What is Tonsillitis?
Tonsillitis is an infection involving inflammation of the tonsils. There are two tonsils, situated on either side of the back of the throat and they form part of the body’s immune system. Like the rest of the immune system they contain special cells to trap and kill bacteria and viruses travelling through the body. When the main site of infection is within the tonsils they swell, become red and inflamed and may show a surface coating of white spots.
Tonsillitis is extremely common in children and young people but it can occur at any age. The characteristics of the disease are pain in the throat, trouble swallowing, fever, glandular enlargenment in the neck and in severe conditions, trismus (difficulty opening the mouth).
How do we contract Tonsillitis?
Whether due to viruses or bacteria, the infection is spread from person to person by airborne droplets, hand contact or kissing hence the term “kissing disease”. It is typically seen in young people but can on occasion effect the older adult, in these cases other possible causes need to be investigated.
There are many different individual viruses and bacteria that can potentially cause tonsillitis e.g. the Epstein-Barr virus, which causes glandular fever. The streptococcus group A is the most common cause of tonsillitis and sore throats – often known as ‘strep throat’. The incubation period between picking up the infection and the disease breaking out is two to four days – sometimes it can be less. Tonsillitis is usually a self-limiting condition, i.e. it gets better without treatment, and generally there are no complications.
Rarely pus can collect just deep to the tonsil itself as a result of infection. This typically produces one sided throat discomfort severe difficulty swallowing and often trismus (difficulty opening the mouth). This is referred to as a “Quinsy” and requires medical intervention.
Signs and symptoms of tonsillitis
- Sore throat.
- Pain or discomfort when swallowing.
- Inability to swallow oral secretions.
- Tonsils may be coated or have a covering of white spots on them.
- Trismus (difficulty opening the mouth).
- Glands in the neck and at the angle of the jaw may be swollen and painful.
- Loss or change in voice.
- In children, tonsillitis may include symptoms that appear less focused on the throat, such as poor feeding, runny nose, ear pain, and a slight fever.
- Visit to the general practitioner (GP) who may commence a course of appropriate antibiotics and analgesia, with advice on oral intake, hygiene and to return if condition does not improve.
- If the condition does not improve the GP should refer the patient either to a local ear, nose and throat (ENT) referral clinic or to accident and emergency (A&E) for review and treatment by an ENT specialist.
- If there is an inability to swallow the oral secretions the patient will need to be admitted for a minimum of 24 hours for re-hydration, pain relief and intravenous (IV) antibiotics and reviewed on a daily basis.
- Visual examination of the tonsils.
- Blood tests, including the mono-spot test to rule out glandular fever.
- Insertion of a venflon for administration of fluids and IV antibiotics.
- Regular temperature check
- Routine observations including oxygen saturation monitoring.
- Analgesia for pain relief both regular and as required. This is also to assist in reducing any above normal temperature. Paracetamol is the most common one given.
- Aspiration if thought to be a quinsy by a trained practitioner.
- If oral medication is not suitable then intra-muscular (IM) or per rectum (PR) should be prescribed.
- Fan therapy if necessary but taking care not to reduce the pyrexial patients temperature too suddenly.
- Documentation of fluid and oral intake.
- Ongoing reviews of care delivered and appropriate alterations, depending on patient response and results of investigations undertaken.
Within 24 hours of analgesia, IV fluids and antibiotics the patient often makes a dramatic recovery and is suitable for discharge home.
The patient is ready for discharge when;
- They are apyrexial
- Are managing adequate oral fluids and diet.
- Their pain is controlled on oral analgesia.
- Any investigations are complete and show no other underlying condition that requires immediate investigation / treatment.
What happens when discharged?
- The patient will continue on a course of oral antibiotics, which must be completed otherwise the infection may return.
- A seven-day supply of appropriate analgesia will be prescribed.
- Verbal and written advice on areas such as dietary advice, when to return to work & refraining or cessation of smoking and oral hygiene should be given to the patient or carer once discharged.
- If the patient suffers from tonsillitis i.e. 3-4 episodes annually and it affects work/ school attendance, they should be offered a tonsillectomy and if agreed, added to the ENT waiting list.
- A copy of their discharge letter will be given to the patient and one posted to their GP.
- They should be advised if their symptoms return they should see their GP and if appropriate the GP will refer them back to the hospital.
What is a Tonsillectomy?
Recurrent tonsillitis, quinsy, obstructive sleep patterns in children are all indications to remove the tonsils in the form of a tonsillectomy.
This procedure is performed under general anaesthetic. Post-operatively patients require regular analgesia and strongly encouraged to continue eating and drinking to speed up their post-operative recovery.
Having a tonsillectomy generally requires an overnight stay in hospital.
Gastro-oesophageal and Pharyngeal Reflux
The stomach produces acid that is corrosive and irritant. It is possible in some situations that the acid can reflux up into the oesophagus and even into the pharynx causing irritant symptoms of indigestion, burning, sore throat, hoarseness, coughing fits or a lump sensation in the throat.
There are things one can do to prevent the production and the reflux of the acid and thereby decrease the symptoms incurred by the patient. It is important to adhere to the advice given to decrease the reflux and its effect.
Over the counter antacids such as Rennies or gelusil or gaviscon a liquid preparation that prevents the acid irritation are available without prescription and can be of help. It is useful to take them before going to sleep but if symptoms are sever then it is useful to take them 30-45 mins before eating meals.
Proton pump inhibitors (PPI’s) are often prescribed in this situation by your GP or ENT surgeon. These should be taken as instructed by your doctor and instructions should be meticulously adhered to. PPI’s decrease the production of acid from the stomach and therefore decrease the effects of the acid when it refluxes.
Beware that some medications increase acid production such as anticholinergics, beta blockers, aspirin, theophylline and non steroidal anti-inflammatory drugs.
Also smoking increases acid production and it’s cessation is beneficial to the treatment reflux.
An increased Body mass index (BMI) above the normal level increases the chances of reflux. In this situation it is beneficial to try to lose weight to reach your target weight for height (BMI).
Acid reflux is not an uncommon symptom at night and is related to the fact that lying down allows for the easier refluxing of acidic contents. Elevating the head end of the bed between 4-10 inches will decrease the chances of reflux whilst not being too high so as to feel like you are sliding off the bed.
Smaller frequent meals are more conducive to avoiding reflux. The avoidance of irritating foods and drinks such as caffeine, chocolate, alcohol should be avoided. Also any specific foods that cause an individual heartburn should be avoided.
Vocal Hygiene Advice
Ensure adequate fluid intake of water / squashes (NOT coffee or tea which contain caffeine and will dry the throat). Approximately 8-10 drinks per day is appropriate.
Steam inhalations to be undertaken carefully if possible twice a day. This may include the steam in a shower. Also ensure humidification of your bedroom / living room (a bowl of water near the radiators).
Avoid smoky noisy environments where you will strain your voice whilst irritating it.
Eat regular balanced meals avoiding late night eating which is associated with indigestion.
Get adequate amounts of sleep as the larynx is a complex muscular organ that will under perform if you are tired.
Chewing gum or sucking ordinary pastilles can keep the mouth moist. Try to avoid medicated lozenges as they may numb the throat or the menthol can dry it.
Avoid aspirin gargles especially if having an acute infection.
Ear Care Advice
- The ear canal is self-cleaning. Do not insert any implements such as cotton buds into the ear. They will damage the delicate skin lining the ear and increase the chance of you developing an ear infection, itchy ears or a problem with wax.
- To dry/ clean the outside of the ear use a dry tissue or alcohol free baby wipes around and behind the ear after showering or bathing.
- If you suffer from excessive wax; insertion of 1 to 2 drops of olive oil on a regular basis may help the ear clean itself.
- If the entrance to the ear canal is dry and/ or itchy, you may find it of benefit to insert one drop of olive oil into the ear canal as instructed by your practitioner. Keep the ears dry from any entry of water, as it may be shampoos and soaps irritating the skin.
- If you have experienced an external ear infection keep the ears dry from any entry of water.
- To keep the ears dry from water entry use cotton wool coated in petroleum jelly or ear plugs placed at the entrance to both ear canals.
- If the symptoms with your ear do not improve make an appointment with your doctor.
How to insert olive oil drops into the ear canal
To obtain the olive oil drops purchase olive oil and the glass dropper bottle that has been designed for ear drops from a chemist. If you have used previous wax dissolving drops, discard all the liquid, wash out the glass bottle and when the container is clean, insert olive oil (almond oil/ coconut oil could be used if you do not suffer from a nut allergy).
- Insert the closed glass dropper bottle containing the oil into a cup of warm water for two minutes. Dry the container and insert one-drop of oil onto your hand to ensure that it is not too hot. If you feel the oil is too hot wait for it to cool prior to commencing. The correct temperature of the oil should be 37?C. Alternatively, for the oil to reach body temperature (37?C) place the bottle in a pocket of your clothing currently being worn for 20 to 30 minutes.
- Holding the prepared dropper bottle lie on a bed with the affected ear towards the ceiling.
- With one hand pull the top of your ear upwards and outwards to straighten the ear canal.
- Placing the filled dropper part of the bottle of oil over the entrance to your ear canal and squeeze the dropper until one drop (or the amount specified by your nurse) is instilled. Maintain that position for a total of five minutes however, after one minute release the ear and massage the tragus (located at the front of the ear at the level of your cheek-bone) for one minute. Remain on your side and relax on the bed for a further 3 minutes.
- Wipe the excess drops that pool outside the ear when you sit up. Do not insert cotton wool into the entrance of the ear canal as this will diminish the effect of the drops.
- Unless instructed otherwise by the nurse insert the drops into both ears, repeating steps two to five on the opposite side.
Patient Advice Prior to Ear Irrigation
- Insert 1 to 2 drops of olive oil into the ear(s) requiring wax removal every morning and evening, commencing one week prior to the appointment (unless instructed otherwise by the nurse).
- Continue to use the drops twice daily until the wax has been successfully removed.
- Instilling olive oil (coconut or almond oil can be used as an alternative if you do not suffer with a nut allergy) will assist with the wax removal process and reduce discomfort that may be felt during the procedure.
Patient Advice Post Ear Irrigation.
- The ear canal may be vulnerable to an ear infection after irrigation. This is caused by removal of all the wax, which has inherent protective properties for the ear canal.
- Until the ear produces more wax to protect the canal keep the ear(s) that have been irrigated dry from entry of water for a minimum of four or five days after the procedure.
- To keep the ears dry when you are washing your hair, showering, bathing or swimming, insert ear plugs or cotton wool coated in petroleum jelly into the outside of the ear canal(s) to act as a protective seal.
- In the unlikely event that you develop pain, dizziness, reduced hearing or discharge from the ear after the procedure, consult with your nurse/ doctor.
The anatomy of the nasal septum has been outlined in the anatomy and physiology section of septoplasty . However, the midline septal cartilage is one of a number of structures that support and create the framework of the nose. In addition there are two alar (lower lateral) cartlages and two upper lateral cartilages. The upper lateral cartilages snuggly fit under the two nasal bones.
The nasal dorsum in a lateral view is of significant importance to patients aesthetically. Too prominent a nasal dorsum contributed from the nasal septum and nasal bones can produce a nasal hump that can is possible to be reduced.
From a frontal view the nose aesthetically should be in proportion to the eyes and face. The nasal bones and septum together with the alar and upper lateral cartilages should be symmetrical and in line.
Lateral views of the nose demonstrate the nasolabial angle that should be approximately 90-100° in males and 100-110° in females.
Septorhinoplasty surgery is undertaken for functional and cosmetic purposes. There are many aspects that should be taken into account when planning with the patient. It is important to be honest with the patient about what can and cannot be achieved.
Surgery can be undertaken in a closed or open technique. Closed techniques involve incisions in the nose occasionally with tiny stab incisions for bony work around the nasal bones. Open techniques involve a mix of internal incisions together with some external incisions to allow the draping skin of the nose to be reflected to reveal the structural cartilages below. All the cartilages of the nose can be altered in different ways to reshape and support the nose in different ways. The nasal bones can be fractured and repositioned.
Because the surgical work of a septorhinoplasty is based on reshaping and repositioning of cartilages and bones which can include fracturing of bony tissues there can be some associated swelling and bruising that subsides fairly quickly after the operation. The internal incisions are closed with dissolving sutures and the nose is sometimes dressed lightly internally. A supportive plaster of paris or moulded splint is used to protect the newly shaped nose for the first 7-10 days.
Anatomy / Physiology
The turbinate’s are folds of mucosa and bone that exist on the lateral wall of the nose. Their absolute function is uncertain but clearly they contribute to the other functions of the nasal mucosa.
- Warming the air
- Filtering the air
- Moistening the air
- Immunological presentation
- Assisting the sense of smell
Clearly however, the turbinates the are bony protrusions from the lateral nasal wall with mucosa overlying them and if this mucosa swells then they can cause a degree of nasal obstruction.
Submucosal Diathermy to the Inferior turbinates (SMDIT’s)
This surgical procedure is aimed at either superficial or deeper cautery to the mucosal layer overlying the bony inferior turbinate. This theoretically shrinks back the mucosa, causes some scarring and improves the nasal airway. It is common for this too cause significant airway obstruction for the first week postoperatively and then some improvement of symptoms. A similar technique using the laser can be employed. As this surgery is aimed at improving nasal obstruction if the patient has a deviated septum it is often combined with a septoplasty .
This surgical procedure requires removal of part or all of the inferior turbinate surgically. This is associated with occasional heavy nosebleeds and although is still performed is not frequently undertaken.
Degloving of the Inferior turbinates
This surgical technique involves the removal of the swollen mucosa overlying the bone of the inferior turbinate and leaving it to heal with fibrosis and scarring. It requires nasal packing and a course of oral antibiotics postoperatively.
Anatomy / Physiology
What are nasal polyps?
Nasal polyps are not an infrequent finding in the nose. Typically they are simple nasal polyps that are related to swellings from the lining of the nasal sinuses and protrude into the nasal cavity. Their presence in the nasal cavity causes a blocked feeling in the nose and sometimes a feeling of intermittent blockage due to the possibility of a ball valve effect. These smooth, insensate swellings in the nose are usually not visible to the naked eye and require a careful examination in the ENT Outpatient environment with an endoscope.
Polyps are usually a change and reaction of the sinus mucosa in response to an allergen. They may swell more in response to an upper respiratory tract infection, or certain alcoholic drinks. It is not unreasonable to have a trial of intranasal steroids for polyps or occasionally an oral course of steroids but if persistent then it is reasonable to consider surgery.
If asymptomatic polyps are seen in the nose by chance then these usually do not require surgical treatment. However, the presence of a unilateral polyp in the nose does warrant an examination under anaesthetic and removal of this polyp for histological diagnosis. Very occasionally a unilateral polyp arises solely from the maxillary sinus (under the cheek). This requires a complete polyp removal and the attached lining to the maxillary antrum to prevent recurrence.
Unilateral nasal polyp (Antrochoanal polyp)
Gross bilateral intranasal polyps
Nasal Polypectomy Surgery
Surgery for this condition has improved significantly over the past few years with the use of powered instrumentation. Rather than the simplistic manual removal by just pulling the polyps out one can carefully suction and then debride the polyps out of the nose using a ‘microdebrider’ leaving as much normal anatomy possible behind in the nose.
This surgery is performed using the endoscope and is a variation on Functional Endoscopic Sinus Surgery and often is combined especially if the polyps have been causing obstructive symptoms leading to chronic sinusitis.
Similar risks are incurred especially as often the nose is filled with abnormaltissue and therefore this has to be removed before normal anatomy is identified. The risks to the skull base and the breach of it producing leakage of the fluid that bathes the brain together with orbital injury although rare are a possibility. Bleeding is not uncommon in very small quantities in the post operative periods and if significant require presentation to a local emergency department. Packing the nose postoperativeley may be performed sometimes to tamponade any initial bleeding.
Postoperativeley the patient should be sent home with a nasal douche and a course of intra nasal steroids to decrease the chance of the polyps coming back quickly. Polyps cannot be cured by surgery and the surgery is aimed at improving the nasal airway and aiding the delivery of intranasal steroids that will be preventative in the longterm future.
Functional Endoscopic Sinus Surgery (FESS)
Anatomy / Physiology
TThe anatomy of the sinuses has not changed for many years, but our understanding of the physiology of the nose and sinuses has evolved significantly in more recent years. Our concept of how sinuses naturally drain has been the source from which we have adapted our surgical techniques in order to improve these natural drainage patterns.
There are a number of sinuses.
- Maxillary sinus x2
- Anterior ethmoid sinus x2
- Posterior ethmoid sinus x2
- Frontal sinus x2 (variable in size and development)
- Sphenoid sinus x1 (often split into 2 by a bony septa)
The maxillary sinus (located under your cheek) drains into a narrow area between two bony folds in the lateral wall of the nose, called the middle meatus (area between the middle and inferior turbinates). In addition the anterior ethmoids and the frontal sinus drains here too. This is a crucial area of confluence referred to as the osteomeatal complex and is where a lot of problems exist with respect to sinusitis. Surgery is often focused here to improve the drainage.
The surgery is referred to as Functional as you are not just anatomically looking at creating a solution but you are improving on the normal function / physiology of the sinus drainage pathway.
The surgery is referred to as Endoscopic as the surgeon uses fine telescopes intranasally to give an excellent visualization of the nose. With the use of fine instruments too the surgeon can rectify any anatomical or pathological anomalies in order to improve the natural drainage of the sinuses.
The surgeon almost always uses a CT scan as a map through the nose and sinus and this will have been performed preoperatively to help with the diagnostic workup of the patient.
Preoperative CT Scan showing opacification of the left maxillary and ethmoid sunuses.
Access sometimes has to be improved with an additional procedure of a Septoplasty to allow visualization of areas obstructed by a deflected nasal septum.
This surgery can often be performed as a day case but occasionally warrants an overnight stay. The nose may be dressed with small soft intranasal packs that are removed after a set length of time depending on the surgeon.
It is not uncommon to feel blocked in the nose for approximately a week as the swelling intranasally goes down and regular nasal douching with appropriate products as recommended by your surgeon should be used to flush out any crusts or blood from the nose. It strongly advised not to blow your nose in the postoperative period.
Anatomy / Physiology
The dividing partition between the left and right nostril is called the nasal septum. It is composed of both cartilage (soft and flexible) in front and bone (solid and inflexible) further back.
The nasal septum is lined with a tightly adherent mucoperichondrium that supplies it with nutrients. It has a number of growth centres from birth that continue with growth until the late teenage years therefore it is sensible not to operate in this area unless there is good reason to do so.
The cartilage is necessary for the support of the nose and surgery to the cartilage may affect this support. The cartilage is sensitive to trauma that can occur at birth and any point afterwards.
If the cartilage or the bone of the nasal septum is deviated it may produce symptoms of nasal obstruction. It is surprising how often people have an asymptomatic deflection of the nasal septum and also the fact that the nasal septum can be deflected in more than one direction. It is for this reason that a septoplasty can be useful in the correction of the symptom of nasal obstruction. Occasionally a septoplasty is used for access in the nose such as with Functional endoscopic sinus surgery.
An incision is made in the mucoperichondrium of the nasal septum and this layer is carefully dissected off the cartilage below. The forwardmost strut of cartilage is preferably preserved to maintain support of the nasal structures together with a strut of cartilage under the midline portion of the nose.
Whatever cartilage is deflected should be augmented, resected or scored in order to straighten the nasal septum. Once this has been achieved then the mucoperichondrium should be replaced and is often stitched back to the nasal septum to firmly replace it and prevent blood from accumulating in the pocket that has been created for the operation.
The nose is not infrequently packed with a soft nasal pack that stays in the nose only for a few hours.
If performed alone this case can be discharged on the same day. This surgery however, is often performed with other procedures in the nose such as turbinate surgery.
Post-operatively the patient will feel very blocked in the nasal cavities and it takes approximately 7-10 days before the swelling goes down and people start to get the benefit from the surgery.
Prominent ears are a developmental abnormality where the normal architecture of the ear has not developed and the ear becomes clearly prominent and cup shaped. A fold in the ear referred to as the anti helix is typically absent and also the conchal bowl (close to the entrance of the ear canal) may be found to be deep.
The ear is made of pliable cartilage and is significantly developing in the first few years of life. The cartilage from birth, during the neonatal period is responsive to splinting in the event of prominent ears being noticed early. This can help mould the ear into the correct shape.
Most children become conscious of their prominent ears on entrance to school where teasing is common. Girls can often hide the developmental abnormality more than boys due to the fact that they grow their hair to cover their ears. The cartilage needs to develop significantly and not be too immature before the ear can be surgically corrected. This typically is around the age of 5-6.
The surgery typically is aimed at recreating the ‘antihelical’ fold typically missing or making the conchal bowl more shallow. This is undertaken with an incision behind the ear and the anti helix is formed, the cartilage may be scored to keep its shape and stitches may be used to keep the cartilage in place.
The ear is carefully dressed with a head bandage that is often worn for 1 week post-operativeley. At this stage the dressings are taken down and the ears are notably bruised but clearly their position has usually been altered for the better. Most surgeons like to protect the ears during the night with a headband so that the cartilage is not sprung back inadvertently.
Anatomy and Physiology
The temporal (mastoid) bone sits at the back of the ear and is composed of 4 portions
- The petrous temporal bone
- The squamous temporal bone (mastoid)
- The styloid process
- The tympanic ring
The mastoid air cells exist within the squamous and petrous temporal bone. There is variation in the pneumatisation (aeration) of these air cells but they are in continuity with the middle ear via a connection called the aditus ad antrum. Within the mastoid the facial nerve runs a course firstly in the middle ear then descending down in the mastoid to exit in the stylomastoid foramen and then to enter into the parotid gland.
The mastoid air cells not only run close to the facial nerve but are also intimate with a thin plate of bone superiorly (tegmen) that abuts the meninges and posteriorly bone overlying the sigmoid sinus that drains into the internal jugular vein.
This operation is performed typically for chronic ear disease in the form of Cholesteatoma or Non cholesteatoma Chronic Suppurative Otitis Media. Occasionally it is performed in addition to a myringoplasty .
Cholesteatoma is a condition where a piece of skin from the tympanic membrane encroaches into the middle ear. The skin sac finds it difficult to self cleanse like the normal ear canal skin and infections recur. The skin sac extends into the space of the middle ear and then into the mastoid air cells as it grows.
Surgery to remove a cholesteatoma follows this skin sac to remove every piece of it so as not to allow a recurrence. There are two types of approaches:
- Canal Up – Where the ear canal is left intact
- Canal down – Where the mastoid is left in continuity with the ear canal.
A mastoidectomy operation has varying degrees of difficulty depending on the disease process. There are risks of a change in the level of hearing, balance alteration, facial nerve weakness (very rare), meningitis (very rare), recurrence of disease, discharge from the ear. The key is a thorough operation ridding the individual of the disease process. The patient has a head bandage that can come down the day after the operation. Typically the patient goes home the following day. A dressing is often placed in the ear canal / cavity for a few weeks and is then removed in the clinic. Often long term follow up is necessary to monitor the ear and look out for recurrence of disease.
The ear drum is composed of two parts, a pars tensa which accounts for the majority of the visible drum and the pars flaccida which accounts for the upper one fifth of the ear drum. Sound is transmitted through the eardrum to the ossicles (tiny bones of the middle ear), these in turn transmit the sound to the cochlea (organ of hearing). Occasionally due to ear disease, trauma or significant infections a perforation / hole in the ear drum occurs. When this happens the patient may be completely asymptomatic but often they have a degree of discharge from the ear and possibly some hearing loss. The degree of hearing loss depends on the integrity of the small bones in the ear and the size / position of the perforation.
The hole / perforation in the eardrum can be repaired using an operation called a ‘myringoplasty’. This operation can sometimes be done through the ear canal but occasionally an incision is used behind the ear or above it. The perforation edges are freshened to encourage new growth and a graft is placed under the eardrum as a template for the new drum to grow over. The ear canal then has a dressing placed inside it and this usually comes out some 7-10 days later in the Out-patient clinic.
There is a failure rate associated with the operation and this is dependant on the site of the perforation and the size. Occasionally people feel slightly unsteady following the operation. It is important not to undertake any heavy lifting or blowing of the nose in the postoperative period as this changes the middle ear pressures and it may cause graft failure. The ear and dressing must be kept meticulously dry in the post-operative period until the surgeon agrees for the patient to go swimming again.
Anatomy / Physiology
The middle ear is a cavity in the skull that houses the small conductive bones of the ear. Sound passes from the external ear canal through the middle ear and then into the inner ear from which neurological stimuli are transmitted to the brain which is where we sense hearing. The middle ear is the area deep to the ear drum as we look at it. It is in connection with a group of air cells called the mastoid air cells that are housed in the mastoid bone behind the ear and is also in connection with the Eustachian tube that connects the middle ear to the back of the nose (nasopharynx).
Typically in childhood in association with upper respiratory tract infections, ear infections and immature Eustachian tubes a phenomenon called glue ear forms behind the eardrum. This is simply fluid that accumulates here but clearly can have a significant impact on the child’s hearing.
Glue ear is visible on otoscopy and typically is seen as a dull or amber coloured ear drum because of the fluid behind it. It can be tested for using an audiogram (hearing test) and tympanometry (pressure traces of the middle ear).
Glue ear (amber fluid behind the eardrum)
Glue Ear and Grommets
Glue ear when first seen should undergo a period of ‘watchful waiting’ for 3 months as a large percentage of them will spontaneously resolve. If however, after this period there is still the presence of glue ear and that the child is still troubled with their hearing affecting schooling, speech development or behaviour then consideration for grommets should be undertaken.
Although in adults local anaesthetic grommet insertion may be considered, for children a general anaesthetic is required. Grommets are usually placed in the safe part of the drum in the anterior inferior segment. A small incision (myringotomy) is undertaken, fluid is sucked out and then the grommet which often is a plastic ventilation tube is snuggly placed in the tympanic membrane. Not infrequently an adenoidectomy undertaken to treat the glue ear problem too
The ears should be kept dry for as long as the ENT surgeon has suggested and the child is often followed up to see that the hearing has improved.
Grommets are occasionally placed for other indications. The following list summarises why grommets are used
- Glue ear
- Recurrent acute otitis media (middle ear infections)
- As part of treatment for large retraction pockets
- Eustachian tube problems
Microsuction for Otitis Externa / Swimmer’s Ear
Otitis externa is an inflammatory condition that affects the external ear canal. It is either infective, reactive or environmental.
Environmental otitis externa
Environmental causes of otitis externa are seen in warm humid climates and can occur when people bathe and water enters the ear canal (so called swimmers ear). The ear canal is a dry blind ended sac that should be dry otherwise the wet environment leads to dessication of the skin and secondary infection.
Infective otitis externa
Infective otitis externa is most commonly bacterial or fungal in its nature. Bacterial infections can often occur if water enters the ear canal or if the ear canal is traumatized by the insertion of implements such as cotton buds or fingernails etc.
Reactive otitis externa
Reactive otitis externa occurs as a result of certain skin conditions such as eczema and psoriasis. It requires aggressive treatment of the condition and careful clearance of the ear.
Otitis externa / swimmers ear is an extremely uncomfortable condition in the acute phase that produces symptoms of pain, blocked ears, decreased hearing and discharge from the ears. When more chronic it produces symptoms of chronic itching and discharge from the ears.
Treatment is in the form of patient advice and medical treatment.
- Keep the ears dry. Use cotton wool with Vaseline on bathing. Do not wash the ears. Do not go swimming in an acute episode without ear protection.
- Do not irritate the ears with any foreign objects such as cotton buds or fingernails these will traumatize the ear canal and introduce infection.
- Contact ENT surgeon if symptoms worsening.
- Ear drops are commonly used in the treatment of otitis externa and they often include a mix of antibacterial and steroids (for the anti-inflammatory effect).
- Microsuction is the gentle hovering of the debris out of the external ear canal to allow for the introduction of the eardrops.
- Ear wicks are a dressing placed in a swollen external ear canal to splint the ear canal open and allow for the administration of the ear drops.
Ear Wax / Cerumen
The ear canal is approximately 2.5 cm long in the adult and is divided into an external 1/3 and an inner 2/3. In the outer 1/3 there are ceruminous and sebaceous glands that secrete into the ear canal minute quantities of cerumen and sebum that combine with the slowly shedding skin of the external auditory canal. Skin of the external canal has a natural tendency to migrate laterally and mix with the cerumen and sebum to create wax in the outer 1/3 of the external auditory canal. It is for this reason that if wax is visualized deep in the external canal that this is often a sign that it has been pushed here.
Wax is a natural protector of the external canal and has some bactericidal properties as well as water protective functions. Unfortunately sometimes patients produce excessive amounts of wax that can cause problems.
Patients often feel a blocked sensation secondary to wax impaction and a decrease in their level of hearing. Occasionally wax produces a degree of discomfort and if irritated can produce a degree of otitis externa.
Wax naturally discharges itself from the ear canal and more often than not it is the incessant fiddling that is commonplace amongst humans that causes irritation and pushes wax deeper into the ear canal. We can help this by not putting any objects such as cotton buds into the ears and also by softening the wax with the use of olive oil drops.
If wax becomes a problem then this can be treated by removal under direct vision with a headlight and specialist instrumentation.
Alternatively ear irrigation can be undertaken by a trained practitioner but it is essential that the ear is dryed after this procedure and that it is undertaken by a person trained specifically in this.
The use of a microscope can be very useful in removing wax as this gives the operator binocular magnified vision whilst having hands free to use instruments and suction to remove wax
UK Head and Neck Cancer
Head and Neck Cancer is a spectrum of disease covering malignant disease of the upper aerodigestive tract, salivary glands and thyroid. They comprise of 3% of all the new cancers seen in the UK per year and are therefore relatively rare therefore should be treated by individuals that deal with this spectrum of disease regularly and in a centre that has the complete infrastructure necessary to support a patient through their treatment.
Risk factors for Head and Neck Cancers include:
- Poor dentition
- Chewing tobacco
Head and Neck Cancer Centre
Head and Neck Cancers by virtue of the fact that they are rare need to be treated through a Centre that has the specialists within it to treat and look after a patient throughout their management plan.
Making the diagnosis of Head and Neck cancer requires skilled clinicians, surgeons and oncologists, used to taking good histories and recognizing risk factors in the history. Appropriate special investigations, reported by experts in their fields is essential. This includes dedicated Head and Neck radiologists to look at the variety of X-Rays taken for patients, dedicated pathologists looking at specimens and biopsies and dedicated cytopathologists looking at cells extracted from head and neck lumps by a process called fine needle aspiration cytology.
Patients should be discussed in a multidisciplinary forum such that unilateral decisions are not made and these will include not just the specialists named above such as the surgeons, oncologists, pathologists and radiologists but also the other very important aspects to a Head and Neck Cancer Centre including Clinical Nurse Specialists, Speech and Language Therapists and Dieticians.
Mr Vaz is a dedicated ENT / Head and Neck surgeon that sees patients with Head and Neck Cancers regularly and channels them through a premier Service at the dedicated Head and Neck Cancer Centre at University College London Hospital. Patients can be seen here and managed both in the private and NHS sectors
Over the years tonsillectomy has had a bad press and this may be related to the fact that previously many people had their tonsils removed surgically without a correct indication.
As an ENT surgeon tonsillectomy is a satisfying operation as it is now performed with specific indications and the results therefore are gratifying for the surgeon and satisfying for the patient.
Clearly you will not die of tonsillitis but it is a huge problem to adults and children. However, when thinking about state services paying for operations, those that are deemed the most life saving will always be paid for and those deemed not serious may not be seen to be value for money (amongst the politicians). It is imperative to understand that tonsillectomy for reccurrent tonsillitis significantly improves an individuals lifestyle and whilst tonsillitis is not life threatening a tonsillectomy can significantly improve the quality of life of individuals.
Nasal polyps cause onbstruction of the nose and can be very symptomatic causing patients to suffer with nasal obstruction, snoring, decreased smell sensation and a runny nose.
Polyps are an inflammatory / allergic response of the nasal (sinus)mucosa that then prolapses and obstructs the nose. A large number of polyps can be treated with intranasal steroid sprays, but I often see patients who have tried these already. If the polyps are symptomatic then it is not unreasonable to remove the polyps surgically via an endoscopic surgical technique (no external scars). This gives the patient immense relief after the intranasal swelling goes down.
Whilst this removes the majority of the polyps there is a tendency for the condition to recurr as it is the sensitivity of the nasal (sinus) mucosa to swell and prolapse that causes them and this still remains. It is for this reason I will often treat people again with intranasal steroid sprays following surgery as the delivery is improved and it will decrease the chance and the need for further surgery.
Sinus surgery has changed significantly over the years. The previous operations that were the norm such as a Caldwell Luc or inferior meatal antrostomies are unusual to perform nowadays. Our technique has been refined to encorporate the normal sinus drainage patterns which is what we refer to as ‘Functional Endoscopic Sinus Surgery’ or ‘FESS’.
What is interesting, when I teach General Practitioners who have had a good grounding in ENT Surgery, this newer approach to sinus surgery is not fully appreciated. This may be because it is simply a development that has occured since they had any formal ENT training so it is essential that we spread the word with this up to date form of treatment of the sinuses.
The treatment does not usually require any surgical scars and is performed through the nose using an endoscope, which is a thin rod that can allow the surgeon to visualise inside the nose and then instrument it. A variety of specialist instruments can then be used intranasally to open the natural drainage patterns of the sinuses and thus improve the symptoms of sinusitis by improving the natural drainage pattern and not creating an unnatural one.
It is not uncommon for people to come to me feeling a lump in the throat being present. It is a very common phenomenon that more often is benign but requires a careful ENT evaluation in the history and examination.
It is imperative to take a clear history in order to elicit high risk cancer association factors such as a smoking and or high alcohol intake. Safer aspects to the history include the ability to continue to eat and drink, no weight loss and if the lump sensation comes and goes.
It is essential that a thorough ENT examination is undertaken to visualise the upper aerodigestive tract and this can be undertaken using nasendoscopy. This allows a direct picture of the upper airway that cannot be undertaken by the patients General Practitioner. It is often for this reason that patients are referred for a specialist opinion.
A wide differential diagnosis exists for this symptom thankfully the majority of cases are related to a ‘globus’ phenomenon which may be related to reflux or stresses however, the high risk malignant conditions have to be excluded.