Saturday, December 7, 2013

Ugh, My Throat is Sore!

Let's talk about sore throats for a minute. But not too long, or we might get laryngitis. When fall and winter arrive, so do the viruses: colds, the flu, bronchitis, and all that coughing and aching. Sore throat is a symptom related to inflammation of the tissues of the throat, and as such can have a variety of causes: strep, allergies, post-nasal drip, GERD, smoking, even voice abuse. Still, behind most sore throats there lurks a virus. As I write this, I'm feeling a little catch in my throat myself.

At least 200 different viruses have been found to cause the "common cold", but 3 make up the majority of cases: rhinovirus is most common, coronavirus second, and (especially concerning in younger children) respiratory syncytial virus. Most of these viral infections cause inflammation of the mucous membranes of the nose, mouth and throat, leading to the most common symptoms of congestion, sore throat, and cough. If the virus targets the vocal cords, laryngitis ensues causing hoarseness and even complete voice loss for a short time.

In addition to common cold viruses, mono is a more severe viral illness that can cause long-lasting fatigue, fever, neck lymph node swelling, and persistent sore throat. Although it's called the "kissing disease", the Epstein-Barr virus that causes it can be contracted by the same mechanism as other sore throat viruses: contact with virus-contaminated food, objects or people. To avoid viruses of any kind (or avoid spreading a virus to others), wash your hands frequently, cover your cough or sneeze, use hand sanitizers, and don't kiss strangers.

About the flu shot: contrary to a well-known former Playboy bunny, immunizations of any kind, including the flu shot, DO NOT CAUSE AUTISM. In case Ms. McCarthy or her supporters are listening, I'll say it again: VACCINES DO NOT CAUSE AUTISM. Get the flu shot every year, even if you are not prone to the flu. Even if you have an iron constitution. The flu vaccine, like all others, works by "herd immunity": if a large enough percentage of the "herd" is immune to a communicable disease, the spread of the disease is slowed down, and an epidemic can be avoided.

For those conspiracy theorists who persist in believing a stripper over a doctor, I'm not going to convince you to immunize yourselves and your children against measles, mumps, tetanus, hepatitis, or H. flu, but I do have this favor to ask: please tell all your friends, neighbors, and fellow citizens THANK YOU. They are the ones, the silent majority, who listen to their doctors and get immunized so that your children don't catch deadly childhood diseases like polio.

Polio? Who gets polio these days? I'm glad you asked: unimmunized children get polio, that's who. Just ask the moms and dads of thousands of Syrian children who have contracted polio the past several years because the despotic Syrian government has withheld polio vaccines and other needed medical supplies from rebel-held areas of Syria. It didn't take long for the herd immunity to fade, leaving hundreds of thousands or millions of children in these areas at risk for polio, diphtheria, and other deadly viral infections. It happens. All I'm saying to you parents who opt out is be grateful to your fellow citizens who opt in and save your bacon. 'Nuf said.

Sorry for the vaccine rant. Back to sore throats: 9 out of 10 sore throats are viral, only 1 in 10 is strep. 90% of you sitting right there with a sore throat will get better with fluids, rest (8 or 9 hours of night time sleep and a nap or two during the day), ibuprofen or tylenol, and hot salt water gargles (1/4 teaspoon salt to 8 oz of hot tap watet, gargle and spit until the glass is empty). VIRAL INFECTIONS DO NOT RESOLVE ANY FASTER WITH ANTIBIOTICS. Don't waste your time and money on them for a viral sore throat.

If you have a very sore throat with a fever above 101 degrees F without any other cold type symptoms (congestion, cough, or bronchitis), chances are higher that you have strep throat. Strep throat is a bacterial sore throat caused by group A streptococcus (S. pyogenes), and usually involve the tonsils (strep tonsillitis) and/or throat (strep pharyngitis). 

About those antibiotics you are always hoping for when you see your doctor with a sore throat: even if your throat swab is positive for strep, it turns out your strep throat would likely get better just as fast without antibiotics as with them. There are two reasons to take antibiotics regularly for strep, and neither have to do with your sore throat: first, antibiotics reduce the length of time you are infectious to others (so you avoid spreading strep to others) and second, antibiotics reduce the risk of post-streptococcal systemic diseases like rheumatic fever, scarlet fever, and glomerulonephritis (kidney damage). These are rare but debilitating diseases with lifelong consequences. 

Lots of other illnesses can present with sore throat as one of the symptoms, so if you have a sore throat without typical cold symptoms or if your sore throat lasts more than 7 days, you should see your doctor to see if further testing or treatment is advisable. If any sore throat is getting worse quickly, or causing breathing problems or inablility to swallow even liquids, then see your doctor on an ungent basis.

Sorry, I have to stop now. My throat hurts. I'm going to finish my honey and lemon tea, take an Aleve, and hit the sack for an afternoon nap.

Monday, November 25, 2013

What's That You Say?

Let's talk a bit about hearing loss. "What?" you say? Yeah, that's what I mean. Seriously, hearing loss is a big deal for a lot of us. 36 million of us here in America. More men than women, many due to noise exposure at work or play. A significant number of us who have hearing loss also have tinnitus (ringing in the ears). It's a noisy world out there, and our ears aren't really built for it.

It is true that most industries are screening their employees' hearing yearly, and requiring ear plugs for noisy occupations. So hopefully, fewer workers will be experiencing hearing loss in the future. Still, Americans are living longer, which is great, but also results in more hearing impaired seniors, since hearing worsens with age. In fact, about half of all seniors over age 75 are hearing impaired.

The situation is better for children of course, since only 3 out of 1,000 are born with hearing loss (90% of them are born to hearing parents). Still, 3 out of 4 children will have ear infections before age 3. Many of them will have persistent fluid which causes hearing loss, though not of a permanent kind. As I mentioned in a previous post, 7% of children will get tubes to treat infections or ear fluid.

The good news: there's help and hope for hearing loss. Hearing aid technology has reached a high point in the past decade, and even profoundly deaf people who don't benefit from hearing aids hear again with cochlear implants. The bad news: only 1 out of 5 people who would benefit from hearing aids actually use them. Yes, you heard me correctly: one in five.
How can this be, you ask? I'll give you my top 3 reasons:
1. Finances. Hearing aids don't grow on trees, and as in most things, you get what you pay for. The only hearing aids that actually block background noise are the more expensive styles. Still, most people don't need all the expensive bells and whistles; modest-priced models can improve most mild to moderate hearing loss, and even severe hearing loss can benefit from these affordable devices.
2. Prejudice. Many of my older patients tell me that "everyone I know who has gotten a hearing aid just leaves it in a drawer." There are a number of reasons why someone who is fitted with a hearing aid ends up not using it: poor choice of aid or poor fitting by an unqualified hearing aid professional; poor customer service by profit-minded hearing aid mills; even vanity on the part of the wearer. The fact is that the vast majority of well-fitted hearing aids work as advertised and benefit the wearer tremendously.
3. Ignorance. Many hearing-impaired people don't realize the extent of their loss. Noise related hearing loss often becomes noticeable long after the noise exposure, and most hearing loss of any kind progresses very slowly, sort of creeping up on people unnoticed. Family members and co-workers often perceive the loss long before the individual does.

Here is Doc's Advice: if you or your loved one seem to miss things, or check out of group conversations, or find themselves increasing the TV volume level, you probably have hearing loss. You should find a reputable hearing professional and get your hearing tested. Most Ear, Nose, and Throat physicians employ audiologists who can test and treat hearing loss. In addition, the ENT can check your ears and make sure there are no medically treatable problems causing your hearing loss.

If you have hearing loss, do yourself a favor and try one of the state-of-the-art digital hearing aids now available. Don't pretend you don't have trouble hearing, and don't let pride or vanity get in the way. Yes, hearing aids are spendy, but not necessarily out of reach for most Americans. Let's face it: most of us have at least some discretionary income (you know, that's what buys RVs, XBoxes, 4 wheelers, bass boats, iPads, AKC puppies, designer sunglasses, smartphones, cable TV). Invest in your hearing health as much as you do your toys, and join back into the conversation!

Tuesday, November 12, 2013

4 Myths About Ear Tubes in Children

1. Tubes are bad for kids' ears: FALSE! Tubes are a good option for kids who have frequent ear infections or a chronic build up of fluid behind the eardrum that affects hearing and speech development. Around 670,000 children under age 16 undergo this procedure each year in the US, and by age 3, 1 in 15 children (7%) will have tubes placed. For children in daycare, 15% will need tubes! Insertion of ear tubes is the most common surgery requiring anesthesia performed on children in the US.

Tube placement is safe, effective, and very commonly done. Children under age 7 are at increased risk of ear infections and eardrum fluid because their immune systems are relatively immature and their eustachian tubes don't always open properly to allow air into the space behind the ear drum. Frequent courses of antibiotics can have significant health risks for children, and frequent visits to the family doctor can become burdensome. Ear tubes offer an option for children to avoid ear infections, antibiotics, and hearing and speech complications while their immune systems and eustachian tubes mature. Which brings up the next myth:

2. Tubes cure ear infections: FALSE! Tubes are placed to "bypass" the immature eustachian tube allowing air to enter the eardrum and fluid to drain or evaporate from the space behind the eardrum. Most ear tubes are shaped in such a way that the eardrum pushes the tube out after 6 to 12 months. During the time that the tubes are in place, the space behind the eardrum dries out and the eustachian tube begins to function properly. Once a child's eustachian tubes reliably open (with swallowing, yawning, and other normal motions of the throat), fluid is much less likely to accumulate in the space behind the eardrum.  A dry chamber is much harder to get infected, and with no fluid to impede soundwaves, hearing improves back to normal.

3. Once placed, kids need multiple sets of tubes: FALSE! As noted, ear tubes simply buy time for a child's immune system and eustachian tubes to mature. This happens at different rates for different kids. 4 out of 5 kids' ears clear up in the months after initial tube placement and don't have further problems. This means that 80% of kids who get tubes once won't need another set. The remaining 20% need another set to "buy more time" for the ears to mature. Some of these kids might also benefit from removal of their adenoids, and a blood test for allergies as well. A small percentage will need a 3rd set of tubes, and I often place a longer acting set of tubes called "T" tubes. These tubes are engineered to stay in for several years, and are easily removed in the office without anesthesia when they have served their purpose.

4. Tubes cause hearing loss: FALSE! A number of medical studies over the past 20 years have shown that ear tubes do not cause hearing loss, and on the contrary eliminate hearing loss caused by fluid behind the eardrum. Many toddlers and preschoolers with eustachian tube problems develop fluid-related hearing loss, and this often causes delay in speech and language development. Ear tubes usually normalize hearing and help young children to learn to talk when they are ready.

There are a few children who end up with permanent hearing loss, but it is usually due to persistent eustachian tube problems or severe recurrent or untreated ear infections. In these rare cases, it's actually the infections that cause damage to the eardrum or ear bones with resultant permanent hearing loss. Fortunately, these cases are rare, and as long as each ear infection is treated (whether by antibiotics or ear tubes), permanent hearing loss is avoidable.

If your child has frequent ear infections (3 or more in the past 6 months that required treatment with antibiotics) or fluid in one or both ears that has been present for 3 months or more, you should consult with your family doctor or an ENT about the possibility of ear tube placement. You can learn more about ear problems here and here.

Check out this YouTube video of the process of ear tube placement if you are curious.

Friday, November 8, 2013

What is wrong with my sinuses, doc?

Let’s talk about sinuses—those pesky air chambers in your face that on a good day are completely forgotten, and on a bad day can’t be ignored no matter what. What are they? Why do we have them? What can go wrong, and how do we fix it?

What they are: the sinuses are 4 paired air chambers in the face and base of the skull as seen in fig. 1.

Fig. 1 Frontal, Ethmoid, and Maxillary sinuses (Sphenoids not seen)

Why we have them: I love teleological “why” questions, but they mostly belong in a philosophical discussion. The sinuses are air spaces in the facial and skull bones, and as such they may lighten the head (instead of the skull being solid bone), they may act as a shock absorber for the brain in a fall or blow to the head, and they may help sounds produced by the voice box to resonate more. The mucous membrane linings produce a blanket of continuously moving mucus that carries bacteria, viruses, fungus particles and foreign material (dust, smoke residue) out of the sinuses to be swallowed or expectorated (spat out). They may also exist solely to keep ENT doctors in business. Just sayin’.

What can go wrong: basically, as air chambers, the openings can become blocked, which starts a cascade of events that result in bacterial or fungal infection of the chamber linings. These mucous membranes swell, resulting in further blockage of the sinus openings. This is commonly known as a vicious cycle, and it can be vicious all right! A sinus infection usually begins with a viral head cold that swells the sinus openings, trapping normally harmless bacteria in an airless chamber where they go crazy. The usual symptoms of an acute sinus infection are pain in the face, forehead, and upper teeth, nasal drainage (out the front or down the throat which is call post-nasal drainage or PND), and nasal congestion.

If the infection remains for longer than a few weeks, it is considered a chronic sinus infection, and symptoms change slightly: post nasal drainage and congestion continue, but facial pain fades and is usually replaced by a chronic pesky cough. Other symptoms are usually related to the nasal congestion or drainage: ear plugging or fullness due to plugged Eustachian tubes, hoarseness from mucus drainage, and sore or dry throat from mouth breathing. Allergies can increase the nasal congestion, and a septal deviation ("broken nose") can obstruct the nose further, worsening an already bad situation.

How we fix them: Sometimes a mild case will clear itself up without specific treatment when the viral infection resolves. Lots of fluids, vitamin C, and natural immune boosters can speed up recovery. If a head cold lasts longer than 7 days or is getting worse after 5 days, it's probably time to check in with your family physician or ENT, as you may need an Rx, especially if you are prone to sinus infections. I usually recommend a 10 to 14 day course of a broad spectrum antibiotic like amox/clav, cefuroxime, or azithromycin; a nasal inhaler such as fluticasone, and a short course of tapering low dose prednisone (like a Medrol dose pack for 6 days). Sudafed can be helpful as well.

If this trio fails to clear the infection up, I might opt for an additional 3 weeks of another antibiotic, continue the nasal spray, and maybe repeat the medrol dosepack. If this additional treatment fails, I often recommend a CT scan at that point: sometimes I find the CT to be completely free of any sinus findings, indicating we've been barking up the wrong tree. Several conditions can mimic chronic sinusitis such as atypical migraines, fibromyalgia, vasomotor rhinitis, and severe allergic rhinitis. Usually though, I find severely blocked sinuses that don't open fully with the treatment, allowing the openings to block shut soon after the antibiotic is finished. These folks generally come to surgery, which is aimed at re-opening the blocked openings to restore airflow into the sinuses and mucus flow out of them. 

There are lots of urban legends and old wives' tales about sinus surgery, so let me assure you: I never leave 20 feet of gauze packing in your sinuses, and I rarely even have to put instruments into the sinuses once the openings are enlarged. Significant bleeding is rare, and post op pain is very manageable (unless a septoplasty is performed in addition to the sinus surgery; then you will be a hurtin' unit for a week). Time off work is usually 3-5 days for sinus surgery and a week or so if both sinus and septal surgery is done.

There is much more to be said, and I've only covered the basics. Every case is unique, and treatment needs to be tailored for each patient. You can find out more about sinusitis here and here. If you have specific questions, discuss your symptoms with your family doctor, or feel free to call your local ENT for an appointment.

Monday, November 4, 2013

Welcome back to Doc's Advice!

I have been a little preoccupied since my last post. Blogging has taken a back seat to living, for which I do not apologize. My two dolls and I have had a great run these past 4 years, and some of my passions (bike racing, golf, flying??!!) have given way to parenting. Oh, and guitars. And bikes minus the racing part (we'll see how long that retirement lasts!).

One passion that has never flagged is my professional curiosity. I am an ENT doctor, and after practicing for 21 years in the same smallish town in central Minnesota, I continue to be fascinated and motivated by my patients' maladies. I recently attended a small hands-on 4 day course in endoscopic and microscopic ear surgery (yes, cadavers were involved!), and I returned yesterday full of ideas, information, and motivation to help my patients with ear problems.

I have collected a lot of information (and not a little misinformation) on all things otorhinolaryngological, and have decided to start jotting a few things down for the benefit of patients, friends, and interested parties. Patient confidentiality prohibits me from posting any specific cases or specific information from my practice, but there's still lots of general info that will be of interest. I may also comment from time to time on ENT related news items already public on news media outlets, such as Adele's throat surgery.

I also apologize in advance that I won't be able to address specific comments to these blogs, tweets, or posts. I can't give anyone specific medical advice without seeing you--though I would love to see you at our clinic! I will use some of the comments, questions, and flames to address ENT issues that would be worthwhile discussing.

Just a few other housekeeping items: first, caveat emptor: I am a scientist, empiricist, surgeon, and allopathic physician. I know, or have available to me almost everything that has been published in western medicine. If you want mostly scientific, evidence-based medical advice, I'm your man. If you want advice on alternative medicine, homeopathy, chiropractic, eastern mysticism, or essential oils, I only have an opinion, like everyone else.

Next, I tend to ramble a bit, and have been accused of stream-of-consciousness writing, so if I get off on a bunny trail about the merits of chemical labyrinthectomy versus endolymphatic sac decompression for recalcitrant Ménière's disease, please forgive me. Did I mention that this constitutes the fundamental professional passion of my life? Yeah, and I'm fairly passionate about my passions.

Finally, you can breathlessly await my next post (or not), either way I will usually announce it on my twitter account @docsadvice if you care to follow along. I also tweet the usual pithy or ironic wit expected of tweeters, though not nearly as well as some hipsters (but a lot better than some pro athletes). You can always check out some of the patient information available on our clinic website or at the AAO/HNS website (I won't bore you with the details of that acronym).

Next post, I plan to talk a little bit about chronic sinusitis, since it is getting to be that season in Minnesota and elsewhere. Meanwhile, if you are really bored, feel free to read my old posts on bike racing and adoption and bunny-trailing on this blog, and travels to France and philosophical musings and bunny-trailing on Mon Avis.