Airborne Allergy 
Hay fever is the common name for the symptoms of seasonal allergies, allergies to airborne pollen: runny nose, itchy eyes and throat, sneezing. It is not caused by hay, and does not produce fever. 

Seasonal allergic rhinitis happens when pollen comes into contact with the lining of the nose, eyes, or throat. The body’s immune system recognizes these foreign proteins and starts a reaction to prevent their invasion, similar to the immune response to a parasite. In some patients the immune system is overactive and identifies harmless particles as dangerous, producing an excessive reaction that actually causes inflammation. This is known as allergy and the substances causing it are allergens. This reaction does not usually appear until after several exposures to a foreign substance protein.

Causes of Airborne Allergies
Seasonal allergic rhinitis In North Texas most commonly is from ragweed in the fall, mountain cedar in winter, then elm, oak and other trees late winter/ early spring, and then grasses in the spring. Flowers rarely cause allergy because the pollen is too heavy and sticky to become airborne.

Perennial allergic rhinitis is caused by allergens present any time of year.  These include house dust mite, pet dander, chemicals, etc. These allergies can be worse in winder indoors:  the dry hot air suspends many tiny allergens such as the dried saliva from animals that lick their fur.  Cat dander has been shown to remain suspended for as long as 3 days!   Mold can be problematic in a building that has had a leak from the roof or faulty plumbing, or has over-watered house plants.  Molds count is elevated after rains, and at dusk with higher humidity. 

Delayed Food Allergies
Delayed food allergy is a minor problem for many people.  In some, the symptoms of delayed food allergy can lead to disability.  The most common symptom of delayed food allergy is nocturnal nasal blockage, with mouth breathing, dry mouth and variable snoring.  This can lead to nasal decongestant addiction and chronic use of oral decongestants, chronic sinus infection and middle ear infection, middle ear fluid.  Other symptoms include headache, wheezing, coughing spells, chest tightness, fatigue episodes, gastrointestinal disorders that include reflux and sudden diarrhea, dermatitis, intermittent joint pains, and Meniere's (fluctuating ear fullness, hearing loss, ear ringing, noise sensitivity, and dizziness).

Delayed food allergy is not related to acute food allergy, such as peanut allergy causing life-threatening emergency reaction.  This is called anaphylactic allergy and requires prompt treatment with adrenalin and a visit to a local emergency facility.  This type of allergy is tested for by doing a blood test for antibody IgE, or Immunoglobulin E.  There is typically only one anaphylactic IgE mediated food allergy.  The delayed food allergy patient typically suffers from multiple food allergies; there is no reliable blood orskin test, The "gold standard" for testing delayed food allergy has been the elimination diet followed several days later by a food challenge.  The patented Allertol protocol offers a much easier and more reliable method for testing and treating delayed food allergies.

Causes of Delayed Food Allergies
The common culprits are the common foods in a person's diet, the foods that are enjoyed the most, often to excess.  This has been called the "food allergy-addiction".  The most common foods are dairy, wheat, corn, yeast, egg, garlic, onion, tomato.  But any food or drink can be the cause for symptoms of delayed food allergy.  Common drink allergy-addictions include coffee, tea, and cola.  Also, a delayed allergy can develop from NutraSweet and other artificial sweeteners, food coloring, and other additives.  

Can Allergies Be Serious?
Allergies, both Airborne and Delayed, can predispose to sinusitis.  Immediate food allergy can be life threatening Airborne and Delayed food allergies commonly cause work/school absence, decreased mental and physical efficiency, fatigue and a poor sense of well-being.  Billions of dollars are spent each year on allergy treatment; billions are lost from missing work.

Why See an ENT Doctor? Chances are good that your allergy can be properly diagnosed and treated, preventing further disease and suffering.   For example, the doctor can determine the cause of nasal obstruction and offer appropriate treatment, medical and / or surgical.   Seldom is a deviated septum the cause for symptoms of nasal blockage;  this can be easily determined by physical exam and by taking a complete history:  if the nasal blockage rotates from side to side, and does not just bother one side of the nose, a delayed food allergy is the likely cause, and not deviation of the nasal septum.  Chronic sinus infection can be the cause of persistent nasal congestion and can be diagnosed by history, physical, culture and CT scan. 

Treatment
SLIT, sublingual immunotherapy, is a cost-effective treatment that has been approved by the FDA.  In Europe for many years allergy drops have been the preferred method of safe allergen immunotherapy.  Increasingly in the US, sublingual allergy treatment is commonly practiced.  Unlike allergy shots, there have been no reports of anaphylactic death from sublingual allergy treatment.  And unlike shots, the treatment is self-administered, without the need for observation in a doctor's office, there is no need for work / school absence, for frequent trips to receive allergy shots.  And because drops offer a pain-free alternative to allergy shots, SLIT is ideal for children and those with needle phobia, leading to fewer "drop-outs", a much greater compliance leading to completion of the course of immunotherapy, usually several years. 

The cost of SLIT is often less than the cost of medications, time away from work/school, traveling expenses, and frequent doctor visits.  Many patients take advantage of tax-deferred "Health Savings Accounts" and "Flexible Spending Accounts" in which out-of-pocket medical expenses are paid with pre-tax dollars. 

Of course avoidance and medications should be tried before considering immunotherapy, however, only immunotherapy can alter the course of the allergic march from one symptom to another.  Avoidance and medications offer only a temporary partial relief.  So suffering from allergies need not continue when medical management is found to be inadequate. 

Airborne Allergy Prevention
When the pollen count is expected to be high, keep windows closed, and consider taking antihistamine such as Allegra in AM and Zyrtec bedtime.  Expect mountain cedar to be high on warm windy winder days.

Use a face mask when mowing, and afterwards be sure to drop clothing in the washer and bath to remove pollen. 

To decrease indoor allergens, change air filters every 1-3 months, avoid indoor plants, and avoid furry pets.

Avoid feather pillows, feather bedding; mite proof covers are ideal for all bedding including the mattress.  Running pillows through a dryer cycle periodically can lower mite populations.

Remember, if you find yourself having to sleep with the head elevated, keep water by the bedside, wake with dry mouth from mouth breathing, snore some nights, you likely suffer from delayed food allergies and should keep a diet diary for symptoms, and consider evaluation and treatment with Allertol.  Nasal decongestant spray addiction is to be avoided. Nasal strips offer only partial temporary relief.  Antihistamine-decongestants are of little help for delayed food allergies.

Sudden paralysis of one side of the face, either partial or complete, is commonly due to swelling of the facial nerve that goes to the facial muscles of expression, to the salivary glands and lacrimal (tear) glands, to the tongue for taste,  and to the muscle in the middle ear that pulls tight the stapes bone. 

The facial nerve can be affected anywhere along its path from the base of the brain, through the opening in the skull, behind the ear drum, then from under the earlobe through the parotid salivary gland.  The nerve function can be impaired by tumor of the brain, of the inner ear, or of the parotid gland.  Trauma and infection can also affect nerve function. 

Bell's Palsy is thought to be due to infection of the facial nerve from a virus.  This causes the nerve to swell, and because the nerve passes through tiny bony passages, the swelling impairs blood supply.  This lack of blood supply can result in temporary or permanent loss of facial nerve function. 

Evaluation of facial nerve palsy may include audiogram, balance testing, tests for tear production, and CT or MRI scans to look for tumor of the inner ear or brain, middle ear growth, evidence of trauma. Electrical stimulation tests can be done to determine the degree of nerve damage.

Treatment commonly includes steroid to reduce nerve swelling, antiviral drugs, and sometimes antibiotic in cases of middle ear infection or Lymes Disease.  Surgical facial nerve decompression is seldom indicated.  Protection of the eye from drying is important and can be accomplished by using eye drops, lubricant, and eye patch to close the eye.  In the rare instances of permanent facial paralysis it is sometimes necessary to help the eyelid close by placing a weight in the eyelid.  Sometimes a nerve transposition procedure is needed.  

A cholesteatoma is a skin growth behind the eardrum and into the middle ear. It is usually due to retraction of the ear drum or tympanic membrane, which causes an in-growth of the skin of the eardrum, producing a cyst from collection of dead skin cells. This cyst can grow and damage the middle ear bones, penetrate into the inner ear resulting in hearing loss, dizziness, and/or facial paralysis. Ear drum retraction can be from Eustachian tube congestion from allergy and sinus infections. Rarely, a person can be born with a cholesteatoma, usually presenting in childhood. Persisting earache, ear drainage, ear pressure, hearing loss, dizziness, or facial muscle weakness are indicators of serious impending complication of cholesteatoma and the need for urgent evaluation and treatment. Symptoms Include drainage from the ear, ear fullness, hearing loss, dizziness, and facial weakness. Rarely the infected cholesteatoma can produce meningitis, brain abscess and even death.  Treatment Ear surgery provides definitive care, often with a "second look" a year later. The infected cholesteatoma requires antibiotic ear drops and careful cleaning of the ear, sometimes under a microscope. CT scan is sometimes needed to show the extent of the skin cyst. Following surgery it is not uncommon to need visits to keep the mastoid cavity clean of dead skin cell debris to help prevent mastoid cavity infection. 

Unsteadiness, almost Dizzy...
Many suffer from loss of balance. Some lose balance from tripping over a rug or something on the floor. Some fall trying to walk on icy concrete. These are examples of common loss of balance, but these become much more common when there is a physical problem that adds to unsteadiness such as diabetic neuropathy in which the feet have less sensation, impaired visual acuity such as from cataracts, loss of inner ear function such as from aminoglycoside antibiotics, stroke, inner ear disorders such as Meniere's and Benign Positional Vertigo, poor blood flow to the head from narrowed vessels, dehydration, or heart failure. In some, hyperventilation can cause unsteadiness and even fainting. Sometimes spinal cord compression from spinal stenosis decreases the sensation from the legs and feet to diminish, leading to balance problems.

The falls from balance problems can result in serious and even life threatening injuries such as skull fracture, bleeding into the brain, hip fracture.

Falls can be partially prevented by seeking proper medical care from the primary care physician or internal medicine doctor. Remaining physically active is of utmost importance. Following a good diet, not smoking and controlling blood pressure are important. Checking blood pressure at home regularly and watching for pressure that is too high as well as too low is important. Use of a walker or four point cane can be of help.

Dizziness
Most people have trouble describing loss of balance but commonly lightheaded and unsteady are used.

Vertigo
Vertigo is a spinning sensation, much like getting off a Merry-Go-Round.

Motion Sickness
This form of dizziness is sometimes severe enough to induce nausea and vomiting and occurs at some time for most, especially after experiencing the rocking back and forth in a boat. For some, the dizziness occurs AFTER getting off of a cruise ship; this is called Mal de Debarquement, and can last weeks to months!

Balance
Balance is simply the absence of dizziness. Several areas contribute to balance:

• Vision
• Inner ear labyrinthine system
• Skin sensation especially of the feet Joints and muscles especially of the neck
• Brain and spinal cord process signals from parts of the body

Some causes for unsteadiness, dizziness, vertigo

• Medications, especially blood pressure medicine
• Smoking (nicotine)
• Alcohol --> effect on brain, inner ear, coordination, dehydration, etc.
• Dehydration --> dizzy with standing
• Debility, such as a person bedridden
• Diabetes
• Anemia
• Heart failure, narrowing of arteries, heart irregularity --> poor blood flow to brain, "TIA" or transient ischemic attack lasting a few minutes, even stroke
• Anxiety with hyperventilation
• Seizure
• Head injury, leaking of spinal fluid, brain injury etc.
• Viral infection of the inner ear
• Middle ear infection, cholesteatoma (cyst) invading the inner ear, mastoiditis
• Tumors of the brain in her ear
• Perilymph fistula, fluid leaking from the inner ear into middle ear
• Multiple sclerosis, other neurological disorders
• Sexually transmitted diseases
• Ménière's, inner ear swelling from delayed food allergies
• Benign positional vertigo, loose microscopic particles in the inner ear
• Migraine headache

Diagnosis
See your primary care-giver regularly for a medical evaluation, and when dizziness occurs, to help rule out general medical problems such as hypertension or diabetes.

Your ENT provider will obtain a thorough history of frequency and duration of dizziness, whether it occurs with movement/ear fullness/ringing/noise sensitivity. The history and a basic physical exam, sometimes with tests of balance, may point to the likely diagnosis. Sometimes it is necessary to obtain audiogram, MRI scan of the head, and neurological evaluation.

Treatment
Diagnosis indicates treatment. Treatment confirms diagnosis. Res Ipsa Loquitur.

Benign positional vertigo is the cause for the majority of positional dizziness lasting less than 10 seconds and can be treated with high success using the Epley maneuver.

Ménière's is suggested by the presence of intermittent random dizziness of varying duration and intensity, often associated with intermittent tinnitus, ear fullness, and noise sensitivity. Using the Allertol® protocol for testing and treatment of delayed food allergies has been effective in the majority of cases.

Viral inner ear infection is treated with medications to suppress dizziness, maintain physical activity as safely possible and use of “tincture of time”; this dizziness usually resolves within 4-6 weeks.

Motion sickness can be more easily prevented than treated. Pre-medicate with Dramamine one hour before boarding a boat or riding in a plane, train, and automobile. Eat lightly. Look at distant landscape to stay oriented. If there is a cruise planned, ask for a "scopolamine patch" to place behind the ear and suppress dizziness up to 3 days.

CAUTION: Visit your emergency facility for sudden onset of severe vertigo accompanied by fever, stiff neck, seizure, head injury, "worst headache ever", slurred speech, numbness or weakness of arm/leg, heart irregularity, chest/neck/arm pain, shortness of breath.

The Eustachian Tube Connection
The Eustachian tube connects the upper throat with the middle ear space, the small pocket of air located behind the eardrum.  Air travels through the tube frequently with swallowing, producing a small “click”.   To keep the middle ear pressure equalized during airplane descent it is sometimes recommended to chew gum which causes frequent swallowing.   

Most of us have experienced sudden equalizing of middle ear pressure described as "popping the ear" when forcefully blowing the nose.  When this happens, the eardrum quickly snaps out, often with temporary discomfort and ear fullness because of the positive air pressure.  After a few hours, the middle ear pressure normalizes, as the lining of the middle ear slowly absorbs the air.  If frequent swallowing does not equalize the middle ear pressure, it may be necessary gently blow against a pinched nose. 

Airplane Travel
As the airplane ascends, the pocket of air behind the eardrum expands, putting positive pressure on the eardrum.  Often this pressure is released as air passes from the middle ear through the Eustachian tube and into the throat.  This seldom causes any ear pain.  Frequent swallowing will help equalize this positive air pressure. 

When the airplane begins its descent, the eardrum begins to be “sucked in” or retracted from negative middle ear pressure.  This produces ear discomfort and a blocked ear sensation with muffled hearing, and eventually if the negative pressure is not equalized, may result in intense ear pain, and in some cases, eardrum perforation and bleeding. 

Diving (Scuba)
Similar to descent in airplane, when the scuba diver descends, the middle ear space contracts with negative pressure and the eardrum is pulled inward unless the diverticular equalizes the middle ear pressure.  Unlike the person on an airplane, the scuba diver can "change altitude",  and swim back toward the surface of the water and decrease the negative middle ear pressure, releasing blockage of the Eustachian tube, allowing more successful equalizing of middle ear pressure.

Persisting Blocked Ear: Middle Ear Fluid
If middle ear pressure is not equalized during descent, this suction pulls fluid from thelining of the middle ear.  This middle ear fluid is serum from tiny blood vessels in the middle ear (serous otitis media).  Sometimes the vacuum is so strong that one of these vessels bursts and blood then collects behind the ear drum (hemotympanum). Ouch! 

Causes for Eustachian Tube Blockage
·        Rapid pressure changes, such as diving to bottom of a pool, or rapid airplane descent
·        Upper respiratory infection such as the common cold
·        Chronic sinus infection
·        Allergies
·        Adenoid enlargement/infection
·        Chronic Eustachian tube narrowing from childhood
·        Infancy because of frequent upper respiratory infection

What To Do
For mild Eustachian tube blockage, simply swallowing frequently often does the trick.  Is important to remember that when people fall asleep, they quit swallowing.  You can ask the stewardess on the airplane to awaken you during descent.  Also, remember that the infant that falls asleep easily on the airplane during ascent, should be awoken when the airplane reaches altitude, and remain awake during the entire descent, and encourage frequent swallowing by using a pacifier or a bottle.  For toddlers, a lollipop may help. 

For moderate Eustachian tube blockage, when swallowing and staying awake during descent does not help, it may be necessary to gently unblock the ears.  Pinch the nostrils closed then the air in the mouth is pushed behind the palate and into the Eustachian tubes.  It is best to practice this (Valsalva maneuver) before it is needed, before the airplane flight, and avoid forcefully popping in the ears.  Unfortunately, if one falls asleep, does not swallow during descent, especially with upper respiratory infection or allergies, they may be unable to equalize the middle ear pressure.  So, prevention is key.

For severe Eustachian tube blockage, there is usually a history of mild–moderate blockage/chronic Eustachian tube problems.  About an hour before descent, antihistamine decongestant and nasal spray decongestant may be of benefit, but limit use if there is high blood pressure.  If there is an active viral upper respiratory infection or sinus infection, consider if possible flying on another day.  Sinusitis should be treated with appropriate antibiotic, and if tolerated, oral steroid.  Some frequent fliers with Eustachian tube problems require placement of ventilating tympanostomy tubes, but this is rather rare.  Usually by treating allergies and chronic sinus infection, the Eustachian tube blockage improves.

When the ears will not unblock, it may become necessary to see a physician who uses a Politzer device or equivalent to push air from the nose into the Eustachian tube with positive air pressure.

Knowing what to do in case of Eustachian tube blockage during airplane descent or scuba diving descent is important, but more important is prevention.  Happy flying/diving!

The average person may inhale millions of fungal (mold) spores in a single day!  Just one of these spores can become trapped in the nasal passages, and produce a fungal sinus infection. 

This form of chronic sinusitis develops over months to years, and is usually seen in an adult with allergy-induced chronic sinus infection, and is often combined with a bacterial infection.

In extremely rare cases the fungus becomes "invasive" and can move into the face, eye and brain.  This happens most often when the immune system is compromised, from chemotherapy or poorly controlled diabetes.  A mold called “Mucor” is often responsible.  This mold infection can be life-threatening, rapidly advancing over a matter of hours to days.  Treatment requires antifungal intravenous medication and emergency surgery to remove infected tissues.  This unusual form of fungal sinus infection will not be further discussed here.

“NON-INVASIVE” FUNGAL SINUSITIS

SYMPTOMS

• Chronic nocturnal nasal blockage and waking with dry mouth
• Sinus infection that persists after repeated antibiotics
• Mucus is thick and “gummy” and difficult to blow from the nose
• Steroid such as Prednisone may “release” the fungal mucus blobs

DIAGNOSIS

• History and physical exam findings can suggest the diagnosis
• Fiber optic exam of nasal passages can reveal the typical fungal mucus
• Nasal culture may reveal unusual bacteria such as pseudomonas and staph
• Nasal culture is sometimes positive for common airborne fungus such as aspergillus
• Sinus CT scan usually reveals typical mineral deposits within the fungal mucus

THERAPY

• When only a few sinuses are involved, a sinus procedure often is curative
• When several sinuses are infected, especially with large numbers of polyps, “Allergic Fungal Sinusitis” or AFS is suspected, and is managed with surgery and medication to reduce inflammation caused by the fungus, such as the steroid prednisone.
• Treatment nasal obstruction from delayed food allergy can be effective, by elimination from the diet of common culprits such as onion.

Allertol® has been used successfully to manage delayed food allergy induced nasal congestion, and help prevent recurrence of fungal sinusitis.

Any change in the voice that lasts 3 weeks or more needs medical attention, especially in a tobacco user, and person with chronic reflux / heartburn.

DIAGNOSIS
A fiber optic exam is usually done for persistent hoarseness, sometimes a CT scan. These studies can reveal vocal cord nodules, a growth, a neurological problem such as a paralyzed vocal cord or quivering vocal cords, inflammation and swelling associated with reflux or infection or allergies.

TREATMENT

REFLUX LARYNGITIS

• GERD (gastroesophageal reflux disease) can damage the larynx (voice box) and the entire throat from the acid and enzymes that try to digest the throat.

Treatment options include:

• diet changes such as no late meals, no garlic / onion
• elevation of head of bed, or sleep in recliner
• acid reducing medications recommended by a health care provider (chronic use of acid reducing medications can result in poor calcium absorption, weak bones)

VOCAL CORD NODULES

• Small nodules of BOTH vocal cords is commonly seen with singers and screamers  Treatment options include: voice rest, speech therapy, surgery to remove the nodules
• A solitary nodule of the vocal cord usually requires excisional biopsy

LARYNGEAL TUMOR

• Benign and cancerous growths of the larynx require biopsy and often CT scan that direct treatment which can include:
• For cancer: excision of tumor, radiation therapy, chemotherapy, and reduce damage from reflux, smoking cessation
• For polyps, cysts, warty growths: excisional biopsy and careful follow-up exams

PARALYZED VOCAL CORD

• Treatment options are directed by neurological exam and evaluation for tumors along the pathway of the vocal cord nerve called the “recurrent laryngeal nerve”, which on the left side passes from the brain, down the neck into the chest where it passes around the aorta, and then back up to the larynx. 
• When one vocal cord is paralyzed, in addition to hoarseness with a “breathy voice”, there can be choking on liquids or food, called “aspiration” and require special diets, and sometimes a feeding tube.  The vocal cord can be injected or have surgery to move the paralyzed vocal cord closer to the normal vocal cord.
• When both vocal cords are paralyzed, this can result in shortness of breath and noisy breathing called stridor; a tracheostomy may be necessary.
• Treatment can involve management of problems found along the course of the laryngeal nerve: 
• trauma including surgery of the heart, chest, thyroid, neck
• intubation (placing a tube in the airway) for anesthesia
• tumors such as cancer of the lung, larynx, thyroid, neck

SPASTIC DYSPHONIA (spasmodic dysphonia)

• This is a neurological disorder in which the vocal cords quiver uncontrollably, causing a characteristic halting speech.  Treatment options include
• Speech therapy
• Surgery
• Botox

Meniere’s Disease: An Inner Ear Allergy
Meniere’s disease is caused when the fluids of the inner ear increase, putting pressure on the delicate membranes that provide hearing and balance.  This increase in inner ear fluid pressure is commonly associated with a delayed food allergy. It occurs in any age group, but most often in ages 20-50. 

Symptoms

• Fluctuating ear fullness and muffled hearing / sound distortion, especially for low pitches
• Recurrent tinnitus:  buzzing, clicking, popping, loud roaring, or ringing
• True vertigo episodes with nausea and even vomiting, sometimes associated with tinnitus and ear fullness.
• Recurrent balance problems
• Sensitivity to certain sounds, often low pitched sounds such as road noise, and a low pitched musical sound or voice.

Although hearing loss early in the disease is intermittent, eventually becomes permanent, and can involve all frequencies. Meniere’s disease can produce disability, especially from dizziness. 

Diagnosis
A complete history is obtained regarding frequency of ear fullness, intermittent tinnitus, dizziness, hearing loss and noise sensitivity.  Also, it may be important to note a trauma to the inner ear from head injury or loud noise (acoustic trauma) prior to the onset of Meniere's symptoms. Some cases of Meniere's are precipitated by excessive salt intake and fluid retention.  

An audiogram often detects a sensorineural hearing loss, particularly in the lower frequencies.  Inner ear and balance tests can be done but are seldom necessary.  An MRI scan of the head with attention to the inner ear is done in some cases, especially when the onset of symptoms is abrupt, or gradually worsening, and there is little if any fluctuation of symptoms.

Therapy
Traditional treatment includes methods of lowering inner ear fluid pressure by low salt diet and diuretics; this offers temporary partial relief at best and does little to halt the progression of the disease.  Similarly, medications to control vertigo have no effect on the overall disease process.  Sedatives and psychiatric counselling for the dizziness and tinnitus have been tried.

In a study of 50 patients over several years, the symptoms of hearing loss, dizziness and tinnitus have improved in the majority of patients with Allertol® multi-food SLIT. Because of the success using Allertol®, very few patients have had to change diet or lifestyle and none have required inner ear shunt or destructive inner ear surgery.

NOISE TRAUMA
Noise-induced hearing loss and tinnitus can be permanent and can occur from

• single loud noise exposure, such as a firecracker or gunfire
• short term noise exposure such as rock concert
• chronic noise exposure such as truck driving or working with machinery, or being married. 

There can be some return of hearing for up to 3 months after noise trauma, then the loss is permanent. A frog or a bird has the ability to recover from noise trauma.   

Prevent noise trauma with ear plugs or muffs if prolonged noise exposure such as mower or tractor.  Use double protection with plugs and muffs around loud noise such as chainsaws, weed eaters, guns.  

Antioxidant vitamin and steroid have been shown to prevent permanent damage from noise trauma. 

Avoiding noise is the most direct way of preventing noise trauma, but is often not an option.

HEARING LOSS
Noise trauma damages high frequency hearing, especially at 4000 cycle per seconds, a pitch similar to the beep of a watch or computer.  Continued noise trauma eventually can damage all pitches.  A high frequency hearing loss makes it difficult to understand soft voices, especially in background noise such as restaurants.   This understanding problem is frustrating because the low pitched vowel sounds (A E I O U) are understood but the high pitched consonant sounds are not. This leads to the common complaint: "I can hear, I just can understand." 

TINNITUS
The tinnitus from noise trauma is usually high pitched and constant.  The ringing seems louder when going to sleep, when it’s quiet.  Some people run a fan in the bedroom to "mask" the ear noise.  Often a properly selected hearing aid will also mask the tinnitus. 

Abnormal ear noise  causes include:

• ear canal blockage from wax, infection, foreign body
• middle ear fluid, infection, bone fixation or damage, skin cyst, Eustachian tube blockage
• ear drum perforation
• inner ear problems such as: noise exposure, advanced age, hereditary, Meniere's,  aspirin and other anti-inflammatories, strong intravenous antibiotics, tumors, ear / brain trauma
• circulatory problems such as occur with:  high blood pressure, diabetes, thyroid problems, aneurysm, abnormal connection between artery and vein called AV fistula, heart valve noise
• miscellaneous causes for ear noise:  insect in the ear, auditory hallucinations such as bipolar person "hearing voices", twitching middle ear muscle similar to eyelid twitching, sleep deprivation, hearing aid "feedback"

EVALUATION AND CARE
Shea ENT team of experienced health care providers, audiologist and otolaryngologist work together to evaluate the multiple different causes for tinnitus and hearing loss with a thorough history, physical exam and audiogram.  Sometimes it is necessary to obtain CT, MRI, vascular studies.  Intermittent ear fullness, ear noise, dizziness, low frequency hearing loss found on audiogram suggest Meniere's which is evaluated with Allertol method testing for delayed food allergies.

Otitis Media
Otitis media is infection of the middle ear, the air cavity behind the ear drum. It is the most frequent diagnosis of children in doctors’ offices, and is the most common cause of hearing loss in children and can be associated with speech and language problems leading to learning disability.  The hearing loss comes from poor vibration of the ear drum from Eustachian tube congestion and the negative pressure or vacuum that is created.  When one pops the ear by trying to blow the nose against pinched nostrils, a positive pressure is created. 

Blockage of the Eustachian tube during a cold, allergy, or upper respiratory infection and the presence of bacteria or viruses lead to the accumulation of fluid (a build-up of pus and mucus) behind the eardrum. This is the infection called acute otitis media. The buildup of pressurized pus in the middle ear causes earache, swelling, and redness. Since the eardrum cannot vibrate properly, you or your child may have hearing problems.

Sometimes the eardrum ruptures, and pus drains out of the ear. But more commonly, the pus and mucus remain in the middle ear due to the swollen and inflamed Eustachian tube. This is called middle ear effusion or serous otitis media. Often after the acute infection has passed, the effusion remains and becomes chronic, lasting for weeks, months, or even years. This condition makes one subject to frequent recurrences of the acute infection and may cause difficulty in hearing.

Symptoms
In infants and toddlers look for:

• Pulling or scratching at the ear, especially if accompanied by the following
• Hearing problems
• Crying, irritability
• Fever
• Vomiting
• Ear drainage

In young children, adolescents, and adults look for:

• Earache
• Feeling of fullness or pressure
• Hearing problems
• Dizziness, loss of balance
• Nausea, vomiting
• Ear drainage
• Fever

Diagnosis
During an examination, the doctor will use an instrument called an otoscope to assess the ear’s condition. With it, the doctor will perform an examination to check for redness in the ear and/or fluid behind the eardrum. With the gentle use of air pressure, the doctor can also see if the eardrum moves. If the eardrum doesn’t move and/or is red, an ear infection is probably present.

Two other tests may be performed for more information. An audiogram tests if hearing loss has occurred by presenting tones at various pitches. A tympanogram measures the air pressure in the middle ear to see how well the Eustachian tube is working and how well the eardrum can move.

Treatment
The doctor may prescribe one or more medications. It is important that all the medication(s) be taken as directed and that any follow-up visits be kept. Often, antibiotics to fight the infection will make the earache go away rapidly, but the infection may need more time to clear up. So, be sure that the medication is taken for the full time your doctor has indicated. Other medications that your doctor may prescribe include an antihistamine (for allergies), a decongestant (especially with a cold), or both.

Sometimes the doctor may recommend a medication to reduce fever and/or pain. Analgesic eardrops can ease the pain of an earache. Call your doctor if you have any questions about you or your child’s medication or if symptoms do not clear.

Most of the time, otitis media clears up with proper medication and home treatment. In many cases, however, your physician may recommend further treatment. An operation, called a myringotomy may be recommended. This involves a small surgical incision (opening) into the eardrum to promote drainage of fluid and to relieve pain. The incision heals within a few days with practically no scarring or injury to the eardrum. In fact, the surgical opening can heal so fast that it often closes before the infection and the fluid are gone. A ventilation tube can be placed in the incision, preventing fluid accumulation and thus improving hearing.

The surgeon selects a ventilation tube for your child that will remain in place for as long as required for the middle ear infection to improve and for the Eustachian tube to return to normal. This may require several weeks or months. During this time, you must keep water out of the ears because it could start an infection. Otherwise, the tube causes no trouble, and you will probably notice a remarkable improvement in hearing and a decrease in the frequency of ear infections.

Otitis media may recur as a result of chronically infected adenoids and tonsils. If this becomes a problem, your doctor may recommend removal of one or both. This can be done at the same time as ventilation tubes are inserted.

Delayed food allergy commonly causes nasal congestion that leads to sinus infection and otitis media.  Allertol sublingual immunotherapy or SLIT can help reduce the frequency of sinus infections and associated middle ear infections.

The Problem: Ear Canal Moisture and Q-Tips
Ear canal infection is the most common cause of ear pain.

The primary cause of ear canal infection is missing protective layer of wax from chronic Q-tip use or other items not meant for the ear canal, allowing moisture and germs to collect in the ear canal, creating ear canal swelling and inflammation. 

With bacterial infection there is intense ear pain, sometimes ear canal drainage and decreased hearing.  With advanced ear canal bacterial infection there can be redness and swelling of the entire ear called cellulitis. The pain and infection can extend into the neck where lymph nodes can become tender and swollen. 

Fungal infection produces ear canal itching and pressure with muffled hearing.  Sometimes this fungal infection involves the tympanic membrane and can even cause painful ulcerations and lead to perforation!  This infection does not spread onto the outer ear, and does not produce fever or neck pain.

Prevention: put nothing smaller than the elbow in the ear!
The ear canal is designed to clean itself: the skin cells of the ear drum and canal migrate slowly to the edge of the ear canal. In fact it takes about a month for a dead skin cell from the center of the ear drum to make its way to the outer edge of the ear canal.  So simply using a washcloth at the edge of the ear canal is sufficient to clean the ear.  Often, it is tempting to use a Q-tip to remove water from the ear canal, but unfortunately, the thin protective layer of cerumen is removed with the water.  The cerumen has antibacterial and antifungal properties! 

So, what to do after the Q-tip is no longer used: Simply place olive oil or mineral oil in the ear canal prior to bathing/swimming at least weekly, and some cases daily.  This oil sheds the water from the canal.  Also, when water gets in the ear canal and cannot come out, placing a 50-50 mixture of middle ear and Everclear® grain alcohol will remove the water, and the vinegar will suppress growth of germs.  (Rubbing alcohol should be avoided, it may contain up to 30% water!). 

CAUTION: Never place any solution in the ear canal unless directed by your physician if there is a history of ear tubes, perforation of the eardrum, ear ache, ear trauma, bleeding or discharge.

Your ear nose and throat doctor may prescribe a steroid alcohol drop to be used after bathing or swimming to suppress itching and the desire to use a Q-tip.

Wax impactions should be removed regularly, by medical professional, not with a bobby pin!  “Ear candling” is both dangerous and ineffective!    

Treatment
Once the damage is done from ear canal manipulation and leaving moisture in the canal, usually the services of an ear nose and throat professional is required, such as a patient and experienced nurse or medical assistant.  Ear canal irrigations and careful suctioning of debris and moisture from the canal/tympanic membrane will allow topical medication to reach the infection.

Bacterial infection usually requires antibiotic steroid eardrop.  When the ear canal is swollen shut, it is necessary to place a sponge ear wick to allow the canal to open and drops to enter.

Fungal ear canal infection is best treated by frequent cleaning of the ear canal and application of antifungal steroid powders.  The canal may need to be cleaned of fungal debris every few days before the antifungal powder reaches the deep set fungal infection. 

Whether bacterial or fungal infection of the ear canal is present, it is important to keep moisture from the ear.  This can be simply done by tipping the head forward in the shower, and never attempting to introduce shower water into the canal.  Once the ear canal infection has resolved, and there is no debris remaining in the canal or on the eardrum, olive oil can be used prior to bathing/swimming. 

LOCATION
Tonsils are located below the soft palate (there is also a set of tonsils hidden at the base of the tongue called lingual tonsils).  The adenoid is hidden above the palate, behind the nasal passages.  

WHAT THEY DO
Tonsils and adenoid are part of the immune system, similar to lymph nodes.  They are part of a ring of tissue in the throat that makes antibody "A" that disables bacteria and viruses.  When bacteria such as strep or virus such as "mono" overwhelm the tonsils and adenoid they can become infected:  tonsillitis and adenoiditis, and enlarged: tonsil hypertrophy and adenoid hypertrophy.

SYMPTOMS
Adenoid or tonsil problems can produce nasal blockage, "nasal” voice, and pain/stiffness in the back of the neck, postnasal drainage, ear ache, swallowing difficulty, snoring and even sleep apnea.  Sleep apnea can cause sleepiness, depression, high blood pressure and heart disease, including "cor pulmonale", a form of heart failure from chronic low oxygen levels.

Adenoid infection is responsible for up to a third of ear infections and Eustachian tube problems.  Nasal obstruction from large adenoid can cause chronic mouth breathing, crooked teeth and long facial appearance. 

STREP THROAT
"Strep throat" is most commonly due to strep infection of tonsils, but also can be due to strep of the adenoid, or strep sinus infection.  Complications of strep throat include: 

• peritonsillar abscess (pus escaping around the tonsil)
• neck abscess
• rheumatic fever (inflammation of heart, joints, skin, brain)
  In WWII, heart murmur from valve damage due to strep was a common reason for 4F classification and medical deferment! Valve damage occurs in about half the cases of rheumatic fever. Valve damage can eventually lead to heart irregularity (atrial fibrillation), infection of the valves, and heart failure. Rheumatic fever causes a quarter of a million deaths each year worldwide!
• kidney inflammation (glomerulonephritis)
• septic shock and death occurs rarely (Jim Henson of the Muppets) 
• Pediatric Autoimmune Neuropsychiatric Disorder from Strep (PANDAS)

HALITOSIS
Chronic bad breath can occur, from soft smelly "stones" or plugs that form deep in the pockets of the tonsils, and sometimes the adenoid.   When this debris blocks a pocket, a tonsil abscess can result and produce severe throat pain, inability to swallow, ear ache, "hot potato" voice, and airway obstruction.

TUMORS
Tonsil enlargement without sore throat can indicate tonsil cancer, and usually occurs in tobacco users, especially with acid reflux.  Eventually this life-threatening growth causes ear pain, trouble swallowing, and spread to lymph nodes.  Adenoid tumors are rare.

EVALUATION:
Medical history and physical exam is sometimes all that is needed.  Lab tests may include throat cultures, blood tests for strep titers, white blood cell count, and mononucleosis.   CT scan may be needed to evaluate a tonsil tumor, and when an abscess is forming around the tonsil (peritonsillar abscess).   Fiber optic exam sometimes is needed.

TREATMENT:
Tonsillectomy / adenoidectomy is done for recurrent infection or hypertrophy that persists after medical management.  Peritonsillar abscess is drained during tonsillectomy.    Infectious mononucleosis usually responds to use of steroid such as prednisone, but can lead to chronic tonsillitis.  Tonsil tumor requires tonsillectomy for diagnosis, and radiation therapy for cancer.

AGE CONSIDERATIONS
Under the age of 3 and certainly under 30 pounds (Dr. Shea's 3 to thirty rule) the risk of complications increases to as much as 30%, usually from undetected bleeding blocking the airway.   If for some reason tonsil surgery is required under age 3 or under 30 pounds, the risks must be fully understood, and the vital signs monitored closely in a hospital.  Under age 3 a "partial" tonsillectomy is usually done, to lessen risk of bleeding and decrease postop pain.

"Preschool" age children seem to fare the best, before the tonsils become "scarred" in place.

Teenage and adult tonsillectomy can be associated with severe sore throat, from chronic tonsillitis.

Adenoidectomy is considered after one year of age.

"PARTIAL" TONSILLECTOMY
Incomplete removal of the tonsils, leaving a rim of tonsil tissue, is not commonly done.  It is usually done in children under 3 years of age to decrease bleeding risk and pain.  Partial tonsillectomy is sometimes done when there is a history of easy bleeding, and for cases of sleep apnea.  The problem with partial tonsillectomy is that the tonsils can "re-grow", and later require completion tonsillectomy. 

TONSILLECTOMY PROCEDURE:
Under general anesthesia, a retractor device puts pressure on the upper and lower teeth to open the mouth, a bright light used to visualize the tonsils which are pulled away as a device called a "Coblator" is used to free the tonsil, and used to coagulate vessels.  Some of the tonsil capsule is left at the bottom of the tonsil to protect vessels and nerves, and reduce bleeding and pain.  This small amount of residual tonsil does not later re-grow.

ADENOIDECTOMY PROCEDURE:
The adenoid is removed with the "Coblator" when inflamed, enlarged, or when debris is noted.  The adenoid is also inspected for any tumor or vascular growth. 

Before surgery

• avoid aspirin products, ibuprofen, Advil, Aleve 2 weeks before and after surgery
• ask for medicine to treat postoperative nausea if this has happened in the past
• if taking any blood thinner medications, stop a week before and after the surgery
• advise if any personal or family history of bleeding problems or trouble with anesthesia
• antibiotic may be prescribed to start a week before surgery and 3 days after
• prednisone may be prescribed to start five days before surgery
• after midnight before surgery, nothing by mouth including water
• bring a list of regular medications, allergies to medicines,  past surgeries and medical problems for the anesthesiologist
• call and reschedule if there is cough or fever the week before surgery
• children do best when they receive positive information and support.  For example explain there will be a sore throat especially with swallowing and even talking, but this will improve after several days with drinking and eating.   Allay fears of anesthesia and the intravenous line; for younger children this will be placed after they receive some "laughing gas".  Do not tell them they are going to "be put to sleep"...  At least one child had a pet that was "put to sleep", then was told the same thing before his surgery!  (He was very happy when he woke up in recovery!!)
• remember, children are scared when they detect fear in the family members; they do better in surgery and postop when they are surrounded by confident and positive family members

After surgery

• drink liquids throughout the day to maintain good hydration; if urine scant/dark, if dizzy upon standing, if veins in hands become flat....increase fluid intake
• the day of surgery, start eating solid food and resume regular medications, start pain medicine
• expect sore throat to increase until about 7 days after surgery, then taper the next week
• postoperative nausea from the anesthesia happens rarely, is usually gone by the next morning
• for continued nausea, stop narcotic pain medicine and use plain Tylenol
• constipation from narcotic pain medicine can be prevented by prune juice or stool softeners, and staying well-hydrated
• the adenoidectomy site can develop a thick white "scab" layer that can produce postnasal drainage, a stiff back of the neck, and a bad smell...  these problems can be lessened by staying hydrated, using saline nasal or colloidal silver spray
• postoperative infection of tonsil or adenoidectomy surgery sties can occur, and need antibiotic
• postoperative coated tongue and throat from candida can occur and prolong recovery time; anti-yeast medication may be prescribed to prevent / treat this common problem

Bleeding

• there is a small risk of postoperative bleeding
• decrease risk by staying well-hydrated and eating at least a few bites of solid food
• decrease  risk by avoiding dry mouth and throat; keep water at bedside
• bleeding can occur at any time for two weeks
• avoid vigorous activity or getting overheated 2 weeks
• remember, no aspirin or aspirin products, Advil, Aleve 2 weeks before and after surgery
• children should be observed for nighttime cough that could represent bleeding
• cold water gargles may be used to control bleeding
• contact the surgeon or emergency facility for bleeding

Please discuss any questions, concerns or suggestions with a member of your healthcare team.

The skin of the outer part of the canal has special cerumen or wax glands. The ear wax serves several purposes including keeping water from collecting in the ear, and has antibacterial and antifungal properties.  Many use a cotton swab or other devices to clean this protective layer from the ear, predisposing to wax impaction, hearing loss, tinnitus, ear fullness or ear ache, fungal and bacterial ear canal infection, swimmers ear, and even perforation of the ear drum. When left alone, the ear canal clears wax and dead skin cells by the skin slowly migrating from the surface of the eardrum to the edge of the ear canal.

Treatment
Home remedies are not suggested, as they can result in worsening of the wax impaction and damage to the ear.  Over the counter ear drops designed to help remove wax from the ear are next to useless, and even worse is the use of hydrogen peroxide: after all the bubbles, one is left with a thoroughly wet ear canal that is more prone to infection. Alcohol should not be used for wax impactions.  The canal can be cleared of impacted wax and dead skin cells with irrigation by an experienced Otolaryngologist and / or his personnel.  Once the canal is normal, the application of olive oil or mineral oil to the canal prior to bathing helps decrease the chances of further wax impaction, or at least makes the problem easier to treat the next time.