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THE EAR: FREQUENTLY ASKED QUESTIONS

• Why do some children get mucus collection in the ear?
  
  All ears make a small amount of lubricating mucus. It normally drains away through the eustachian tube to the back of the nose.
  
  This tube is however the main problem in that it’s literally a millimetre wide at its narrowest and its lining as sensitive as the nose with which it’s collected. So it doesn’t take very much to block it off. When this happens mucus dams up and collects in the middle ear.

• What symptoms can a build up of mucus in the ear cause?
  
  Well first, although it’s producing a degree of hearing loss, this might be so small you won’t even notice it.In more serious cases up to 40% hearing loss can occur. This of course is temporary. In essence the eardrum isn’t able to move normally hence the hearing loss.

• Does mucus build up predisposed to ear infections?
  
  Yes it certainly does. The mucus is an excellent culture medium and bacteria can reach it from behind the nose where the adenoids lie by going up the eustachian tube and causing a middle ear infection. It will obviously occur more often in winter with the frequent upper respiratory infections.

• Can mucus build up cause behaviour change?
  
  Yes it certainly can. The child can become irritable….sometimes extremely so….

• Do you always have to drain a build up of mucus away surgically?
  
  Definitely not. Many children will drain the mucus spontaneously through the eustachian tube. Depending on the symptom and the appearance of the eardrum, one can wait a couple of months before deciding the drain the mucus away and insert grommets.

• Is there no medication which can open up the eustachian tube?
  
  Nothing is really guaranteed but a short dose of oral cortisone which is absolutely safe is always worth a try.

• When do you insert grommet tubes?
  
  If the mucus has persisted and failed to resolve or with frequent middle ear infections, grommets are an excellent procedure. It’s an outpatient procedure with minimal discomfort and in the correctly selected cases, an absolute life saver. Parents in particular are usually delighted by how their child has improved.

• What are grommets?
  
  They are small ventilation tubes made of either plastic or metal. They’re inserted through the incision made in the eardrum after all the mucus has been sucked out and by-pass the function of the eustachian tube.They seldom cause problems. They have enormously reduced the amount of reconstructive surgery we now have to do on the ear.

• When does the eustachian tube usually become mature?
  
  By the age of 5 or 6 it’s normally functioning as well as it’s going to function. In most people it will be absolutely fine. We have no way of controlling this. In cases where it is permanently dysfunctional, then it needs to be by-passed.
  
  In this case one uses the long term ventilation tube which can last for a couple of years. The usual grommet tube will last some 6 months. There are occasions when grommet tubes need to be repeated.

• Swimming and Grommets
  
  This is a controversial question.There are no papers suggesting that you get more infections with grommets from swimming but there is a small group which disproves this. So in essence what one suggests is that the child be allowed to swim without restriction but if they fall into that small group where the ears are a problem with grommets then ear plugs or protective head gear are needed.
  
  But to tell a mother that the child can’t swim because of grommets is absolutely incorrect. The child for obvious reasons must become water confident. One can handle a discharging ear but not a child who has drowned because of being told not to swim due to grommets…. It’s as simple as that. So in this practice I fight very strongly not that grommets affect the child’s water exposure.

THE NOSE: FREQUENTLY ASKED QUESTIONS

NASAL ALLERGY: HAYFEVER

• Allergies are increasing Internationally by some 10% annually.
  
  
• Nasal allergies affect some 20% of South Africans. It’s much underrated as regards the negative effects it has on reducing one’s quality of life.
  
• The nose is the first part of the chest. It together with the lungs is called the United Airway. Many nasal allergy cases will either have an unstable chest or definite asthma of varying degrees and the two are intimately inter-related.
• Treatment of nasal allergy can help stabilise asthma.
  
  
• Environment and diet are important. They need to be assessed. Allergy tests are reasonably accurate and can suggest treatment profiles. Similarly food allergy can be an important factor…not only in children.
  
  
• Can allergy be cured?
  
  In many cases not. Treatment remains on an environmental and medical basis.However in certain cases with limited allergen oral desensitising can be done. This is painless and lasts over roughly a 2 year period. It is in fact the only way of trying to go for a cure.

• Does surgery have any part to play in nasal allergy?
  
  Yes it certainly does.Recall that unless your nose has been examined by someone who is wearing a headlight…and that it’s the ENT Surgeon….then you have been likely poorly assessed.
  
  There’s a lot one can do surgically in selected allergy cases.Whereas it’s not curative it certainly can significantly improve your nasal airway and that in fact is what it’s all about.
  
  So when people say that surgery has no part to play in allergy…they’re talking from the view point of someone who doesn’t know what they’re talking about.

• Are the nasal cortisone sprays used so often in allergies dangerous?
  
  Absolutely not. Used correctly they’re an absolute life saver.A common mistake is not to direct the spray in the correct direction. That is the side wall of the nose.

• What do antihistamines do?
  
  In essence they’re primarily used to reduce the amount of nasal mucus. In other words to give you a more “dry” nose. Some of the new antihistamines will also improve the airway but not as much as the steroid cortisone sprays.

• Can you combine antihistamines with this steroid cortisone nasal spray?
  
  In selected cases you certainly can. Nasal allergy can also be reflected in the chest and the combination of nasal and chest symptoms is not unusual. That is literally hay fever and asthma.
  
  It’s important to treat the nose in that this can stabilise the chest and reduce the chances of allergy progressing from the nose to the chest in what is called the “allergic march”.
  
  Any allergic patients needs to be assessed by someone who’s able to examine the upper and lower airway and this requires the use of a headlight if the nose is to be correctly assessed. That’s why one suggests that the ENT group is very well positioned to do this.

AND ON PUTTING IT ALTOGETHER

Treatment consists of assessing environmental factors including food and testing to see whether the allergen can be identified. This is not always possible and then often it’s a combination.

In South Africa it’s usually house dust mite and pollens that are the main factors. Treatment is based around environmental and symptomatic control and in most of cases where medical control is not proving effective, then there’s always an option for varying degrees of surgical support.

This either by limited procedures to the lining to the nose or on occasions actual decompression of the surrounding nasal sinuses. And as regards cure, there is a group with limited allergens where oral desensitising, a two year course, can be very helpful and is literally the only way a cure is possible. This is a relatively new development.

THE THROAT: FREQUENTLY ASKED QUESTIONS:

Please remember that unless your throat examination includes the doctor being able to examine the hidden parts behind the nose and the voice box area, then significant and sometimes dangerous diseases can be missed.Just looking in the mouth gives you some information about the tongue and tonsils but nothing else.

• Does throat cancer cause pain?
  
  Quite frankly it seldom does until it’s quite advanced. Pain in the ear can be referred from the throat and by such dangerous conditions as cancerUnless cancer of the larynx (voice box) involves the actual vocal cords, symptoms of hoarseness and voice change may only appear much later.
  
  
• Should every patient with hoarseness be comprehensively examined to exclude cancer?
  
  The answer is a definitive “yes”. However, in cases where it seems to be a viral laryngitis causing hoarseness then it would be quite appropriate to wait for a couple of weeks before seeing an ENT Specialist. Viral laryngitis is self-limiting.
  
  
• Is surgery of the vocal cords in general successful in treating hoarseness?
  
  It all depends on what the vocal cord problem is. In the cases of a polyp or a nodule in many cases it is very successful. There are other conditions that are less successfully treated. In singers one is particularly cautious.
  
  
• Can speech therapy and vocal training help people with hoarseness?:
  
  Yes in many cases it certainly can. A lot of the vocal cord problems, especially in those using their voice a lot, are due to poor speech technique.
  
  
• Can hoarseness be caused by acid from the stomach?
  
  It certainly can. Reflux is a well-known cause and needs to be considered and if necessary excluded.
  
  
• Can the lump in my neck be caused by cancer inside the throat?
  
  It certainly can. This is called secondary spread. Examination of the throat as described above is an essential part of assessing any patient with a lump in the neck. There are obvious exceptions to this.

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