swabs) that may scratch the ear canal and provide a site for infection.

If you think you have otitis externa, consult your healthcare provider. Otitis externa can be treated with antibiotic ear drops.

NOSEBLEEDS (EPISTAXIS)

A nosebleed (epistaxis) is the relatively common occurrence of bleeding from the nose, usually noticed when it drains out through the nostrils.

There are two types of nose bleed:

- anterior (the most common), and
- posterior (less common, more severe).

All nosebleeds are due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause the tears, while inflammation, coagulation problems and other disorders may make the injury harder to repair.

Causes

Local factors

Anatomic deformities
Chemical inhalant
Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants)
Foreign bodies
Intranasal tumours (Nasopharyngeal carcinoma in adult, and juvenile angiofibroma in adolescent males)
Nasal prong O2 (continuous positive airway pressure therapy)
Nasal spray
Surgery (such as septoplasty and endoscopic sinus surgery)
Trauma

Systemic factors

Drugs - aspirin, warfarin, clopidogrel, desmopressin and others
Alcohol (due to vasodilation)
Allergies
Blood dyscrasias
Heart failure (due to an increase in venous pressure)
Hematological malignancy
Hypertension
Infectious diseases
Malnutrition (especially anemia)
Narcotics
Vascular disorders
Muscle tightness as caused by scoliosis (the tightened muscles cause blood vessels to be come constricted, resulting in nosebleeds from the same side as the tightened muscles).

Treatment

The flow of blood normally stops when the blood clots, which may be encouraged by direct pressure and reducing the blood pressure in the head by sitting upright with the head tilted forward for about 10 minutes. Tilting the head back is not advised, as it can lead to blood flowing into the respiratory system, and possibly resulting in death or vomiting. Petroleum jelly is sometimes applied to stop the blood from seeping out of and prohibit the loss of moisture in the nasal cavity. However, the jelly can drain into the lungs producing a buildup that leads to lipoid pneumonia.

If other techniques do not work, an anterior packing is a possible remedy. An anterior pack works by applying pressure from the inside of the cavity, thus stopping the bleeding. This procedure can be performed at home for minor nosebleeds by gently packing tissue or gauze into the nasal cavity. Nasal sponges are readily available at most drugstores and supermarkets.

If bleeding continues, seeking emergency medical attention is important. Continued bleeding is an indication of more serious underlying conditions.[3] First aid includes inserting either a balloon inflated nasal tampon or dry hydrophilic nasal tampon.

Chronic epistaxis resulting from a dry nasal mucosa is often treated by spraying saline in the nose up to three times per day. There are also non-petroleum based gels that can be used.

Persistent epistaxis is an indication for urgent medical consultation. Nasal packing, cryosurgery, electrocautery or application of trichloroacetic acid are options that may be used in severe epistaxis.

It is uncommon to die from bleeding through nosebleeds. However, damage to the maxillary artery can lead to rapid blood loss via the nose and present difficulty in treatment, pressure, vasoconstrictor and rhinocort occasionally proving ineffective. Embolization or ligation of the artery, risking damage to the facial nerves, may be the only solution.

Nevertheless, severe protracted nosebleeds may cause anaemia due to iron deficiency.

If a nosebleed lasts for more than 15 minutes, occurs following a serious injury, or is accompanied by severe blood loss, you should call your doctor or go to the emergency room.

NASAL SURGERY (RHINOPLASTY)

Also known as a ‘nose job’ or nose reshaping surgery this is one of the most popular cosmetic procedures. In fact, it is the number 1 procedure for men.

It is performed for a variety of reasons which can include increasing or reducing the size of the nose; changing the nasal tip or the bridge, removing any unsightly humps or bumps and making the nose straighter or narrower.

The nasal tip itself can be rotated upwards or downwards, projected forwards or backwards or enlarged or decreased in size.

There are several variations of this procedure: rhinoplasty, septo-rhinoplasty and revision rhinoplasty.

Here is a list of the most popular questions about rhinoplasty.

What is ‘rhinoplasty’?

This is more commonly known as a ‘nose job’. It is surgery undertaken on the nose for a variety of reasons. It can be performed for one or both reasons. These are:

Functional
Aesthetic

Functional reasons include surgery to remove a blockage, correct a deformity or improve breathing. Surgery undertaken for aesthetic reasons tends to mean improving the shape of the nose.

Basically, it means reshaping the nose.

The cartilage, bones and sometimes the soft tissues of the nose are reshaped.

This is a very safe procedure and most people are very satisfied with the results of their surgery, still there is always a chance in all surgeries no matter big or small for mistakes so please do your research about the doctor who will do the procedure, his expertise and also you should infor him/her about certain allergies in case of any complications.

MOUTH ULCERS

A mouth ulcer is an open sore inside the oral cavity. Two common mouth ulcer types are aphthous ulcers (canker sores) and cold sores (caused by the herpes simplex virus).

The types of oral ulcers are diverse, with a multitude of associated causes including: physical or chemical trauma, infection from microorganisms or viruses, medical conditions or medications, cancerous and sometimes nonspecific processes. Once formed, the ulcer may be maintained by inflammation and/or secondary infection.

Symptoms

The symptoms preceding the ulcer may vary according to the cause of the ulcerative process.

Some oral ulcers may begin with a sharp stinging or burning sensation at the site of the future mouth ulcer. In a few days, they often progress to form a red spot or bump, followed by an open ulcer. Sometimes this takes a little bit longer, depending on the cause of the ulcer.

The oral ulcer appears as a white or yellow oval with an inflamed red border. Sometimes a white circle or halo around the lesion can be observed. The grey, white, or yellow coloured area within the red boundary is due to the formation of layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is often extremely painful, especially when agitated, may be accompanied by a painful swelling of the lymph nodes below the jaw, which can be mistaken for toothache.

Causes

There are many processes which can lead to ulceration of the oral tissues. In some cases they are caused by an overreaction by the body's own immune system.

Factors that appear to provoke mouth ulcers include stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies and deficiencies in vitamin B12, iron and folic acid.

Treatment

Treatments based on antibiotics and steroids are reserved for severe cases, and should be used only under medical supervision.

Some doctors may also prescribe a local anaesthetic, such as lidocaine, for cases of multiple or severe oral ulcers.

Some people benefit from using the over-the-counter topical gel Bonjela, which contains choline salicylate -- choline salicylate is a local analgesic that helps to reduce the pain and inflammation associated with oral ulcers.

Hearing Aids

What is a hearing aid?

A hearing aid is an electronic, battery-operated device that amplifies and changes sound to allow for improved communication. Hearing aids receive sound through a microphone, which then converts the sound waves to electrical signals. The amplifier increases the loudness of the signals and then sends the sound to the ear through a speaker.

How common is hearing loss and what causes it?

Approximately 28 million Americans have a hearing impairment. Hearing loss is one of the most prevalent chronic health conditions in the United States, affecting people of all ages, in all segments of the population, and across all socioeconomic levels. Hearing loss affects approximately 17 in 1,000 children under age 18. Incidence increases with age: approximately 314 in 1,000 people over age 65 have hearing loss. Hearing loss can be hereditary, or it can result from disease, trauma, or long-term exposure to damaging noise or medications. Hearing loss can vary from a mild but important loss of sensitivity, to a total loss of hearing.

There are different types of hearing loss. Conductive hearing loss occurs when sound waves are prevented from passing to the inner ear. This can be caused by a variety of problems including buildup of earwax (cerumen), infection, fluid in the middle ear (ear infection or otitis media), or a punctured eardrum. Sensorineural (nerve) hearing loss develops when the auditory nerve or hair cells in the inner ear are damaged by aging, noise, illness, injury, infection, head trauma, toxic medications, or an inherited condition. Mixed hearing loss is a combination of both conductive and sensorineural hearing loss. A conductive hearing loss can often be corrected with medical or surgical treatment, while sensorineural hearing loss usually cannot be reversed.

People with hearing loss may experience some or all of the following problems:

Difficulty hearing conversations, especially when there is background noise.
Hissing, roaring, or ringing in the ears (tinnitus).
Difficulty hearing the television or radio at a normal volume.
Fatigue and irritation caused by the effort to hear.
Dizziness or problems with balance.

How can I find out if I have hearing loss?

If you think you might have hearing loss, visit your physician, who may refer you to an otolaryngologist or audiologist. An otolaryngologist is a physician who specializes in ear, nose, and throat disorders, and will investigate the cause of the hearing loss. An audiologist is a hearing health professional who identifies and measures hearing loss and will perform a hearing test to assess the type and degree of loss.

How can hearing aids help?

On the basis of the hearing test results, the audiologist can determine whether hearing aids will help. Hearing aids are particularly useful in improving the hearing and speech comprehension of people with sensorineural hearing loss. When choosing a hearing aid, the audiologist will consider your hearing ability, work and home activities, physical limitations, medical conditions, and cosmetic preferences. For many people, cost is also an important factor. You and your audiologist must decide whether one or two hearing aids will be best for you. Wearing two hearing aids may help balance sounds, improve your understanding of words in noisy situations, and make it easier to locate the source of sounds.

What are the different kinds of hearing aids?

There are several types of hearing aids. Each type offers different advantages, depending on its design, levels of amplification, and size. Before purchasing any hearing aid, ask whether it has a warranty that will allow you to try it out. Most manufacturers allow a 30- to 60-day trial period during which aids can be returned for a refund.

There are four basic styles of hearing aids for people with sensorineural hearing loss:

In-the-Ear (ITE) hearing aids fit completely in the outer ear and are used for mild to severe hearing loss. The case, which holds the components, is made of hard plastic. ITE aids can accommodate added technical mechanisms such as a telecoil, a small magnetic coil contained in the hearing aid that improves sound transmission during telephone calls. ITE aids can be damaged by earwax and ear drainage, and their small size can cause adjustment problems and feedback. They are not usually worn by children because the casings need to be replaced as the ear grows.
Behind-the-Ear (BTE) hearing aids are worn behind the ear and are connected to a plastic earmold that fits inside the outer ear. The components are held in a case behind the ear. Sound travels through the earmold into the ear. BTE aids are used by people of all ages for mild to profound hearing loss. Poorly fitting BTE earmolds may cause feedback, a whistle sound caused by the fit of the hearing aid or by buildup of earwax or fluid.
Canal Aids fit into the ear canal and are available in two sizes. The In-the-Canal (ITC) hearing aid is customised to fit the size and shape of the ear canal and is used for mild or moderately severe hearing loss. A Completely-in-Canal (CIC) hearing aid is largely concealed in the ear canal and is used for mild to moderately severe hearing loss. Because of their small size, canal aids may be difficult for the user to adjust and remove, and may not be able to hold additional devices, such as a telecoil. Canal aids can also be damaged by earwax and ear drainage. They are not typically recommended for children.
Body Aids are used by people with profound hearing loss. The aid is attached to a belt or a pocket and connected to the ear by a wire. Because of its large size, it is able to incorporate many signal processing options, but it is usually used only when other types of aids cannot be used.

Do all hearing aids work in the same way?

The inside mechanisms of hearing aids vary among devices, even if they are the same style. Three types of circuitry, or electronics, are used:

Analog/Adjustable: The audiologist determines the volume and other specifications you need in your hearing aid, and then a laboratory builds the aid to meet those specifications. The audiologist retains some flexibility to make adjustments. This type of circuitry is generally the least expensive.
Analog/Programmable: The audiologist uses a computer to programme your hearing aid. The circuitry of analog/programmable hearing aids will accommodate more than one programme or setting. If the aid is equipped with a remote control device, the wearer can change the programme to accommodate a given listening environment. Analog/programmable circuitry can be used in all types of hearing aids.
Digital/Programmable: The audiologist programs the hearing aid with a computer and can adjust the sound quality and response time on an individual basis. Digital hearing aids use a microphone, receiver, battery, and computer chip. Digital circuitry provides the most flexibility for the audiologist to make adjustments for the hearing aid. Digital circuitry can be used in all types of hearing aids and is typically the most expensive.

What can I expect from hearing aids?

Using hearing aids successfully takes time and patience. Hearing aids will not restore normal hearing or eliminate background noise. Adjusting to a hearing aid is a gradual process that involves learning to listen in a variety of environments and becoming accustomed to hearing different sounds. Try to become familiar with hearing aids under nonstressful circumstances a few hours at a time. Programs are available to help users master new listening techniques and develop skills to manage hearing loss. Contact your audiologist for further information about programs that may suit your individual needs.

What questions should I ask before buying hearing aids?

Before you buy a hearing aid, ask your audiologist these important questions:

Are there any medical or surgical considerations or corrections for my hearing loss?
Which design is best for my hearing loss?
What is the total cost of the hearing aid?
Is there a trial period to test the hearing aids? What fees are nonrefundable if they are returned after the trial period?
How long is the warranty? Can it be extended?
Does the warranty cover future maintenance and repairs?
Can the audiologist make adjustments and provide servicing and minor repairs? Will loaner aids be provided when repairs are needed?
What instruction does the audiologist provide?
Can assistive devices such as a telecoil be used with the hearing aids?

What problems might I experience while adjusting to my hearing aids?

Become familiar with your hearing aid. Your audiologist will teach you to use and care for your hearing aids. Also, be sure to practice putting in and taking out the aids, adjusting volume control, cleaning, identifying right and left aids, and replacing the batteries with the audiologist present.
The hearing aids may be uncomfortable. Ask the audiologist how long you should wear your hearing aids during the adjustment period. Also, ask how to test them in situations where you have problems hearing, and how to adjust the volume and/or programme for sounds that are too loud or too soft.
Your own voice may sound too loud. This is called the occlusion effect and is very common for new hearing aid users. Your audiologist may or may not be able to correct this problem; however, most people get used to it over time.
Your hearing aid may "whistle." When this happens, you are experiencing feedback, which is caused by the fit of the hearing aid or by the buildup of earwax or fluid. See your audiologist for adjustments.
You may hear background noise. Keep in mind that a hearing aid does not completely separate the sounds you want to hear from the ones you do not want to hear, but there may also be a problem with the hearing aid. Discuss this with your audiologist.

What are some tips for taking care of my hearing aids?

The following suggestions will help you care for your hearing aids:

Keep hearing aids away from heat and moisture.
Replace dead batteries immediately.
Clean hearing aids as instructed.
Do not use hairspray or other hair care products while wearing hearing aids.
Turn off hearing aids when they are not in use.
Keep replacement batteries and small aids away from children and pets.

GLUE EAR AND OTITIS MEDIA

What is otitis media?

Otitis media is an infection or inflammation of the middle ear. This inflammation often begins when infections that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear. These can be viral or bacterial infections. Seventy-five percent of children experience at least one episode of otitis media by their third birthday. Almost half of these children will have three or more ear infections during their first 3 years. Although otitis media is primarily a disease of infants and young children, it can also affect adults.

Are there different types of otitis media?

Yes. There are two main types. The first type is called acute otitis media (AOM). This means that parts of the ear are infected and swollen. It also means that fluid and mucus are trapped inside the ear. AOM can be painful.

The second type is called otitis media with effusion (fluid), or glue ear or OME. This means fluid and mucus stay trapped in the ear after the infection is over. OME makes it harder for the ear to fight new infections. This fluid can also affect your child's hearing.

How does otitis media happen?

Otitis media usually happens when viruses and/or bacteria get inside the ear and cause an infection. It often happens as a result of another illness, such as a cold. If your child gets sick, it might affect his or her ears.

It is harder for children to fight illness than it is for adults, so children develop ear infections more often. Some researchers believe that other factors, such as being around cigarette smoke, can contribute to ear infections.

Why are more children affected by otitis media than adults?

There are many reasons why children are more likely to suffer from otitis media than adults. First, children have more trouble fighting infections. This is because their immune systems are still developing. Another reason has to do with the child's eustachian tube. The eustachian tube is a small passageway that connects the upper part of the throat to the middle ear. It is shorter and straighter in the child than in the adult. It can contribute to otitis media in several ways.

The eustachian tube is usually closed but opens regularly to ventilate or replenish the air in the middle ear. This tube also equalizes middle ear air pressure in response to air pressure changes in the environment. However, a eustachian tube that is blocked by swelling of its lining or plugged with mucus from a cold or for some other reason cannot open to ventilate the middle ear. The lack of ventilation may allow fluid from the tissue that lines the middle ear to accumulate. If the eustachian tube remains plugged, the fluid cannot drain and begins to collect in the normally air-filled middle ear.

One more factor that makes children more susceptible to otitis media is that adenoids in children are larger than they are in adults. Adenoids are composed largely of cells (lymphocytes) that help fight infections. They are positioned in the back of the upper part of the throat near the eustachian tubes. Enlarged adenoids can, because of their size, interfere with the eustachian tube opening. In addition, adenoids may themselves become infected, and the infection may spread into the eustachian tubes.

Bacteria reach the middle ear through the lining or the passageway of the eustachian tube and can then produce infection, which causes swelling of the lining of the middle ear, blocking of the eustachian tube, and migration of white cells from the bloodstream to help fight the infection. In this process the white cells accumulate, often killing bacteria and dying themselves, leading to the formation of pus, a thick yellowish-white fluid in the middle ear. As the fluid increases, the child may have trouble hearing because the eardrum and middle ear bones are unable to move as freely as they should. As the infection worsens, many children also experience severe ear pain. Too much fluid in the ear can put pressure on the eardrum and eventually tear it.

What are the effects of otitis media?

Otitis media not only causes severe pain but may result in serious complications if it is not treated. An untreated infection can travel from the middle ear to the nearby parts of the head, including the brain. Although the hearing loss caused by otitis media is usually temporary, untreated otitis media may lead to permanent hearing impairment. Persistent fluid in the middle ear and chronic otitis media can reduce a child's hearing at a time that is critical for speech and language development. Children who have early hearing impairment from frequent ear infections are likely to have speech and language disabilities.

How can someone tell if a child has otitis media?

Otitis media is often difficult to detect because most children affected by this disorder do not yet have sufficient speech and language skills to tell someone what is bothering them. Common signs to look for are

unusual irritability
difficulty sleeping
tugging or pulling at one or both ears
fever
fluid draining from the ear
loss of balance
unresponsiveness to quiet sounds or other signs of hearing difficulty such as sitting too close to the television or being inattentive

Can anything be done to prevent otitis media?

Specific prevention strategies applicable to all infants and children such as immunization against viral respiratory infections or specifically against the bacteria that cause otitis media are not currently available. Nevertheless, it is known that children who are cared for in group settings, as well as children who live with adults who smoke cigarettes, have more ear infections. Therefore, a child who is prone to otitis media should avoid contact with sick playmates and environmental tobacco smoke. Infants who nurse from a bottle while lying down also appear to develop otitis media more frequently. Children who have been breast-fed often have fewer episodes of otitis media. Research has shown that cold and allergy medications such as antihistamines and decongestants are not helpful in preventing ear infections. The best hope for avoiding ear infections is the development of vaccines against the bacteria that most often cause otitis media. Scientists are currently developing vaccines that show promise in preventing otitis media. Additional clinical research must be completed to ensure their effectiveness and safety.

How does a child's physician diagnose otitis media?

The simplest way to detect an active infection in the middle ear is to look in the child's ear with an otoscope, a lightinstrument that allows the physician to examine the outer earand the eardrum. Inflammation of the eardrum indicates aninfection. There are several ways that a physician checks for middle ear fluid. The use of a special type of otoscopecalled a pneumatic otoscope allows the physician to blow a puff of air onto the eardrum to test eardrum movement. (An eardrum with fluid behind it does not move as well as an eardrum with air behind it.)

A useful test of middle ear function is called tympanometry. This test requires insertion of a small soft plug into the opening of the child's ear canal. The plug contains a speaker, a microphone, and a device that is able to change the air pressure in the ear canal, allowing for several measures of the middle ear. The child feels air pressure changes in the ear or hears a few brief tones. While this test provides information on the condition of the middle ear, it does not determine how well the child hears. A physician may suggest a hearing test for a child who has frequent ear infections to determine the extent of hearing loss. The hearing test is usually performed by an audiologist, a person who is specially trained to measure hearing.

How is otitis media treated?

Many physicians recommend the use of an antibiotic (a drug that kills bacteria) when there is an active middle ear infection. If a child is experiencing pain, the physician may also recommend a pain reliever. Following the physician's instructions is very important. Once started, the antibiotic should be taken until it is finished. Most physicians will have the child return for a followup examination to see if the infection has cleared.

Unfortunately, there are many bacteria that can cause otitis media, and some have become resistant to some antibiotics. This happens when antibiotics are given for coughs, colds, flu, or viral infections where antibiotic treatment is not useful. When bacteria become resistant to antibiotics, those treatments are then less effective against infections. This means that several different antibiotics may have to be tried before an ear infection clears. Antibiotics may also produce unwanted side effects such as nausea, diarrhoea, and rashes.

Once the infection clears, fluid may remain in the middle ear for several months. Middle ear fluid that is not infected often disappears after 3 to 6 weeks. Neither antihistamines nor decongestants are recommended as helpful in the treatment of otitis media at any stage in the disease process. Sometimes physicians will treat the child with an antibiotic to hasten the elimination of the fluid. If the fluid persists for more than 3 months and is associated with a loss of hearing, many physicians suggest the insertion of "tubes" in the affected ears. This operation, called a myringotomy, can usually be done on an outpatient basis by a surgeon, who is usually an otolaryngologist (a physician who specializes in the ears, nose, and throat). While the child is asleep under general anaesthesia, the surgeon makes a small opening in the child's eardrum. A small metal or plastic tube is placed into the opening in the eardrum. The tube ventilates the middle ear and helps keep the air pressure in the middle ear equal to the air pressure in the environment. The tube normally stays in the eardrum for 6 to 12 months, after which time it usually comes out spontaneously. If a child has enlarged or infected adenoids, the surgeon may recommend removal of the adenoids at the same time the ear tubes are inserted. Removal of the adenoids has been shown to reduce episodes of otitis media in some children, but not those who are under 4 years of age. Research, however, has shown that removal of a child's tonsils does not reduce occurrences of otitis media. Tonsillotomy and adenoidectomy may be appropriate for reasons other than middle ear fluid.

Hearing should be fully restored once the fluid is removed. Some children may need to have the operation again if the otitis media returns after the tubes come out. While the tubes are in place, water should be kept out of the ears. Many physicians recommend that a child with tubes wear special ear plugs while swimming or bathing so that water does not enter the middle ear.

GLANDS

A gland is an organ in an animal's body that synthesizes a substance for release such as hormones, often into the bloodstream (endocrine gland) or into cavities inside the body or its outer surface (exocrine gland).

Types of gland

Glands can be divided into two groups:

Endocrine glands - are glands that secrete their product directly onto a surface rather than through a duct.

Exocrine glands - secrete their products via a duct, the glands in this group can be divided into three groups:

- Apocrine glands - a portion of the secreting cell's body is lost during secretion. Apocrine gland is often used to refer to the apocrine sweat glands.
- Holocrine glands - the entire cell disintegrates t- secrete its substances (e.g., sebaceous glands)
- Merocrine glands - cells secrete their substances by exocytosis (e.g., mucous and serous glands). Also called "eccrine."

The type of secretory product of an Exocrine gland may also be one of three categories:

Serous glands - secrete a watery, often protein-rich product
Mucous glands - secrete a viscous product, rich in carbohydrates (eg. glycoproteins)
Sebaceous glands - secrete a lipid product

Exocrine glands

Typical exocrine glands include sweat glands, salivary glands, mammary glands, and many glands of the digestive system.

Endocrine glands and the hormones secreted

Hypothalamus produces - Thyrotropin-releasing hormone (TRH)
- Gonadotropin-releasing hormone (GnRH)
- Growth hormone-releasing hormone (GHRH)
- Corticotropin-releasing hormone (CRH)
- Somatostatin (SS; also GHIH, growth factor-inhibiting hormone) - Dopamine (DA)

Pineal Gland produces

Pituitary gland (hypophysis) produces

Thyroid gland produces

Parathyroid gland produces

Heart produces

Stomach and intestines produce

Liver produces

Islets of Langerhans in the pancreas produce

Adrenal glands produce

Kidney produces

Skin produces
Adipose tissue

In males only

Testes

In females only

Ovarian follicle

Corpus luteum

Placenta (when pregnant)

CHILD HEARING CHECKLIST

Infants and young children with hearing problems can have difficulty developing speech and language. Some babies are born with hearing problems. Other children are born with normal hearing and begin to have hearing problems as they grow older. You can help your child's doctor to decide if your child's hearing needs to be tested. Hearing problems can be temporary or permanent. Hearing problems can happen because of ear infections, injuries, or diseases. If your child doesn't hear well or speak clearly, take action.

Read the hearing checklist below, find your child's age, & check yes or no for every item. After you complete the checklist, show it to your child's doctor. Ask the doctor questions. Talk about the items checked "no". If you think your child has trouble hearing, tell the doctor right away.

Hearing checklist Birth to 3 Months

YES	NO
		Reacts to loud sounds.
		Is soothed by your voice.
		Turns head to you when you speak.
		Is awakened by loud voices and sounds.
		Smiles when spoken to.
		Seems to know your voice and quiets down if crying.

3 to 6 Months

YES	NO
		Looks upward or turns toward a new sound.
		Responds to "no" and changes in tone of voice.
		Imitates his/her own voice.
		Enjoys rattles and other toys that make sounds.
		Begins to repeat sounds (such as ooh, aah, and ba-ba).
		Becomes scared by a loud voice.

6 to 10 Months

YES	NO
		Responds to his/her own name, telephone ringing, someone's voice, even when not loud.
		Knows words for common things (cup, shoe) and sayings ("bye-bye").
		Makes babbling sounds, even when alone.
		Starts to respond to requests such as "come here."
		Looks at things or pictures when someone talks about them.

10 to 15 Months

YES	NO
		Plays with own voice, enjoying the sound and feel of it.
		Points to or looks at familiar objects or people when asked to do so.
		Imitates simple words and sounds; may use a few single words meaningfully.
		Enjoys games like peek-a-boo and pat-a-cake.

15 to 18 Months

YES	NO
		Follows simple directions, such as "give me the ball."
		Uses words he/she has learned often.
		Uses 2-3 word sentences to talk about and ask for things.
		Knows 10 to 20 words.

18 to 24 Months

YES	NO
		Understands simple "yes-no" questions (Are you hungry?).
		Understands simple phrases ("in the cup," "on the table").
		Enjoys being read to.
		Points to pictures when asked.

24 to 36 Months

YES	NO
		Understands "not now" and "no more."
		Chooses things by size (big, little).
		Follows simple directions such as "get your shoes" and "drink your milk."
		Understands many action words (run, jump).

Talk to your doctor Talk to your doctor if you think your child has a hearing problem.

YES	NO
		Do others in the family, including brothers or sisters, have a hearing problem?
		The child's mother had medical problems in pregnancy or delivery (serious illness or injury, drugs or medications).
		The baby was born early (premature). Weight at birth:_______.
		The baby had physical problems at birth.
		The child rubs or pulls on ear(s) often.
		The child had scarlet fever.
		The child had meningitis.
		The child had _____ ear infections in the past year.
		The child has colds, allergies, and ear infections, once a month_____ more often_____