Madras ENT Research Foundation (P) Ltd

Q: What is the best way to clean my ears?

 

Ears have a self-cleansing mechanism. Presence of ear wax does not mean your ears are dirty. Wax is a normal component of the ear canal manufactured by specialized (ceruminous) glands in the outer ear. Its function is to protect the delicate skin of the ear canal. Massage of the ear canal by talking and chewing tends to naturally propel wax out of the ear canal. Those who have normal ears (with no hole in the ear drum or other ear disease) can safely use an over-the-counter ear wax softening solution. People with very small ear canals and whose wax tends to be very dry and mixed with a lot of dry skin should have their ears cleaned periodically by an ENT specialist. Inserting a bud or pin into the ear has to be avoided because it actually pushes wax further down into the canal. It can also puncture the ear drum and cause more serious injuries.

 

Q: 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 sensori-neural impairment or nerve deafness. In most cases, the end organs of hearing are damaged or do not function optimally. 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. Severe to profound inner ear hearing loss cannot be corrected with medicines & it can be treated only with a cochlear implant.

 

Q: What is Cholesteatoma? Why is it an unsafe ear disease?

Cholesteatoma is a serious disease which affects the ear. The skin of the ear drum grows retracts inwards into the middle ear and may becomes a cholesteatoma. This looks like an onion peel of white skin formed into a ball. It can destroy the bones of hearing as it grows. Symptoms include hearing loss, recurrent ear discharge which may be foul smelling. It tends to actively erode bone and may cause nerve deafness, ringing in the ears, imbalance and dizziness. The thin plate of bone that separates the roof of the ear from the brain can also be eroded by cholesteatoma. This exposes the covering of the brain. In extreme situations, it can lead to brain infection and other serious complications. Cholesteatoma infection of ear is a very serious condition and when diagnosed requires prompt surgical treatment (micro ear surgery).

 

Q: What is micro-ear surgery?

Structures of the ear are very small. Hence, ear surgery is usually performed with an operating microscope which enlarges the view of the ear structures sufficiently so the surgeon can perform the delicate & intricate tasks needed. The incision is made behind or in front of the ear. The wall separating the middle ear from the mastoid (bone behind the ear) is removed. Disease clearance is done. Hearing reconstruction is then done. After the surgery the ear becomes disease free & hearing improves. Patients undergoing ear surgery need regular, meticulous follow ups as advised the treating physician.

 

Q: What is a Cochlear Implant?

Cochlear Implant (Bionic Ear) is an electronic hearing device, designed to produce useful hearing sensations by electrically stimulating nerves inside the inner ear. It is implanted into the inner ear by surgery & it is programmed to provide hearing to individuals who have severe to profound hearing loss. The Bionic Ear was pioneered in 1978 by Professor Graeme Clark and his team. The present day multi-channel cochlear implants consist of 2 main components: 1) Internal Components - cochlear implant electrode array with a receiver-stimulator and 2) Exernal Components – transmitter coil & speech processor.

 

Q: What are the benefits of Cochlear Implants?

Cochlear Implants are designed for individuals with severe to profound nerve deafness, who attain almost no benefit from hearing aids. Candidates may be children born with congenital hearing impairment or older persons. Local doctors need to refer such individuals to an implant clinic for an evaluation. The evaluation will be done by an implant team (an otolaryngologist, audiologist, nurse, and others) that will give you a series of tests: Ear (otologic) evaluation: Trained Otolaryngologists (ear, nose, and throat specialists) perform cochlear implant surgery. 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 an objective hearing test battery to find out how much you can hear with or 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. Psychological evaluation: Some patients may need a psychological evaluation to learn if they can cope with the implant. Pre-anaesthetic evaluation: The anesthesiologist will give a comprehensive physical examination in order to identify any potential problems with the general anesthesia needed for the implant procedure. To rule out syndromic associations, children born with hearing impairment are also routinely evaluated by an eye specialist prior to implant surgery and by a child specialist for immunization.

 

Q: How is Cochlear Implant Surgery done?

Cochlear Implant surgery is performed under general anesthesia and lasts two to three hours. An incision is made behind the ear to open the mastoid bone leading to the middle & inner ear. The electrode array is placed within the inner ear & the coil is placed in the mastoid bone. The procedure usually requires a stay in hospital for 2-3 days, for post-operative care.

 

Q: Is There Care And Training After The Operation?

Three weeks after surgery, the implant audiologist team places the signal processor, microphone, and implant transmitter outside the opearated ear and adjusts them with computer support to tune the implant effectively & make the person hear. They teach the implantee, how to look after the system and how to listen to sound through the implant. Some implants take longer to fit and require more training. Implant team will ask the individuals to come back to the clinic for regular checkups and readjustment of the speech processor as needed. All implantees have to mandatorily undergo auditory verbal habilitation with well trained & experienced teachers, for a minimum period of one year at our institution.

 

Q: What Can be Expected from a Cochlear Implant?

Cochlear implants do not restore normal hearing immediately and benefits may vary from one individual to another depending on how best they are trained to use the implant by undergoing intensive auditory verbal therapy. Most users find that cochlear implants help them communicate much better and also get avid awareness to environmental sounds. 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, intensity of auditory habilitation and a patients / parents motivation. The implant team will clearly explain all the expectations & anticipated outcomes of implantation.

 

Q: What do we mean by a Sinus?

Sinus is an air filled space within the hollow bones of the face. There are 8 sinuses (4 on each side) which contain air and communicate with the nose. Sinuses play an important role in breathing & voice production.

 

Q: What is Sinusitis?

It is an inflammation of the membrane lining the para-nasal sinuses. In acute sinusitis, facial pain/pressure, nasal obstruction, nasal discharge, diminished sense of smell, fever and cough may occur. It is generally treated with antibiotics and decongestants. In chronic sinusitis, facial pain/pressure, facial congestion/ fullness, nasal obstruction, nasal/ postnasal discharge, diminished sense of smell, fever, headache, bad breath and cough may be present. In Chronic sinusitis, the symptoms are usually present for 12 weeks or more.

 

Q: What are the diagnostic tests for chronic sinusitis?

X-ray / CT scan of the para-nasal sinuses, diagnostic nasal endoscopy, allergy testing and blood tests may be required.

 

Q: What is Diagnostic Nasal Endoscopy?

Nasal endoscope is an instrument for the examination of the nose and sinus drainage areas. The patients nasal cavity is anesthetized with a local anesthetic and diagnostic nasal endoscopy is done. Signs of obstruction, nasal polyps hidden from routine nasal examination are visualized. Structural abnormalities that cause recurrent sinusitis are also identified.

 

Q: What is the course of treatment for sinusitis?

Nasal spray / nose drops, decongestants, antibiotics in patients with bacterial infection, antihistamines for treatment of nasal allergies are usually prescribed. Patients are advised to refrain from smoking.

 

Q: When is sinus surgery necessary?

Mucus is formed in the nose and acts as a lubricant. In the sinus cavities this lubricant is moved across mucous membrane linings towards the opening of each sinus by millions of cilia (mobile extensions of a cell). Inflammation from allergy causes membrane swelling and the sinus opening to narrow, thereby blocking sinus ventilation & drainage. Endoscopic sinus surgery may be required to correct this problem.

 

Q: What is functional endoscopic sinus surgery?

This basic endoscopic surgical procedure is performed under general or local anesthesia, wherein the natural opening of the sinuses is enlarged and areas of obstruction are removed to allow the normal flow of mucus. This procedure is highly effective in restoring the normal function of the sinuses. The patient returns to normal activities within four days and full recovery takes about 4 weeks.

 

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

Not seeking treatment of sinusitis leads to pain and discomfort. In rare circumstances, meningitis, brain abscess, loss of vision, infection of facial bones, etc may occur.

 

Q: What Lasers are used in ENT Surgery?

Laser has proved to be a very valuable tool in ENT due to its high precision, blood less dissection with minimal damage to surrounding tissues and its ability to produce minimal post-operative swelling, pain and scarring. The CO2 laser had been the workhorse of ENT surgery for many years. It is a good cutting tool but a poor coagulator. Today KTP /532 laser has provided much better results since it cuts nerve endings & laserizes tissues smoothly, thus decreasing postoperative pain. Its precision, with decreased damage to surrounding structures leads to decreased postoperative pain and scarring. It is an ideal laser for ENT and Head and Neck surgery. In the ear, the laser can be used to treat disorders of the outer ear such as stenosis (narrowing) and benign tumors, removal of disease in the middle ear, stapedotomy (an operation done in patients with a fixed bone in the middle ear causing hearing loss). In the nose, the laser can be used to remove disease from the nose and sinuses, tumors, etc. In the throat, it has many applications such as tonsillectomy, LAUP (removal of redundant tissue in the back of the throat in patients with snoring and sleep apnoea), tumors - both benign and malignant, cysts, narrowing in the windpipe etc. With the introduction of lasers in ENT, a majority of ENT surgeries have become day care procedures today.

 

Q: How are Head & Neck Cancers treated?

 Head and neck cancers include many different malignancies. The way a particular cancer behaves depends on the site it arises (primary site). The main parts of the head and neck include nasal cavity, nasopharynx, paranasal sinuses, oral cavity, oropharynx, hypopharynx, larynx, thyroid and salivary glands. Most common types of cancer in the head and neck region is squamous cell carcinoma. The others include lymphoma, sarcoma & salivary gland tumours. Typical symptoms include a neck lump or sore that does not heal or difficulty in swallowing / breathing or change or hoarseness in the voice. Diagnosis of head and neck cancers is done by a complete physical examination, CT/MRI scan, endoscopy and tissue biopsy. The three main types of treatment for head and cancers are surgery, radiotherapy (high energy X-ray to kill cancer cells) and chemotherapy (anti-cancer drugs). Surgical treatment consists of removal of cancer and some of the healthy tissue around it. Cancerous Lymph nodes in the neck also neds to be removed. Optimal combination of the three treatment modalities for a patient with a particular head and neck cancer depends on the site of the cancer, extent of the disease and medical condition of the patient. Rehabilitation with long-term regular follow-up care forms an important part in the treatment of head & neck cancers.

 

Q: What is Phonosurgery?

It is a surgical procedure that maintains, restores or enhances the human voice. Phonosurgery includes phonomicrosurgery (microsurgery of the vocal folds done through an endoscope), laryngoplastic phonosurgery (open neck surgery that restructures the cartilaginous framework of the larynx - voice box), soft tissue laryngeal injection (injection into the larynx of medications as well as synthetic and organic biologic substances) and reinnervation (restoration of the nerve supply) of the larynx. Use of the microscope during laryngeal surgery enhances precision. The results of surgery are excellent but have to be followed up with voice rest, hygiene and rehabilitation to get good long-term results of voice improvement.

 

Q: What is snoring and Obstructive Sleep Apnoea Syndrome (OSAS)?

Snoring is a social problem and may be associated with significant sleep disturbances, waking episodes etc. Individuals who snore may also be suffering from OSAS. OSAS is characterized by significant and prolonged interruptions of breathing (airway obstruction) during sleep. These episodes of cessation of breathing may be associated with substantial decrease in blood oxygen levels, irregularities in the heart's normal beating pattern (cardiac arrythmias), high blood pressure, and even sudden death. OSAS is a serious disorder which is strongly associated with obesity & sedentary life patterns. Symptoms of sleep apnoea include excessive day time tiredness / sleepiness, a feeling of dullness or napping during work hours, falling asleep while driving & headaches.

 

Q: What are the investigations for sleep apnoea?

The main investigation required is a polysomnogram (sleep study) which is an overnight test usually performed in a sleep laboratory, where one simply falls asleep for a number of hours. During this sleeping time, important processes including ECG, blood oxygen levels, number and duration of apnoeic spells are monitored. A sleep MRI is also essential to identify the level of obstruction.

 

Q: What is the treatment for Obstructive Sleep Apnoea Syndrome?

The treatment can be nonsurgical (weight loss, CPAP etc) or surgical (e.g. Laser assisted uvulo-palato-pharyngoplasty or Genioglossal advancement). In Continuous positive airway pressure (CPAP) - pressurized air is administered by way of a face mask which is worn during sleep. This maintains adequate pressure to overcome airway obstruction. In Laser assisted uvulopalatopharyngoplasty (LAUP), a laser beam is utilized to reduce the redundant tissue in the back of the throat. In Genioglossal advancement the tongue is surgically pulled forwards in order to increase the posterior airway space for breathing well in sleep.

 

Q: What is Balloon Sinuplasty?

Balloon Sinuplasty surgery is the latest advancement in sinus surgery. It is performed with FDA-cleared, endoscopic, catheter-based instruments specifically designed to be used in sinus surgery. The Sinus Balloon Catheter is gradually inflated to gently restructure the previously blocked sinus opening, which restores normal sinus drainage and function, without damaging the sinus.

 

Q: What is Skull Base Surgery?

Skull Base Surgery is one of the most exciting and challenging innovations in modern surgery. Skull Base Surgery is performed for brain tumors extending out through the base of skull (e.g. mengioma, schwannoma, pituitary adenoma), head and neck diseases extending into the brain (e.g. advanced sinus cancer, invasive fungal lesions) and for tumors originating in the skull base (e.g. Glomus tumors, chondroma, chondrosarcoma). Lesions involving skull base are rarely limited to areas that are assigned to a single speciality and may necessitate a team effort by ENT surgeons & Neurosurgeons working in tandem to access these areas (e.g. CSF Leak Repair, pituitary surgery). Today skull-base malignancies, which were previously considered inaccessible & hence inoperable, are being removed with sophisticated instruments by advanced surgical techniques by ENT Surgeons.

 

Q: What is Tonsillitis?

Tonsils are lymphoid tissues located in the oropharynx, which provide immunity against infections in the upper aero-digestive tract. Tonsils are similar in function to the Adenoids which lie behind the nose in the nasopharynx. Adenoid tissue is also called the nasopharyngeal tonsil. Sometimes these adenoids and tonsil tissues get infected and become inflammed when the diagnosis of adenoiditis and tonsillitis is made.

 

Q: When is it necessary to remove the tonsils?

Recurrent septic infections of the tonsils refractory to a complete course of medications (oral or intravenous antibiotics), should be treated by tonsillectomy surgery. If a patient develops a peri-tonsillar abscess (Quinsy) around the tonsils, then an Interval tonsillectomy is done after a period of 6 weeks aftewr the Quinsy has subsided.

 

Q: How is Adenoiditis treated?

The commonest cause for Adenoid enlargement is Allergy. The enlargement of Adenoid tissue behind the nose can compromise the nasal airway especially in children and can lead to a myriad of symptoms like mouth breathing, snoring, dental mal-alignment and glue ears. In such cases it is necessary to remove the Adenoid tissue by conventional method or with laser and the patient needs to be on regular follow up with antio-allergic nasal spray and oral medications. Adenoid removal is most often combined with tonsillectomy whenever necessary.

 

Q: What is Tonsillectomy and by what methods can it be done?

Surgical removal of tonsil tissue is called tonsillectomy. It is performed intra-orally under general anesthesia. Apart from the conventional technique used for removal of tonsils, recent techniques include the use of Laser, Co-ablation, Radio-frequency and Cryo-surgery.

 

Q: What is a Glue Ear & How is it treated?

A long standing blockage of the tube which connects the back of the nose to the middle ear (Eustachian Tube) leads to a collection of non-infective serous fluid within the middle ear cavity. This fluid gets organized like 'Glue' over time leading to conductive hearing loss and blocking sensation in the ears.This condition is termed as Otitis Media with Effusion' and this fluid needs to be drained by a surgical procedure called Myringotomy with insertion of a ventilation / drainage tube – 'Grommet'in the ear drum.

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Q: What to expect after tonsil surgery?
Most patients may have pain after tonsil surgery, with pain resolving 5 – 12 days after surgery. Older children and adult patients seem to have more discomfort. Most patients can go home on the following morning.
 

*Patients may complain of ear aches (this is due to referred pain from the throat and settles with pain medications and by encouraging liquid intake).

 

*Patients may have a low-grade fever after surgery (upto 101.5 o F/38 o C). This settles with paracetamol and plenty of fluids. High grade fever and prolonged fever must be reported to the surgeon.
 

*Bad looking/bad smelling throat can occur for upto 2 weeks after surgery. This is because the operated area is covered with a white exudates/slough and this may produce bad breath. There can also be some redness and swelling. Good oral hygiene and betadine throat gargle given after the surgery will help resolve the issue.

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Q: Following tonsil surgery, which conditions need to be reported to the surgeon?
In case of any of the following, the patient will need to contact the surgeon/hospital –

*Bleeding – Significant bleeding is rare. More than 2 tablespoons of fresh bleed should be reported. If the bleeding persists, ice water mouth washes may help. For severe bleeding, report to the hospital/nearest emergency care immediately.
 

*Dehydration – If there has been little or no liquid intake for 24 hours, notify the surgeon. Signs of dehydration include lethargy, and reduced urine output or very dark urine.
 

*High fever – Temperatures more than 102 o F, when accompanied by cough or breathing difficulty, should be reported to the surgeon.

 

Q: What diet is to be followed after tonsil surgery?
The post tonsillectomy diet is as follows –
Day of surgery – Ice cream (plain vanilla), ice water, ice chips to be given till 8 pm. After 8 pm, plain milk at room temperature can be consumed.
1st day after surgery – Soft, non-spicy food kept at room temperature can be consumed.
2nd day after surgery – Normal diet (including spicy food) kept at room temperature can be consumed.
*Till 2 weeks following surgery, avoid hard and tough food stuffs that may be difficult to chew or those which may cause injury to the operated areas).
*Avoid ice and iced products till 2 months following surgery.

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Q: What is Microlaryngeal Surgery?
It is surgery done on the vocal cords using a microscope and is advocated for problems like vocal cord polyps, vocal cord nodules and growth arising from the vocal cords.

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Q: How to maintain good vocal hygiene?
The following may be followed to maintain good vocal hygiene –
*Avoid vocal abuse (talking loudly/shouting, talking for prolonged periods of time or talking in the wrong pitch).
*Maintain adequate hydration by drinking plenty of water (it is advisable to avoid more than 2 cups of tea/coffee in a day).
*Avoid lengthy phone conversations.
*Avoid spicy food.
*Avoid frequent and aggressive throat clearing.

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Q: What is stapedotomy?
It is a minute and delicate surgery done on the stapes, which is one of the three tiny bones of the middle ear (also called the ossicles). Stapedotomy is done to help conduct sound to the inner ear and restore hearing. This surgery is usually done under local anaesthesia with intravenous sedation.

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Q: When can the patient hear after stapedotomy and what are the outcomes with respect to hearing?
Hearing improves once the postoperative swelling subsides and after the ear canal pack is removed on the 7 th postoperative day. Hearing continues to get better over the next 3 months. About 95 % of the patients will have marked improvement in hearing following the procedure. However, in 2 % there may not be any change in the hearing (neither improvement nor decline from existing level). In 2 % patients there may be an additional hearing loss in the operated ear and in fewer than 1 %, hearing may be lost completely in the operated ear. This is a dreaded complication of surgery and it occurs not because of bad surgery, but due to the constitutional reaction of the patient, which is unpredictable.

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Q: Is air travel advisable when the patient has a cold or nasal congestion?
Avoid flying when you have a cold. If air travel is unavoidable, then visit the ENT surgeon for a prescription of antihistaminics, topical and systemic decongestant medications. Flying with a severe cold may perforate the eardrum due to changes in air pressure (especially on landing).

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