The ear consists of the outer, middle and inner ear. Sound travels through the outer ear and reaches the eardrum, causing it to vibrate. The vibration is then transmitted through three tiny bones (ossicles) in the middle ear. The vibration then enters the inner ear where the nerve cells are. The nerve cells within the inner ear are stimulated to produce nerve signals. These nerve signals are carried to the brain, where they are interpreted as sound.

What is a hole in the eardrum? A hole in the eardrum is known as a ‘perforation’. It may be caused by an infection or an injury to the eardrum. Quite often a hole in the eardrum may heal itself and sometimes it does not cause any problem. However a hole in the eardrum may cause a discharge from the ear. If the hole in the eardrum is large, then a person’s hearing capacity may be reduced.
A normal ear drum.
This patient has a hole in their right ear drum.

How is the condition diagnosed? You will need an examination by an otolaryngologist (ENT specialist) to rule out any hidden infection behind the perforation. The hole in the eardrum can be identified using a special medical instrument called ‘auriscope’/otoscope’. It consists of a magnifying lens and light. Examination with the auriscope is pain free. The amount of hearing loss can be determined only by careful hearing tests. A severe hearing loss usually means that the ossicles are not working properly, or that the inner ear is damaged.

How can a hole in the eardrum be treated?
If the hole in the eardrum has only just occurred, no treatment may be required. The eardrum may simply heal itself. However if an infection is present, the one may need antibiotics. As a precaution you should avoid getting water in the ear until the eardrum heals completely.
A hole in the eardrum that is not causing any problems can be left alone. If the hole in the eardrum is causing discharge or deafness, or if you wish to swim, it may be sensible to have the hole repaired. The operation is called a ‘myringoplasty’. You should discuss with your surgeon whether this surgery is appropriate for you.

Aims of the operation
The benefits of closing a perforation include prevention of water entering the middle ear while showering, bathing or swimming (which could cause ear infection). It can be done as part of a mastoid operation.
Repairing the eardrum usually leads to good improvement of hearing.

How is the operation done?
Most myringoplasty operations in our institution are done under local anaesthetic, although some surgeons prefer to do it under general anaesthetic.
A cut is made behind the ear or above the ear opening. The material used to patch the eardrum is taken from under the skin. This eardrum ‘graft’ is placed against the eardrum. Dressings are placed in the ear canal. You may have an external dressing and a head bandage for a few days. For a small perforation, your surgeon may even be able to plug it without making any cut in the ear. Occasionally, your surgeon may need to widen the ear canal with a drill to get to the perforation.

How successful is the operation?
The operation can successfully close a small hole ninety nine percent of the time (99%) in our hospital.

Possible complications
There are some risks that you must be aware of before giving consent to this treatment. These potential complications are rare and you should consult your surgeon about the likelihood of problems in your specific case.

Taste disturbance:

The taste nerve runs close to the eardrum and may occasionally be damaged. This can cause an abnormal taste on one side of the tongue. This is usually temporary but occasionally it can also be permanent.

Dizziness: Dizziness is common for a few hours following surgery. On rare occasions, dizziness can last for months or even years if the inner ear is damaged during surgery.

Hearing loss: In a very small number of patients, severe deafness can happen if the inner ear is damaged.

Tinnitus: Sometimes the patient may notice noise in the ear, in particular if the hearing loss worsens.

Facial Paralysis: The nerve for the muscle of the face runs through the ear. Therefore, there is a slight chance of a facial paralysis. The facial paralysis affects the movement of the facial muscles for closing of the eye, to smile or raising the forehead. The paralysis could be partial or complete. It may occur immediately after surgery or have a delayed onset. Recovery can be complete or partial.

What happens after the operation?
The ear may ache a little but this can be controlled with painkillers provided by the hospital. You will usually go home after the head bandage is removed, which is either the day after the operation or sometimes after a couple of days. The stitches will be removed 1-2 weeks after the operation at your doctor’s suggestion. There may be a small amount of discharge from the ear canal. This usually comes from the antiseptic solutions in the ear dressings. Some of the ear dressings may fall out and if this occurs there is no cause for concern. The dressings in the ear canal will be removed after 2-3 weeks by your surgeon at the hospital.
You should keep the ear dry and avoid blowing your nose too vigorously. Plug the ear with a cotton wool ball coated with vaseline when you are having a shower or washing your hair. If the ear becomes more painful or is swollen then you should consult your doctor.

How long will I be off work?
The exact time needed off work varies between patients, but as a guide you may need to take 2-3 weeks off work.

Glue ear is common. Up to eight in every ten children (80%) will have a short episode of glue ear before they start primary school. The medical name for glue ear is ‘otitis media with effusion’.

Doctors are not sure about all the causes of glue ear. Sometimes it follows after an ear infection, but many children with glue ear have never had an ear infection. The adenoid in the back of the nose may become infected with coughs and colds and the bacteria spread into the ear causing inflammation. The fluid (or glue) probably forms in the ear as a result of this inflammation.

Often, the hearing loss from glue ear is not enough to be noticed by the parents. Often, it is the child minder or nursery teacher who notices that the child cannot hear that well in a group situation. Sometimes in a younger child, the hearing does not seem to be a problem, but it has been noticed that the child’s speech and language development is slower than his or her friends of the same age.

Some children complain of earache because of the fluid in their ears, some have balance problems or poor attention as a result of glue ear. Sometimes the only problem reported by parents or childminders are behavioral problems. This is probably due to frustration on the part of the child because they are not able to hear properly.

If you have concerns about your child’s hearing or speech and language development, you should refer your child for a hearing test in our hospital.

For most children, the glue ear will get better with no treatment. You will probably be asked to come back for a second hearing test 3-4 months after the first test. Many children usually will get better over this time.
Those children who still have problems after this period, what doctors call ‘watchful waiting’ or ‘active monitoring’ will probably be recommended for surgical treatment. This may be grommet surgery or adenoidectomy.

Frequently asked questions

Is there any treatment that will help the glue ear clear away more quickly?
The evidence is that neither medical treatments such as antibiotics or antihistamines nor alternative treatments are any better than waiting for a period of 3 months to see if the glue ear clears on its own.

If my child has glue ear, are there any alternatives to grommets?
Hearing aids will help the hearing and give more time for the glue ear to clear. You can discuss this with your specialist.

Should some children with glue ear have hearing aids as a first treatment?
For some children, glue ear can be a problem for much longer than others. In children with Down’s syndrome or cleft palate, hearing aids should be discussed with your specialist as a first treatment for glue ear.

What happens if the glue ear is not treated?
Doctors do not really know if any damage occurs to the ear or hearing if the glue ear is not treated. We usually advise treating the problem if it does not clear up on its own to avoid the risk of long-term damage to the ear, and hearing or problems in later life with language skills.

Is glue ear common in adults? Glue ear is uncommon in adults. However it can follow on from a bad head cold, flu or other viral infections of the ear, nose or sinuses. Rarely though, it can be caused by a serious blockage of the tube that goes from the back of the nose to the ear. (Eustachian tube).Adults with glue ear should be seen by an ENT specialist as soon as possible.

What are grommets? Grommets are very small plastic tubes which sit in a hole in the eardrum. They let air get in and out of the ear which keeps the ear healthy.

Why do we use grommets?

Some people get fluid behind the eardrum. This is sometimes called ‘glue ear’. It is very common in young children, but it can happen in adults too. We don’t know exactly what causes glue ear.

Most young children will have glue ear at some time, but it doesn’t always cause problems. We only need to treat it if it causes problems with hearing or speech, or if it is leading to multiple counts of ear infections.

How are grommets put in?

The grommets are placed in the eardrum under a short general anaesthetic and the procedure is usually performed as a day-case admission to hospital. The operation is carried out down the ear canal so there are no cuts to see on the outside of the ear. A small opening is made in the eardrum using a microscope to magnify the area and the fluid is sucked out of the ear with a fine sucker. The grommet is then placed in the opening in the eardrum. The procedure takes between 10-20 minutes.

How long do grommets stay in for?

Grommets fall out by themselves as the eardrum is constantly growing. They may stay in for six months, or a year, or sometimes even longer in older children. You may not notice when they drop out.

Does my child have to have grommets?

Glue ear tends to get better by itself but this can take a while. We like to leave children alone for the first 3 months because about half of them will get better in this time. After 3 months, we will see your child again and decide whether we need to put in grommets.

If the glue ear is not causing any problems ideally one must just wait for it to settle by itself. If it is causing problems with poor hearing, poor speech or lots of infections, it may be better to put grommets in.

If we do put in grommets, the glue ear may come back when the grommet falls out. This happens to 1 out of 3 children who have grommets put in. Hence we may need to put more grommets in to last until your child grows out of the problem.

What are the alternatives to grommets?

Steroid nasal sprays may help some children if they have nasal allergy. Congestion in the nose caused by allergy may affect the normal function of the nose and ears. Antibiotics, antihistamines and decongestants do not help this type of ear problem.

Using a nasal balloon to open the tube to the ear may help older children if used regularly.

Taking out the adenoids may help the glue ear get better, and your surgeon may want to do this at the same time as putting grommets in.

Can I do anything to help my child?

Speak clearly and wait for your child to answer. Make sure he or she can see your face when you speak. Call your child’s name to get them to look at you before you speak. Let nursery and school teachers know that your child has a hearing problem. It may help for your child to sit at the front of the class.

Are grommets sore?

Grommets are not usually sore at all. You can give your child simple painkillers (e.g. paracetamol or ibuprofen) if you need to. Grommets should improve your child’s hearing straight away. Some children think everything sounds too loud until they get used to having normal hearing again. This usually takes only a few days.

What about ear infections?

Most people with grommets do not get any ear infections. If you see yellow fluid coming out of the ear, it may be an infection. It will not be as sore as a normal infection and your child won’t be as ill. In this situation we advise you to take your child to see your doctor. If you get some antibiotic ear drops from your doctor, the problem will quickly settle. Some doctors may give antibiotics for oral consumption instead of antibiotic ear drops.

Can my child swim with grommets in?

Your child can start swimming a couple of weeks after the operation, however diving under the water is not a good idea as water may pass through the grommet into the ear. Some parents have earplugs made if their child is a very keen swimmer, to use until the grommets have come out. The hole in the grommet is too small to let water through, unless the water is dirty or has shampoo or soap in it. So you need to be careful in the bath or the shower. You can plug your child’s ears with a cotton-wool ball covered in vaseline until the grommets have come out.

How long will my child be off nursery or school?

Your child should be able to get back to normal the day after the operation

What else should I know about grommets?

It is okay to travel by air with grommets. The pain from the change in pressure in an aeroplane cannot happen when the grommets are working. We need to check your child’s hearing after grommets have been put in, to make sure their hearing is better, and see your child once the grommets have come out to check their ears and hearing; this will usually be about 9-12 months after the operation. Sometimes when a grommet comes out, a small hole in the eardrum is left behind. This usually heals up with time and we rarely need to operate to close the hole. The grommet can leave some scarring in the eardrum and this does not usually affect the hearing.

Otosclerosis is a common cause of hearing impairment and is hereditary.  Someone in earlier generations of your family had the condition and passed it down to you.  Similarly, your descendants may inherit this tendency from you, although the hearing impairment may not manifest itself for a generation or two.  Being hereditary, diseases such as scarlet fever, ear infection and influenza have no relationship to the development of otosclerosis.

Function of the normal ear

The ear is divided into three parts: the external ear, the middle ear and the inner ear.  The external ear collects sound, the middle ear mechanism transforms the sound and the inner ear receives and transmits the sound.

Sound vibrations enter the ear canal and cause the eardrum membrane to vibrate.  Movements of the membrane are transmitted across the middle ear to the inner ear fluids by three small ear bones.  These middle ear bones (hammer or malleus, anvil or incus and stirrup or stapes) act as a transformer, changing sound vibrations in the air into fluid waves in the inner ear.  The fluid waves stimulate delicate nerve endings in the hearing canals.  Electrical impulses are transmitted on the nerve to the brain where they are interpreted as understandable sound.

Types of hearing impairment

The external ear and the middle ear conduct sound; the inner ear receives it. If there is some

difficulty in the external or middle ear, a conductive hearing impairment occurs.  If the trouble lies in the inner ear, a sensorineural or nerve hearing impairment is the result.  When there is difficulty in both the middle and the inner ear a mixed or combined impairment exists.  Mixed impairments are common in Otosclerosis.

Hearing impairment from otosclerosis

Had we been able to examine your inner ear bone under a microscope before a hearing impairment developed, we would have seen minute areas of both softening and hardening of the bone.  This process may spread to the stapes, the inner ear, or to both these areas

Cochlear Otosclerosis

When otosclerosis spreads to the inner ear a sensorineural hearing impairment may result due to interference with the nerve function.  This nerve impairment is called cochlear otosclerosis and once it develops it is permanent.  In selected cases medication may be prescribed in an attempt to prevent further nerve impairment.

On occasion the otosclerosis may spread to the balance canals and may cause episodes of unsteadiness.

Stapedial Otosclerosis

Usually otosclerosis spreads to the stapes or stirrup bone, the final link in the middle ear transformer chain.  This stapes rests in a small groove, the oval window, in intimate contact with the inner ear fluids.  Anything that interferes with its motion results in a conductive hearing impairment. This type of impairment is called stapedial otosclerosis and is usually correctable by surgery.

The amount of hearing loss due to involvement of the stapes and the degree of nerve impairment present can be determined only by careful hearing tests.

Treatment of otosclerosis

Medical

There is no local treatment to the ear itself or any medication that will improve the hearing in persons with otosclerosis. In some cases medication may be helpful in preventing further loss of hearing.

Surgical

The stapes operation (Stapedectomy / Stapedotomy) is recommended for patients with otosclerosis who are candidates for surgery.  This operation is performed under local anesthesia and requires a short period of hospitalization and convalescence.  Over 90 percent of these operations are successful in restoring the hearing permanently.

Your hearing

Hearing is measured in decibels (dB).  A hearing level of 0 to 25 dB is considered normal hearing for conversational purposes.  Pure Tone Audiometry tests will reveal the exact level of your hearing loss.  The hearing levels are depicted as follows:

Right ear ____________________________________decibels

Left ear   ____________________________________decibels

(Conversion to degree of handicap)

25 dB  ____________________0%

55 dB (Moderate)_________________45%

30 dB (Mild) _______________8%

65 dB (Severe) ___________________60%

35 dB (Mild) ______________15%

75 dB (Severe) ___________________75%

45 dB (Moderate) __________30%

85 dB (Severe) ___________________90%

SURGERY RECOMMENDATIONS

Depending on the level of hearing handicap and severity of disease, the recommendations may be any of the following:

• You have a minor degree of stapedial otosclerosis.  As such we do not advise surgery at this time.
  
  

• You have unilateral (one ear) otosclerosis.  If the stapes operation is successful you will have improved hearing from the involved side, will have less difficulty in determining the direction of sound and should hear better in difficult listening situations.
  
  

• You have good hearing nerve function and are a very suitable candidate for the stapes operation.
  
  

• Your hearing nerve has deteriorated slightly.  If the stapes operation is successful, serviceable hearing will be restored to you.
  
  

• Your hearing nerve has deteriorated to some extent.  If the stapes operation is successful, you should be able to hear in many situations without an aid, but may need an aid for distant hearing.
  
  

• Your hearing nerve has deteriorated considerably.  If the stapes operation is successful, you will gain more benefit from the use of a hearing aid.
  
  

• Your hearing nerve has deteriorated severely.  For this reason the chances of surgery improving your hearing are reduced.  If surgery should prove successful, your hearing should be improved to the extent that you may be able to use a hearing aid.
  
  

• Your hearing loss is due to inner ear and nerve involvement.  As such, surgery would not be of benefit to you at this time.  Many of the operations performed today were not available a few years ago.  Through ear research we hope to be able to help sensorineural (nerve) hearing impairment in the future.
  
  

The stapes operation

(Stapedectomy / Stapedotomy)

Stapedectomy is performed through the ear canal under local anesthesia. At times an incision may be made above the ear to remove muscle tissue for use in the operation.

Under high power magnification the eardrum membrane is turned forward and the fixed stapes partially or completely removed.  The stapes may be removed with instruments, a drill or in some cases, a laser. Prosthesis is inserted to replace it.  The eardrum membrane is then replaced in its normal position. The stapes prosthesis allows sound vibrations to again pass from the eardrum membrane to the inner fluids. The hearing improvement obtained is usually permanent.

The patient may return to work in seven to ten days depending upon occupational requirements.  Patients residing outside Chennai area should plan to remain in Chennai for a total of five days including the day of surgery.

One should not plan to drive a car home from the hospital. Air travel is permissible 10 days following surgery.

Hearing improvement following stapes surgery

Hearing improvement may or may not be noticeable at surgery. If the hearing improves at the time of surgery, it usually regresses in a few hours due to swelling in the ear.  Improvement in hearing may be apparent within 3 weeks of surgery.  Maximum hearing, however, is obtained in approximately four months.

The degree of hearing improvement depends on how the ear heals.  In the majority of patients the ear heals perfectly and hearing improvement is as anticipated.  In some the hearing improvement is only partial or temporary.  In these cases the ear usually may be reoperated upon with a good chance of success.

In 2 percent of the cases the hearing may be further impaired due to the development of scar tissue, infection, blood vessel spasm, irritation of the inner ear or a leak of inner ear fluid (fistula).

In less than 1 percent, complications in the healing process may be so great that there is severe loss of hearing in the operated ear, to the extent that one may not be able to benefit from a hearing aid in that ear.  For this reason the poorer hearing ear is usually selected for surgery.

When further loss of hearing occurs in the operated ear, to the extent that one may not be able to benefit from a hearing aid in that ear, head noise may be more pronounced. Unsteadiness may persist for some time.

Tinnitus

Most patients with otosclerosis notice tinnitus (head noise) to some degree.  The amount of tinnitus is not necessarily related to the degree or type of hearing impairment.

Tinnitus develops due to irritation of the delicate nerve endings in the inner ear.  Since the nerve carries sound, this irritation is manifested as ringing, roaring or buzzing.  It is usually worse when the patient is fatigued, nervous or in a quiet environment.

Following the successful   Stapedectomy tinnitus is often decreased in proportion to the hearing improvement.

Hearing aids

If you are a suitable candidate for surgery, you are also suitable to benefit from a properly fitted hearing aid.  If you have otosclerosis and are not suitable for stapes surgery, you still may benefit from a properly fitted aid.

Fortunately, patients with otosclerosis very seldom go “totally deaf”, but will be able to hear with an electronic aid.  The older the patient, the less the tendency for further hearing loss due to the otosclerotic process.

Hearing aid donation

If you regain hearing through surgery and there is no longer a need for you to wear hearing aids, it would be greatly appreciated if you would donate your hearing aids to the KKR Hearing Aids.   Donated hearing aids are used as “loaners” for the occasional patient who requires hearing aid only for brief time, or who cannot afford to purchase a hearing aid.

General comments

If you are a suitable candidate for surgery and do not have the stapes operation at this time, it is advisable to have careful hearing tests repeated at least once a year.

How does the ear work?

The ear consists of the outer, middle and inner ear. The outer ear is covered by skin. The middle ear is covered by a mucus producing membrane. Sound travels through the outer ear and reaches the eardrum, causing it to vibrate. The vibration is then transmitted through three tiny bones (ossicles) in the middle ear. The vibration then enters the inner ear where the nerve cells are. The nerve cells within the inner ear are stimulated to produce nerve signals. These nerve signals are carried to the brain, where they are interpreted as sound.

What is the mastoid bone?

The mastoid bone is the bony prominence that can be felt just behind the ear. It contains a number of air spaces, the largest of which is called the antrum. It connects with the air space in the middle ear. Therefore ear diseases in the middle ear can extend into mastoid bone.

Why is mastoid surgery done?

Operations on the mastoid may be necessary when ear infection within the middle ear extends into the mastoid. Most commonly this is a pocket of skin growing from the outer ear into the middle ear, known as cholesteatoma. This causes infection with discharge and some hearing loss. The pocket gets slowly larger, often over a period of many years, and causes gradual erosion of surrounding structures. Erosion of the ossicles can result in hearing loss. The only effective way to get rid of this pocket of skin is surgery.

A normal ear drum.

A cholesteatoma.

How is mastoid surgery done?

A local or general anaesthetic is used. There are several ways of doing the operation, depending on the extent of the ear disease and the surgeon. They have various names such as atticotomy and mastoidectomy and take between 1-3 hours. It involves a cut either above the ear opening or behind the ear.

The bone covering the infection within the mastoid cells is removed. The resultant bony defect is called a mastoid cavity. Some surgeons leave the mastoid cavity open into the ear canal. This allows the surgeons to inspect the mastoid cavity easily. Other surgeons close up the mastoid cavity with bone, cartilage or muscle from around the ear. You should discuss with your surgeon his/her preferred approach. At the end of the operation, packing will be placed in your ear while it heals.

Does it hurt?

The ear may ache a little but this can be controlled with painkillers provided by the hospital.

How successful is the operation?

The chances of obtaining a dry, trouble free ear from this operation by our experienced surgeons are over 95%. In some patients it is possible to improve the hearing as well. You should enquire from your surgeon the likelihood of success in your particular case.

Possible complications

There are some risks that you must be aware of before giving consent to this treatment. These potential complications are rare. You should consult your surgeon about the likelihood of problems in your case.

Loss of hearing

In a small number of patients the hearing may be further impaired due to damage to the inner ear. If the disease has eroded into the inner ear, there may be total loss of hearing in that ear.

Dizziness

Dizziness is common for a few hours following mastoid surgery and may result in nausea and vomiting. On rare occasions, dizziness is prolonged.

Tinnitus

Sometimes the patient may notice noise in the ear, in particular if the hearing loss worsens.

Weakness of the face

The nerve that controls movement of the muscles in the face runs inside the ear and may be damaged during the operation, but this risk is rare. If it happens, the face may lose its movement on one side but it is usually temporary.

What happens after the operation?

You will usually go home the day after the operation after the head bandage is removed, or sometimes the same day. There is sometimes some dizziness but this usually settles quickly. The stitches are removed 1 to 2 weeks after the operation. There may be a small amount of discharge from the ear canal. This usually comes from the ear dressings. Some of the packing may fall out. If this occurs there is no cause for concern. It is sensible to trim the loose end of packing with scissors and leave the rest in place. The packing in the ear canal will be removed in the hospital after 2 or 3 weeks.

You will visit our hospital occasionally for follow up of your ear for up to 5 years after the operation. You should keep your ear dry. Plug the ear with a cotton wool ball coated with vaseline when you are having a shower or washing your hair. If the ear becomes more painful or is swollen then you should consult the Ear, Nose and Throat department.

How long will I be off work?

2 weeks.

Is there any alternative treatment?

The only way to remove the infection completely is a mastoid operation. In patients who are unfit for surgery, the only alternative is the regular cleaning of the ear by a specialist and the use of antibiotic eardrops. This at best could only reduce the discharge

What is tinnitus?

Tinnitus is a sensation or awareness of sound that is not caused by a real external sound source. It can be perceived in one or both ears, inside the head or in the person's immediate environment. Although it is commonly assumed to be a ringing noise, tinnitus can take almost any form including hissing, whistling, humming and buzzing. Some people even hear musical sounds or sounds resembling indistinct speech. Some people hear a single sound whereas others hear multiple noises. For some, the sound is constant, for others it is constantly changing.

What causes tinnitus?

It is often assumed that tinnitus is caused by damage to the ears. This is true in some cases but it is perfectly possible to have tinnitus with normal ears and normal hearing. Several studies have been performed where people who do not have tinnitus were placed in soundproofed rooms and told to listen intently. In this situation almost everyone becomes aware of a sound sensation.

Many scientists think that tinnitus is generated by random electrical signals that can occur in any part of the hearing pathway. Thus tinnitus may originate in the ears, in the hearing nerve or in the brain. Such random signals are common and usually we are not aware of them happening. Occasionally something happens that causes some people to interpret these random signals as sound. Common triggers for this process are emotional shocks and loss of hearing, either gradual or sudden. However, in many people the trigger is unknown. Once we become aware of the tinnitus signal, it draws the attention of the brain making tinnitus even more distressing. This type of tinnitus is called subjective tinnitus because it is only heard by the sufferer.

A few people have tinnitus that is attributable to a real sound, generated inside the body by blood flow or muscular activity. This type of tinnitus may be detectable by other people, either just by careful listening or by using a stethoscope. This kind of tinnitus is known as objective tinnitus.

What are the symptoms?

• Tinnitus is a symptom in itself.
  
  
• It may be accompanied by hearing loss, dizziness, pain in the ears (otalgia) or dislike of loud sounds (hyperacusis).
  
  
• Many people with tinnitus also feel that their ears are blocked.
  
  

Your specialist will consider these other symptoms when making a diagnosis and developing a plan for your treatment.

How is tinnitus diagnosed?

The first thing your specialist will do to diagnose your condition is to ask some questions about your symptom. This is actually all that is necessary to reach a diagnosis and there is no special ‘tinnitus test’.

Of course your specialist will want to know as much as possible about your hearing and will perform a full examination of your ears. Other areas such as the nose, jaw joints and throat may be examined. If the specialist thinks that you may have objective tinnitus he or she may listen around your ear and neck with a stethoscope.

In almost all cases the specialist will arrange some tests. The most common test is a hearing test (pure tone audiogram). There are some hearing tests that try and match the person’s tinnitus but they do not influence treatment greatly. Many specialists therefore do not request these tests. For selected patients, the doctor may wish to order an MRI scan though other tests such as CT scans or ultrasound scans are sometimes utilized. Blood tests may occasionally be required but this is unusual in the diagnosis of tinnitus.

What can I do to help myself?

Tinnitus is extremely common. Approximately 1 in 10 of the population have some degree of tinnitus. In most people, the symptom is mild and does not interfere greatly with their lives. Many people think that tinnitus will never go away. This is incorrect and with time most tinnitus lessens or disappears. Knowledge of these simple facts can help many people to cope with it.

Most people with tinnitus find that it appears louder if they are sitting somewhere very quiet. Having a little bit of quiet background sound from a radio, CD player or television can help.

Many people notice that their tinnitus becomes more distressing if they become stressed or anxious. Learning to try and avoid stressful situations can help.

There have been anecdotal reports that certain foods and drinks can exacerbate tinnitus. People may therefore put themselves on exclusion diets. Caution should be urged in this respect; there is a little if any scientific evidence to support the theory that food causes tinnitus.

Treatment options

Although there is no simple pill or operation to cure the majority of cases of tinnitus there are several strategies that are very helpful in ameliorating the condition.

For people with mild tinnitus simple explanation and reassurance may be all that is required. For more intrusive tinnitus a form of counseling may prove helpful. This can be administered as a standalone therapy or as part of a wider treatment strategy such as Tinnitus Retraining Therapy (TRT) which is a mixture of counseling and sound therapy.

If tinnitus is associated with hearing loss then trying to correct the hearing loss is usually very helpful. Depending on the cause of the hearing impairment, medication, surgery or hearing aids may be needed.

Sound therapy can help many people with tinnitus. This can take the form of an electronic device that sits at the person’s bedside and produces low level soothing sound to distract them from their tinnitus at night. During the daytime it is possible to wear a sound generator which is a small device that resembles a hearing aid and produces white noise.

Psychological techniques such as Cognitive Behavioral Therapy (CBT) and Mindfulness Meditation can be used in the management of tinnitus; also Relaxation Therapy is very helpful for those who find that stress worsens their problem.

For a very small number of people, usually those with objective tinnitus, there may be a drug or surgical procedure that can cure the problem.

Monitoring and reassessment

Tinnitus is such a variable symptom that it is extremely difficult to make any hard and fast rules regarding the long-term management. This is a very individual decision that will be made by you and your specialist.

Uncertainties

There are many questions regarding tinnitus that remains to be answered regarding both the mechanisms by which it is generated and the search for more effective treatments. Various research avenues are currently being explored including the use of certain types of drug and electromagnetic stimulation of the auditory system.

What is Hearing Loss?

Hearing loss is a symptom of a variety of conditions affecting the hearing organ or its nerve connection to the brain. It may be caused by problems affecting the transmission of sound through the eardrum and bones of hearing (called ossicles) to the cochlea (the organ of hearing), or it may be due to problems in the cochlea and the auditory nerve that connects the cochlea to the brain.

Conductive hearing loss is caused when something interferes with the transmission of sound from the ear canal to the cochlea. Sensorineural hearing loss is caused when there is a problem with the cochlea, or the nerve connection from the cochlea to the brain.

What Causes Hearing Loss?

Conductive hearing loss can be due to problems in the ear canal, ear drum (tympanic membrane) or the middle ear bones (ossicles). These three bones are called the Hammer, Anvil and Stirrup (or Malleus, Incus and Stapes).

In children the commonest type of hearing loss is conductive hearing loss. This is usually due to fluid being trapped behind the eardrum. This condition is called glue ear, or Otitis Media with Effusion (OME). The fluid stops the eardrum from vibrating. Sometimes there are other causes for childhood conductive hearing loss. Rarely children may be born with poorly formed middle ear bones, or these structures can be damaged through ear infection.

Conductive hearing loss in adults is less common, but may be due to problems with the bones of hearing or occasionally glue ear. Heavy wax accumulation in the ear canal can also cause a mild degree of conductive hearing impairment.

Infection which damages the ossicles may lead to conductive hearing loss. One such condition is called cholesteatoma. Here infected skin grows around the ossicles. This can restrict movement of the ossicles or even damage their structure and connections. Other conditions may affect the ossicles, for instance the stapes bone can become attached to the surrounding bone which stops it transmitting sound. This is a condition called otosclerosis.

Sensorineural hearing loss is due to loss of sound sensing cells in the cochlea (these are called hair cells) or damage to the nerves that take hearing signals to the brain. There are many causes of this type of hearing loss.

Age related hearing loss is sensorineural, and due to loss of hair cells with ageing it is the commonest cause of hearing loss in adults. Sensorineural loss can also be due to excessive noise exposure in both work situations (industrial noise damage) or through excessively loud music exposure (recreational noise damage).

Other causes of sensorineural hearing loss include some prescribed medication, and some infections.

Children can also suffer from sensorineural hearing loss, and for some children this is an inherited disorder that may even be present at birth. It can vary from a mild hearing loss to severe deafness.

Finally it is worth remembering that hearing loss can be due to a mixture of conductive and sensorineural causes.

Some types of sensorineural hearing loss require urgent treatment. Please seek medical advice immediately if:

1. You lose your hearing suddenly i.e over just a few hours or days
   
   
2. If your hearing loss is associated with ear discharge, dizziness or earache
   
   

What are the symptoms?

Most adults first start to notice difficulty in following conversation when there is background noise or when more than one person is talking. Often their friends will complain that they don’t listen or that they turn the television volume up too loud. They may become increasingly withdrawn and frustrated that they cannot socialize easily.

In children, parents find that they might be inattentive, or ignore instructions or appear naughty. Listening to the television at high volumes is common and sometimes the child’s teachers will complain. Young children with delayed speech production should always be assessed for hearing loss.

What should you do if you suspect hearing loss?

In most circumstances you should see your doctor, who will be able to examine you for wax impaction and look for signs of ear disease. Your doctor can then arrange hearing tests and if necessary review by an ENT consultant.

Investigations and Treatment

Your doctor or specialist will arrange for you to have hearing tests performed. A variety of tests are available, and special test techniques can be used to assess children, even when they are newborns.

This will help establish the nature and severity of the hearing loss. The severity of the hearing loss is graded mild, moderate, severe and profound. Treatment depends on the severity of the hearing loss and whether it is conductive or sensorineural.

In conductive hearing loss there may be an infection of other disease process that needs to be treated. Treatment may include surgery, both to treat the infection and also restore the hearing.

In cases where the hearing loss is due to a problem with the ossicles (egotosclerosis) surgical hearing restoration is usually possible. This may involve using metal or plastic implants or reusing your existing ossicles to restore the hearing mechanism.

  In many cases hearing aids will be advised. These come in different sizes and types to suit different users and hearing needs. The technology in hearing aids is always improving to make them more discreet and offer better sound quality. An example of modern hearing aids is shown in the picture alongside. Your doctor will be able to refer you to our  audiology unit for assessment and fitting of hearing aids.

For some patients with specific types of hearing loss a surgically implanted hearing device may be advised. These devices include bone anchored hearing aids and cochlear implants. With modern surgery and high technology devices ENT surgeons are able to offer even the most severely deaf patients useful hearing. There is a hearing restoration solution available for almost everyone who is hearing impaired.

What is dizziness?

Dizziness is a sense of feeling lightheaded or unsteady or woozy that is often accompanied by sensations of swaying, tilting, whirling, spinning, floating or moving that could also be described as vertigo. Dizziness can hit even when you are standing or lying down absolutely still.

What Causes dizziness?

Our body’s balance maintenance system is very complex. For the body to perceive itself in a state of balance, the brain needs to integrate optimal inputs from muscles, joints, eyes and inner ear. If any of these body parts get diseased or if that part of the brain that integrates and analyzes signals received from these parts is affected, dizziness can occur. Because of these complexities, diagnosing the root cause of dizziness becomes a tough and multi-specialty task requiring inputs from different specialists.

That said, inner ear disorders show up as one of the more common cause of dizziness.

Which are the inner ear disorders can cause dizzy spells?

Meniere’s syndrome

– This syndrome is connected to your inner ear‘s fluid balance regulatory system. In this condition, the patient gets attack-like episodes with sudden onset of multiple symptoms such as ringing noises in the ear, sense of fullness in the ear, distortion in hearing, loss of hearing, nausea, vomiting and severe dizziness. These attacks can last anywhere from 20 minutes to 24 hours. To treat this, your doctor can prescribe anti-nausea and anti-vertigo medicines along with dietary and medication changes. You will also be advised to quit smoking. If medical treatment is not effective or available, you may be advised to undergo a surgical procedure.

Benign paroxysmal positional vertigo (BPPV)

– Your inner ear’s balancing section is equipped with delicate sensory units. BPPV can result from damage inflicted on these units. The symptoms show up as sensations of spinning, dizziness, imbalance, and lightheadedness which are felt when the patient changes his head and body position, for example, at the time of turning over in the bed or bending the head backwards. These sensations usually last no more than a few moments and may range anywhere between mild to moderate to severe. The patient can get complete relief by learning a few simple head and body repositioning maneuvers that can be done anywhere.

Vestibular neuritis (labyrinthitis)

- This condition occurs due to inflammation of balance-controlling inner ear nerve cells that is usually caused by an upper respiratory tract viral infection such as influenza. The patient suffers from sudden vertigo spells lasting anywhere between 1-7 days. This condition is eminently treatable with full chances of a complete recovery without requiring any surgery. Your doctor will most likely prescribe medications for symptomatic relief from dizziness and nausea and will recommend a 6-8 weeks’ balance rehabilitation program.

In some cases, dizziness can also result from medications such as those prescribed for seizure disorders (e.g, carbamazepine, phenytoin) or sedatives and antidepressant drugs.

In some cases, dizziness can also result from medicines prescribed for inner ear infections (e.g. gentamicin, streptomycin). Last but not the least, alcohol intake can also cause dizziness.

What should I do if I have dizziness?

We recommend a visit to our ENT specialist. He will undertake the required tests and investigations and may also have to consult other specialists (as we stated earlier, body’s balancing system involves inputs sent to brain from muscles, joints, eyes, and inner ear). Once the underlying cause is diagnosed, you will be given a suitable treatment

What could be the cause of my ear pain?

Ear pain can arise due to many reasons such as an injury from poking your ear with an outside object (e.g. hairpin, pencil, or safety pin), an infection in your ear canal (otitis externa) or an infected hair follicle in your ear canal (furuncle), or an infection of middle ear (acute or serous otitis media). It could also arise due to earwax buildup or due to sudden pressure changes at takeoff and landing times during air travel. If areas near the ear are infected e.g. tonsillitis, sinusitis, neuralgias, pharyngitis or aching jaw or jaw joint or toothache or mouth ulcers, you could get bouts of pain in the ear. Some more serious conditions causing ear pain could be malignant otitis externa or complicated unsafe type of chronic otitis media.

How can my ear pain be eased? Do I need to go to a doctor?

Yes, you should schedule a visit to our ENT doctors without delay. Most ear pains can be treated successfully but the key to effective treatment lies in first making the correct diagnosis.

The doctor will give you a thorough checkup to find the cause and will prescribe treatment accordingly.

What is earwax?

Earwax is a lubricating and antimicrobial protective fluid secreted by the ear. It is called cerumen in medical terms.

The ear is quite capable of cleaning itself through a ‘conveyor-belt’ like process in which the ear canal skin grows from inside out and it is aided by chewing and other jaw movements in pushing out the older earwax. Once it reaches the outside of the ear, it flakes off on its own.

What is impacted ear wax?

The earwax is termed as impacted when its buildup in the ear canal reaches abnormal quantities indicating an issue with the natural self-cleaning process. The most common reason of this buildup is the unsafe habit of using items like ear buds and safety pins to clean the ear that actually do quite the opposite by pushing earwax further into the ear. Add to it the added problem of ear canal trauma inflicted by these pointy things and you have an ear that’s impacted by earwax. The irony here is that as ears are naturally equipped with a self-cleaning mechanism, most people do not need to clean them at all!

How do I know that I am suffering from impacted earwax?

You can suspect impacted earwax when the following symptoms show up:

• Your ear feels heavy from inside
  
  
• There is pain in your ear
  
  
• There is itchiness inside the ear
  
  
• You are facing hearing problems that seem to be getting worse with time
  
  
• You hear ringing sounds in the ear (also called tinnitus)
  
  
• Your ear is letting off a brownish discharge
  
  
• There is a foul odour emanating from your ear
  
  
• You are getting dizzy spells
  
  

  Who all can suffer from earwax Impaction?

  While earwax impaction can occur in anyone, the following people may be more prone to it:

 

• Those using hearing aids
  
  
• Those habitual of putting  ear buds, hairpins and safety pins etc into their ears
  
  
• Ageing persons
  
  
• Those with awkwardly shaped ear canals that are ill-suited for efficient self-cleaning mechanism
  
  

  How can I get treatment for my ear wax impaction?

We advise a visit to our ENT doctors who is best equipped to treat your earwax impaction. Post-examination, he/she will:

• Prescribe cerumenolytic solutions to soften and dissolve the earwax buildup.
  
  
• Irrigate the ear canal with water or saline using a syringe after the earwax softens.
  
  
• Remove the earwax using special and sterile instruments.
  
  

  Is there any way by which I can save my ear from earwax impaction?

  While it is not always possible to prevent earwax impaction from happening, you can certainly take the following precautions:

 

• Never put ear buds, safety pins, or hairpins in your ear canal.
  
  
• If you suspect earwax impaction, do not try to clean it out yourself. Get an ENT specialist to do it for you.
  
  

Why is detecting deafness in children so very important?

Do you know that a baby starts hearing while still a foetus in the mother’s womb? It is crucial to understand that speech and hearing are intricately interconnected in children. Actually, the first few years are crucial to development of communication skills in babies. Children learn and develop their speaking skills by copying those around them. If they can’t hear properly, they won’t learn to speak properly either. Therefore, if a newborn baby or a toddler suffers from any kind of hearing impairment, it can have a drastic and long lasting negative impact on their speech and communication skills for an entire lifetime. You need to ensure that your baby’s hearing is in good shape at the earliest.

What are the causes of deafness in Children?

Children can suffer from deafness due to many reasons. These could be present from the time of the birth or could have arisen later.

 

• Inheritance of malfunctioning genes from parents
  
  

 

• Presence of Down’s Syndrome or Goldenhar Syndrome with hearing loss as one of the many syndromic disabilities
  
  

 

• Infection received in the womb such as rubella (German measles), cytomegalovirus, or herpes simplex virus
  
  

 

• Blood’s Rh factor related complications
  
  

 

• Premature birth
  
  

 

• Diabetes in mother
  
  

 

• Toxaemia during pregnancy
  
  

 

• Anoxia or lack of oxygen
  
  

  Post-birth conditions in children that can cause deafness at any age:

 

• Ear infections (otitis media)
  
  

 

• Ototoxic medicines that damage the auditory system
  
  

 

• Infectious diseases such as encephalitis, meningitis, measles, chickenpox, mumps, or influenza
  
  

 

• Head injury or trauma to ear
  
  

 

• Exposure to loud noises
  
  

 

• Foreign bodies in ear
  
  

 

• Earwax impaction
  
  

 

• In rare cases, deafness could be caused by cancers
  
  

  Do some babies have an increased risk of being deaf at birth?

Yes, some babies are more at risk than other babies. Get your baby checked for deafness if the baby:

• Has a family history of permanent hearing loss
  
  

 

• Is born premature or has a birth weight of less than 2 kgs
  
  

 

• Has low Apgar scores (numbers assigned at birth that reflect the newborn's health status)
  
  

 

• Required post-birth ventilator support for breathing for more than 10 days
  
  

 

• Was in neo-natal intensive care unit (NICU) for more than 5 days
  
  

 

• Had severe jaundice after birth
  
  

 

• Suffers from hydrocephalus (fluid accumulation in brain)
  
  

 

• Suffered meningitis
  
  

 

• Has received exposure to ototoxic medications that can cause damage to the ear
  
  

 

• The mother suffered some illness (e.g. rubella) during pregnancy
  
  

  Is it possible to test hearing at a very young age?

  Yes, it is absolutely possible to conduct hearing tests, whatever the age of the child. However, the type of testing will vary from child to child depending on their age / level of development. Some hearing evaluations employ interactive games to engage the child, some other do not need any behavioural response from them. Hearing tests are specialized assessments that require professionals trained in diagnostic hearing testing techniques and auditory rehabilitation of adults and children. They are called audiologists. Nevertheless, as hearing tests for children need special diagnostic equipment and set up along with advanced training, not every audiologist is able to test hearing of children.

How can deafness in children be treated?

The imperative first step is to assess the child’s hearing and pinpoint the condition that’s responsible for its loss. If the cause is treatable through surgical intervention, the ENT surgeon undertakes it. For example, if the deafness is due to a condition called the secretory otitis media, the surgeon will conduct a surgery called myringotomy grommet to restore hearing.

On the other hand, if the underlying condition is incurable, rehabilitation is the next step that needs to be taken at the earliest. First, hearing assessments are carried out and then based on the result, hearing aids may be prescribed. Hearing aids amplify the sounds around the child to make him or her hear what they have been missing and thus provides the stimuli to their growth as well as speech and language development.

However, not all children are suitable for hearing aids. Some children with higher severities or hearing loss configurations may require other types of technological assistance such as the BAHA hearing system or a cochlear implant. These alternatives can be used along with speech therapy, special education, and FM (frequency modulated) or IR (infrared) systems to provide superior access to auditory information in afflicted children.

A cochlear implant is an electronic device that is partially implanted surgically into the cochlea which is the hearing organ of the inner ear. The remaining part of the device consisting of microphone, processor, and transmitter has to be worn externally. This cochlear implant uses electrical current to stimulate the remaining hearing nerve fibers by bypassing defective cochlear parts.

Cochlear implants are best suited for children with severe to profound affliction (hearing loss in both ears, >70 dB/ poor speech discrimination, < 50% correct on a sentence recognition test) that hearing aids are not able to improve much. Suitability for cochlear implant requires complete evaluation including hearing tests along with a CT or MRI scan of the ear.

Cochlear implants can be given to children as young as 6 months old. However, first it has to be ruled out that the child will not receive equivalent hearing gain from hearing aids. Therefore there is a preceding trial lasting 3 to 6 months in which hearing aids are installed in both ears and intensive auditory training is also given to ensure that cochlear implant is the only viable option.

What gives the nose its shape?
The shape of the nose on the outside is due to the shape of the bone and cartilage and the overlying skin. The top of the nose is made of bone shaped like a roof, which is hard. The middle and tip of the nose are made of cartilage, which is softer. The skin varies in thickness from person to person, and this also affects the shape.

What is Rhinoplasty?
Rhinoplasty is an operation to change the shape of the nose. The type of rhinoplasty depends on which particular area of the nose needs correction.

• The nose can be straightened, made smaller or bigger, and bumps may be removed.
  
  
• The shape of the tip of the nose can be changed.
  
  
• Pieces of cartilage or bone may be removed from or added to the nose to change its shape.
  
  

Sometimes the wall that separates the nose into right and left (nasal septum) is twisted. We may need to correct it at the same time. The combined operation is called septorhinoplasty.

How successful is the operation?

Everybody’s nose and face is different, so it may not be possible to make your nose look exactly like your perfect nose.

The thickness of the skin is important in how much better the nose will look after rhinoplasty and in what can be done. If the skin is thin, it makes bumps or hollows in the nose difficult to hide. If it is thick not all changes that can be made on the inside will show up on the outside.

Your surgeon will aim to produce a nose that looks natural. However, your surgeon may not be able to say exactly how your nose will look after your operation. It is important that you discuss your expectations with your surgeon. 90-95% of patients are happy with the results of their operation but some people request more surgery.

How is the operation done?

Photographs will be taken to allow a record to be kept in your notes of how your nose looked before surgery, and to allow the surgeon to plan your operation.

Rhinoplasty and septorhinoplasty are usually performed with you asleep. Cuts are made inside your nose. Occasionally a small cut on the skin between the nostrils or at the base of the nostrils may be necessary. The skin of your nose is gently lifted off the bone and cartilage underneath. A hairline fracture may be made in the nasal bones to allow the surgeon to change the shape of the nose. Pieces of bone and cartilage can be removed from or added to the nose to smooth out any bumps or dips.

After the operation packs and splints

We may need to put a dressing in each side of your nose to keep things in place and prevent bleeding. The dressings are called ‘packs’, and they will block your nose up so that you have to breathe through your mouth.

We may take them out the morning after your operation. You may get a little bit of bleeding when the packs come out – this will settle quickly.

Sometimes we put small pieces of plastic in your nose to prevent scar tissue from forming. These are called ‘splints’ and we will take them out after a week.

You will have a temporary splint on the outside of the nose for a week. This should be kept dry.

Does it hurt?

Not really, but sometimes the front of your nose can be a bit tender for a few weeks.

What happens after the operation?

• Do not blow your nose for about a week, or it might start bleeding.
  
  
• If you are going to sneeze, sneeze with your mouth open to protect your nose.
  
  
• You may get some blood-coloured watery fluid from your nose for the first two weeks or so – this is normal.
  
  
• Your nose will be blocked both sides like a heavy cold for 10-14 days after the operation.
  
  
• We may give you some drops or spray to help this.
  
  
• It may take up to three months for your nose to settle down and for your breathing to be clear again.
  
  
• Try to stay away from dusty or smoky places.
  
  
• There will be some stitches inside your nose – these will dissolve and fall out by themselves.
  
  
• You may have some bruising and swelling around your nose and eyes for one to two weeks.
  
  
• Sleeping upright with extra pillows for a few days helps.
  
  
• Following rhinoplasty or septorhinoplasty, the skin of the nose is very sensitive to the sun. It is important to wear strong sunscreen and a hat for at least six months.
  
  
• The nose may feel a little stiff and numb for up to three months, particularly around the tip. Fine swelling may take up to a year to settle at which time the final results of surgery may be judged.
  
  

How long will I be off work?

You can expect to go home the day after your operation. You should rest at home for at least a week. Most people need one to two weeks off work, especially if their work involves heavy lifting or strenuous activity.

You should not play sports where there is a risk of your nose being knocked for six weeks

Possible complications

Sometimes your nose can bleed after the operation, and we may have to put packs into your nose to stop it. This can happen within the first 6 – 8 hours after surgery or up to 5 – 10 days after surgery. Very occasionally patients need to have another operation to stop the bleeding.

Infection in your nose is rare after this operation but if it happens it can be serious, so you should see a doctor if your nose is getting more and more blocked and sore.

Rarely, the operation may leave a hole in your septum inside the nose going from one side of your nose to the other. This can cause a whistling noise when you breathe, crusting with blockage or nosebleeds. Most of the time it causes no problems at all and needs no treatment. If necessary, further surgery can be carried out to repair a hole in the septum. Very rarely, you can have some numbness of your teeth, which usually settles with time.

About 5-10% patients need further operations in the future to further adjust the shape of the nose.

Is there any alternative treatment?

There are no pills or tablets that can be used to change the shape of the nose. Very rarely an injectable skin filler might be helpful for small refinements in the shape of the nose.In some cases a patient’s wish for rhinoplasty may be related to a disorder of body image (body dysmorphic disorder). These patients should not have surgery and should be offered a referral to a psychiatrist.

What is septal surgery?

The septum is a thin piece of cartilage and bone inside the nose between the right and left sides. It is about 7 cms long in adults. In some people this septum is bent into one or both sides of the nose, blocking it. Sometimes this is because of an injury to the nose, but sometimes it just grows that way. We can operate to straighten the septum.

Why have septal surgery?

• If you have a blocked nose because of the bend in the septum, an operation will help.
  
  
• Sometimes we need to straighten out a bent septum to give us room to do other things, such as sinus surgery. The operation is not meant to change the way your nose looks.
  
  
• In some cases a bent septum may occur with a twist in the outside shape of the nose. In these cases septal surgery may be combined with nose reshaping surgery (septorhinoplasty) to straighten the nose.
  
  

Do I have to have septal surgery?

A bent septum will not do you any harm, so you can just leave it alone if you want to. Only you can decide if it is causing you so much bother that you want an operation.

How is the operation done?

The operation takes about 30-45 minutes. You might be asleep after anaesthesia. The operation is usually all done inside your nose - there will be no scars or bruises on your face. We make a cut inside your nose and straighten out the septum by taking away some of the cartilage and bone and moving the rest of the septum back to the middle of the nose. Then we hold it all in place with some stitches. Complex cases may require a cut across the skin between the noses and may be combined with rhinoplasty procedures.

Packs and splints

• We may need to put a dressing in each side of your nose to keep things in place and prevent bleeding. The dressings are called ‘packs’, and they will block your nose up so that you have to breathe through your mouth. We will take them out the morning after your operation.
  
  

You may get a little bit of bleeding when the packs come out - this will settle quickly.

• Sometimes we put small pieces of plastic in your nose to prevent scar tissue from forming. They are called ‘splints’ and we will take them out after about a week.
  
  

Does it hurt?

Not really, but sometimes the front of your nose can be a bit tender for a few weeks.

After the operation

We may give you some drops or spray to help this. It may take up to three months for your nose to settle down and for your breathing to be clear again. Try to stay away from dusty or smoky places.

There will be some stitches inside your nose - these will dissolve and usually fall out by themselves.

• Do not blow your nose for about a week, or it might start bleeding.
  
  
• If you are going to sneeze, sneeze with your mouth open to protect your nose.
  
  
• You may get some blood colored watery fluid from your nose for the first two weeks or so - this is normal.
  
  
• Your nose will be blocked both sides like a heavy cold for 10-14 days after the operation.
  
  

How long will I be off work?

You can expect to go home the day after your operation. Sometimes it is possible to go home the same day. You will need to rest at home for at least a week

If you do heavy lifting and carrying at work, you should take two weeks off. You should not play sports where there is a risk of your nose being knocked for about a month.

Possible complications

Septal surgery is safe, but there are some risks. Sometimes your nose can bleed after this operation, and we may have to put packs into your nose to stop it. This can happen within the first 6 – 8 hours after surgery or up to 5 – 10 days after surgery. Rarely you may need to return to the operating theatre with another general anaesthetic to stop the bleeding.

Infection in your nose is rare after this operation but if it happens it can be serious, so you should see a doctor if your nose is getting more and more blocked and sore.

Rarely, the operation may leave you with a hole in your septum inside the nose going from one side of your nose to the other. This can cause a whistling noise when you breathe, crusting with blockage or nosebleeds. Most of the time it causes no problems at all and needs no treatment. Further surgery can be carried out if necessary to repair a hole in the septum.

Very rarely you may find that the shape of your nose has changed slightly, with a dip in the bridge of your nose. Most people do not notice any change, but if you are not happy with it, it can be fixed with surgery. Very rarely though, but you can have some numbness of your teeth, which usually settles with time.

Is there any alternative treatment?

Only an operation can fix a bent septum, but nose spray or drops can help treat swelling in the nose which might be making your nose feel blocked.

If septal deformity is the cause of your nasal blockage there is no treatment other than surgery to correct the shape of the septum.

What are sinuses?

Sinuses are air-filled spaces in the bones of the face and head. They are connected to the inside of the nose through small openings. The sinuses are important in the way we breathe through the nose and in the flow of mucus in the nose and throat. When the sinuses are working properly we are not aware of them but they often are involved in infections and inflammations which cause symptoms. These infections and inflammations are called sinusitis.

What is sinusitis?

Sinusitis is caused by blocked, inflamed or infected sinuses. Patients will often complain of a blocked nose, pressure or congestion in the face, runny nose or mucus problems. Other symptoms include headache and loss of sense of smell. Sinusitis can be difficult to diagnose and your specialist will want to examine your nose with a telescope in order to help find out what is wrong. Most patients with sinusitis get better without treatment or respond to treatment with antibiotics or nose drops, sprays or tablets. In a very small number of patients with severe sinusitis an operation may be needed. In rare cases if sinusitis is left untreated it can lead to complications with infection spreading into the nearby eye socket or into the fluid around the brain. These very rare complications are just some of the reasons that a sinus operation may become necessary.

What is endoscopic sinus surgery or FESS?

Endoscopic Sinus Surgery is the name given to operations used for severe or difficult to treat sinus problems. In the past sinus operations were done through incisions (cuts) in the face and mouth but endoscopic sinus surgery allows the operation to be performed without the need for these cuts. Before any operation patients will be treated using drops, tablets or sprays for a period of weeks if not months. Only if these treatments are unsuccessful will an operation become necessary. After an examination of your nose with a telescope your surgeon will discuss whether or not you will need to have a CT scan to help decide about the need for an operation.

Do I have to have the operation?

Endoscopic sinus surgery is only one approach to the treatment of sinusitis. Endoscopic sinus surgery is as safe, and possibly safer, than other methods of operating on the sinuses. The other methods of operating on the sinuses involve cuts in the face or mouth and if you feel that this may be more appropriate in your case you should discuss this with your surgeon.

In some patients an operation can be avoided by use of antibiotics and steroid medicines, again this should be discussed with your surgeon.

How is the operation done?

Usually the operation is done with you asleep (General Anaesthetic) but it can also be done with just your nose anaesthetised (Local Anaesthetic). The operation is all done inside your nose. The surgeon will use special telescopes and instruments to unblock your sinuses. Small amounts of bone and swollen lining blocking your sinuses are removed. Once the sinuses are unblocked, the inflammation usually settles and your symptoms should start to get better. Rarely there may be some bruising around the eye but this is very uncommon. There should be no need for incisions (cuts) unless the operation is a complicated one in which case this will have been discussed with you before the operation.

After the operation

Immediately after the operation you may feel your nose blocked. This may be because of some dressing inside your nose or some special plastic sheets called splints. These are not used in every case but your surgeon will explain if they have been necessary in your case. Dressings, if used, will usually be removed from your nose within 24 hours but plastic splints may have to stay longer.

It is common to have a stuffy blocked up nose even after removing the dressing or splints and this does not mean that the operation has not worked.

Does it hurt?

It is common for the nose to be quite blocked and to have some mild pain for a few weeks after the operation. This usually responds to simple painkillers.

Can I blow my nose?

It is important that you do not blow you nose for the first 48 hours following your operation. Your surgeon will advise you on when you can start to gently blow your nose. Some doctors recommend the use of drops, ointments and salt water sprays after the operation. You will be given specific instructions by the ward staff before your discharge from hospital. Some mucus and blood stained fluid may drain from your nose for the first week or two following the operation and this is normal. It is important to stay away from dusty and smoky environments while you are recovering.

How long will I be off work?

You can expect to go home on the day of your surgery or the day after your operation depending on the size of your operation. You will need to rest at home for at least a week. If you do heavy lifting and carrying at work you should be off work for at least 2 weeks. You will be given instructions on when to return to the hospital for your follow-up visit.

Possible complications

All operations carry some element of risk in the form of possible side effects. There are some risks that you must know about before giving consent to this treatment. These potential complications are very uncommon. You should discuss with your surgeon about the likelihood of problems in your case before you decide to go ahead with the operation.

How often do complications happen?

In general, complications are very rare. If you are particularly worried you should ask your surgeon about his or her experience of these complications.

What is allergy?

  Our bodies have an in-built and complex system to defend against microbes such as viruses and bacteria etc but when our immune system kicks up an overly heightened response on getting exposed to certain foreign substances, it is called allergy.

  What symptoms show onset of nasal allergy?

  Runny nose, stuffy nose, multiple recurring bouts of sneezing, itching in throat and/or nose – a patient with nasal allergy can show all these and some of these symptoms.

  How is nasal allergy treated?

  Unfortunately, the medical science still hasn’t found any permanent cure for allergies. Most medicines prescribed – such as antihistamines, with or without decongestants; steroid nasal sprays, or antihistamine-delivering nasal sprays or cromolyn sodium - can only offer symptomatic relief.  For those suffering from chronic allergy, allergy testing and allergy shots (also called immunotherapy) can help to an extent. The ENT doctor can also prescribe antihistamine and steroid sprays for long term usage but these must be used correctly.

  What is a blocked nose?

The sensation of a blocked nose is often referred to as nasal obstruction, a stuffy nose and nasal congestion. The severity of the nasal obstruction varies from one patient to the next. Some people find even mild nasal blockage quite troublesome, whereas others, with quite severe nasal obstruction, find it does not have a significant impact on their daily activities. Your specialist will take this into account when developing a plan for your treatment.

What causes a blocked nose?

Nasal obstruction can be due to problems with the shape of the inside of the nose, or swelling of the lining of the inside of the nose. Problems with the shape of the inside of the nose can be due to twisting of the middle partition of the nose (the nasal septum), or to weakness of the outside of the nose. Either of these may be associated with abnormalities of the shape of the outside of the nose. Occasionally other structures, such as the adenoids, can be enlarged leading to nasal obstruction.

The nose is lined by a thin mucous membrane which can swell to cause blockage. Folds of the mucous membrane called turbinates are particularly prone to swelling. We all experience this swelling in response to the common cold, in which case the lining swells in response to a viral infection. Doctors often refer to swelling of the lining of the nose as “rhinitis” and it can have many other causes. Apart from viral infections, rhinitis may be due to bacterial infection in the nose and sinuses, allergy, or overuse of nasal decongestant medication. Occasionally the mucous membrane swells enough to cause the formation of polyps in the nose.

What are the symptoms?

Nasal obstruction is a symptom in itself. In certain conditions it may be accompanied by other symptoms such as rhinorrhoea (nasal discharge, which can drip from the front of the nose, or into the back of the throat - catarrh), facial pain, anosmia (loss of sense of smell), sneezing, itching and crusting. Your specialist will consider these other symptoms when making a diagnosis and developing a plan for your treatment.

What can I do to help myself?

Mild nasal obstruction may not require any treatment. If your symptoms are short lived, lasting only a few days to a couple of weeks, you may want to treat it yourself using over the counter medication such as a decongestant nasal spray. Decongestant sprays should not to be used in the long term. Sometimes people find it soothing to breathe in steam, or vapours such as menthol and eucalyptus. Saline drops or sprays, or other nasal douching preparations from your pharmacist may also be used to help wash away any thick sticky mucus in your nose.

If your symptoms are caused by a seasonal allergy and are mild and intermittent an antihistamine tablet may help. Alternatively, your doctor may prescribe a steroid nasal spray. It is important to follow the instructions provided with this treatment. If the cause of your nasal obstruction is collapse of the outside of the nasal tip, you may find it useful to wear an adhesive dilating strip, particularly at night. If you find your symptoms troublesome and persistent, or if they are caused by an injury to your nose, you should contact your doctor for advice.

How is the condition diagnosed?

The first thing your specialist will do to diagnose your condition is ask some questions about your symptoms. Asking about your symptoms is very important to help narrow down the possible causes of your condition. To help clarify the cause of your symptoms your specialist will then examine your nose often with the help of a headlight or an endoscope (a thin telescope with a camera). This examination is not painful but some people find it slightly uncomfortable.

Occasionally your doctor may want to do some other tests to help clarify the cause of your symptoms. Common tests include blood tests, skin tests for allergy, and imaging studies such as a CT scan of the nose and sinuses. It is important to remember that not all conditions causing nasal obstruction need investigations. Your specialist will decide which investigations are necessary.

Treatment options

The treatment options for your blocked nose depend on the underlying cause and severity of your symptoms; they include medication and surgery. If the cause of your nasal obstruction is rhinitis your specialist may prescribe a course of medication such as an intranasal steroid spray, antihistamines or decongestants. It is important to follow your specialist’s instructions closely.

What is the correct manner of using steroid spray?

• Wash your hands thoroughly.
  
  
• Use a nasal decongestant or blow your nose gently to clear your nasal passages.
  
  
• Shake the steroidal spray container a few times.
  
  
• Close one nostril using index finger.
  
  
• Put the nozzle into the open nostril away from the nose’s midline (nasal septum) and spray straight back. Never spray up towards the tip of the nose. This becomes easy if you spray into the right nostril using the left hand and into the left nostril using the right hand.
  
  
• Sniff in gently and deeply to activate the spray and exhale through the mouth.
  
  
• Now repeat these steps for the other nostril.
  
  

Caution:  Spray only one nostril at one time. Spray into alternate nostrils each time. Never give two sprays in one nostril. One spray per nostril is sufficient.

What causes nosebleeds?

  Think about the human face. You will see that the nose protrudes out from the face and is actually rather vulnerable to injuries. A trauma on the face can cause injury to the nose and result in nosebleed (medically called epistaxis). Depending on the site and the extent of injury, this bleeding can be minor or major. Nosebleeds can occur on their own as well without an outside injury. It can also happen if the nasal membrane becomes overly dry and cracks open letting out blood.

  As a matter of fact, such nosebleeds are extremely common in very dry climates whether summer or winter. Plus, if a person is on anticoagulant or blood thinning medicine such as warfarin or aspirin or anti-inflammatory drugs, even minor traumas can result in heavy nosebleeds.

  Who are more prone to nosebleeds?

  Nosebleeds can happen more among people with:

 

• Infection  i.e. rhinosinusitis
  
  
• Allergic and nonallergic rhinitis
  
  
• Use of blood thinning drugs
  
  
• Trauma that can also be self-inflicted through actions such as nose picking. This is commoner in children.  
  
  
• Hypertension (high blood pressure)
  
  
• Alcohol abuse
  
  
• Pregnant women undergoing hormonal changes
  
  
• In rare cases, nosebleeds can be due to tumours or inherited bleeding disorders
  
  

  What is the recommended first-aid for stopping a common nosebleed?

Actually tackling a common nosebleed is easy and does not require help from a doctor. Of course, you should know the correct first-aid steps which we are outlining below:

 

• Use your index finger and thumb to pinch together the soft part of the nose.
  
  
• Compress the pinched part of the nose towards the face bones.
  
  
• Lean forward a bit and tilt the head forward as well. This will stop blood from running back into sinuses and throat which can lead to gagging or inhalation of blood.
  
  
• Keep on holding the pinched nose for minimum 5 minutes. Repeat the entire process until nosebleed stops.
  
  
• Keep the head higher than the level of the heart. Do not lie down. Do not put your head between your legs. Just sit quietly.
  
  
• Wrap some ice in towel and place it on cheeks and nose.
  
  
• If the problem recurs, visit your ENT physician for a checkup.
  
  

  When should I rush to a hospital’s emergency section over a nosebleed?

While most nosebleeds are the common type and can be handled at home, you need to watch out for the following symptoms and rush to the hospital immediately:

 

• If the bleeding is unstoppable or keeps happening again and again.
  
  
• If the bleeding is heavy and the blood loss seems considerable.
  
  
• If the patient is feeling faint or weak.
  
  
• If the nosebleed is happening due to facial trauma, or is accompanied by loss of consciousness or blurred vision.
  
  
• If the nosebleed is occurring with fever or headache.
  
  
• Last but not the least, if your infant or toddler gets a nosebleed, visit your pediatrician.
  
  

Is snoring a common problem?

Yes, at least 20% of the adult population snore regularly and loud enough to disturb those around them.

Why do some people snore and others do not?

The following 5 things are most likely to make you snore:

 

• Being overweight- People who are overweight are much more likely to snore than those who are the correct weight for their height. Gaining weight makes existing snoring worse and losing it makes snoring better.
  
  
  
  

• Getting older -Snoring gets worse with age.
  
  

• Gender -Men are three times more likely to snore than women, but of course women are also afflicted. After the menopause women tend to catch men up.
  
  

• Drinking alcohol- Alcohol makes snoring worse. This is a direct effect because alcohol relaxes the muscles of the throat and this causes airway collapse – the cause of snoring.
  
  

• Smoking -Smoking makes snoring worse.
  
  

    Some other factors that influence whether people snore

Families who snore

Snoring may run in families. Snoring is related to the shape of your throat, and in the same way that families look alike, they may snore alike!

A blocked nose

If you have a blocked nose at night, this may cause snoring. Correcting the nasal abnormality may reduce the snoring.

Sleeping position

Often lying on your side reduces snoring, particularly if it is not very severe. This is because when lying on your back, your tongue tends to fall backwards and block the airway.

In children

Large tonsils and adenoids can cause severe snoring and sleep apnoea in children. This may be so severe as to require urgent treatment.

What is sleep apnoea and is it related to snoring?

Sleep apnoea is when you stop breathing during sleep. The sleep apnoea which occurs in snorers is called obstructive sleep apnoea because the throat actually blocks while you are sleeping. Sufferers can be seen to be struggling for air and tend to wake with a loud grunt or snort. Sometimes they actually hear their own snoring and if a snorer is waking himself up at night, it is often because of sleep apnoea.

Apart from causing restless sleep, the sufferer may be very tired in the daytime because of the disturbed sleep. Such people may find it difficult to stay awake even when doing important tasks such as driving a vehicle. Sleep apnoea and snoring are part of the same condition. Bad snorers tend to develop sleep apnoea. The 5 important factors in snoring also apply to sleep apnoea. However, occasional stopping of breathing during sleep is not unusual. This can happen up to four times an hour and not be important, but if it is happening regularly and causing sleep disturbance and tiredness, it may well be significant.

When you visit our doctors

• You will be asked about the problem.
  
  
• You will be examined, including your weight and height to calculate your Body Mass Index (BMI).
  
  
• You will be advised about weight loss if appropriate.
  
  
• You may have some form of ‘sleep study’ recommended and arranged. This essentially involves measuring your blood oxygen level, breathing and pulse rate. It can be done in the hospital overnight.
  
  
• If the ‘sleep study’ reveals you have sleep apnoea specific treatment will be recommended: ‘Continuous Positive Airway Pressure’ (CPAP) treatment. This involves wearing a mask over your nose at night. The mask gently blows air into you all the time, holding the airway open during breathing. This treatment is effective but needs careful supervision, particularly at first and not all patients find it tolerable or useful.
  
  
• If your nose is blocked and the surgeon thinks this is contributing significantly towards the snoring, you may be offered an operation to clear your nose.
  
  
• If you are slim and have a narrow throat, you may be offered surgery to your palate to shorten or stiffen it so that the snoring stops. There are a range of operations done for this and you need to discuss the benefits and risks of what you are being offered.
  
  
• In children who snore badly or have obstructive sleep apnoea, tonsillectomy and adenoidectomy can be very effective in curing the problem.
  
  

What are the different surgical options to improve snoring and obstructive sleep apnoea?

The surgeon will first examine and investigate to identify the sites of airflow obstruction. Then as per the diagnosis, he may decide to undertake single or multiple procedures in one stage or in multiple stages to minimize these obstructions and bring relief from snoring and sleep apnoea.

Surgical treatments for obstructive sleep apnoea  available in our hospital include:

Septoplasty and Turbinate Reduction:

The septum is a bony partition that divides the nose into two nostrils. A bent septum can block the air passage and cause airflow obstructions. Septoplasty is a surgical procedure for straightening the bent septum and clearing the airway. Turbinates are curved bones along the walls of the nasal passage. Enlarged turbinates can also block the airflow and worsen the sleep apnoea. Reducing their size makes the airway bigger and brings relief.

Uvulopalatopharyngoplasty (UPPP):

In this surgery, the soft palate (at the back of the roof of your mouth) is trimmed or adjusted forward. In addition, your tonsils and uvula may also be removed. While this is a common surgical treatment for sleep apnoea, its effectiveness varies from patient to patient, depending on the size of the tonsils, palate, jaw, and tongue.

Barbed stitch Palatoplasty:

is a form of repositioning the palate to widen the airway at the level of nasopharynx and oropharynx. A barbed suture is a type of knotless surgical suture that has barbs on its surface. While suturing tissue, these barbs penetrate inside the tissue and lock them into place, eliminating the need for knots to tie the suture.

Midline Glossectomy and Base of Tongue Reduction:

These two procedures enlarge the airway by removing a section of the back half of the tongue. Latest surgical techniques such as coblation are making these surgeries more common and easier as well. In severe cases, the surgeon can opt for more aggressive procedures as detailed below:

Hyoid Suspension:

If the airway is getting blocked at the base of your tongue, the surgeon can seek to connect your hyoid bone (a U-shaped bone in the front of your neck that supports the tongue) to the bony projection in the front part of the throat known as "Adam's apple" or suspend it from your jaw to keep the airway open and check sleep apnoea.

Genioglossus Advancement (GGA):

GGA is a specialized procedure to open the airway in order to treat sleep apnoea. The surgeon tightens a tendon in the front section of the tongue so that it can’t slide back and close off the breathing passage. In most cases, GGA is combined with UPPP or hyoid suspension.

Maxillomandibular Osteotomy (MMO) and maxillomandibular advancement (MMA):

These surgeries are probably the best treatments for severe sleep apnoea. In it, the airway is enlarged by making cuts into the jawbones to pull the jaws forward. However, these are complex surgeries that require overnight hospital stay. Plus, the surgeon may choose to shut your jaw using wires for a few weeks to ensure optimal healing.  

What are tonsils and adenoids?

Tonsils are small glands in the throat, one on each side. They are there to fight germs when you are a young child. After the age of about 3 years, the tonsils become less important in fighting germs and usually shrink. They are lymph-like soft tissue located on both sides of the back of the throat. Along with adenoids (soft tissue behind the nose), tonsils help your body fight infection by producing antibodies to combat bacteria that enter through the mouth and nose.

Approximately 600,000 people have their tonsils removed each year.

Does my child / Do I need them?

Your body can still fight germs without them. We only take them out if they are doing more harm than good.

Why take them out?

We will only take your child’s tonsils out if he or she is getting lots of sore throats, which are making him or her lose time from school. Sometimes small children have tonsils so big that they block their breathing at night.

Before your child’s operation

Arrange for a week off school. Let us know if your child has a sore throat or cold in the week before the operation - it will then be safer to put it off for a week. It is very important to tell us if your child has any unusual bleeding or bruising problems, or if this type of problem might run in your family.

How is the operation done?

Your child will be asleep. We will take his or her tonsils out through the mouth, and then stop the bleeding. This takes about 20 minutes. Your child will then go to a recovery area to be watched carefully as he or she wakes up from the anesthetic. He or she will be away from the ward for about an hour in total.

What is coblation tonsillectomy?

  Unlike traditional tonsillectomy procedures, which remove tonsils by burning or cutting, Coblation is an advanced technology that combines gentle radiofrequency energy with natural saline — to quickly, and safely remove tonsils. Because traditional procedures use high levels of heat to remove the tonsils, damage to surrounding healthy tissue is common.

  Coblation does not remove the tonsils by heating or burning, leaving the healthy tissue surrounding the tonsils intact. The innovative approach of Coblation results in minimal pain and rapid recovery for patients. Coblation has been used in nearly three million procedures by surgeons in ear, nose, and throat (ENT) and other areas of medical specialty.

  How chronic tonsil problems are usually treated?

  Depending on symptoms, and the frequency of infection, tonsils are typically treated with antibiotics or removed surgically in a procedure called a tonsillectomy.

  How is coblation tonsillectomy performed?

  Coblation uses radiofrequency energy and natural saline, not heat, to gently dissolve tonsil tissue and remove the infected or enlarged tonsils. Coblation Tonsillectomy is a quick outpatient procedure that takes less than 30 minutes, and is performed in an operating room with general anesthesia. Most patients stay in the hospital only a few hours.

A coblator machine and wand

  Why is coblation tonsillectomy a better choice?

  Patients report a better overall experience with Coblation Tonsillectomy after surgery when compared to traditional procedures. Studies show that patient calls and visits to the doctor due to complications after surgery are significantly less with Coblation Tonsillectomy.

  Because of tissue damage caused by the heat of traditional tonsillectomy procedures, patients often take up to two weeks to return to a normal diet and to resume normal activity. Coblation Tonsillectomy is the gentle alternative offering a rapid recovery and minimal pain, with most patients resuming a normal diet and activities within just a few days.

  Am I a Candidate for Coblation Tonsillectomy?

  If your doctor recommends your tonsils and/or adenoids be removed, you are a candidate

  Why have your tonsils removed?

  Tonsils and adenoids can cause health problems when they become infected or obstruct normal breathing or nasal/sinus drainage. Recurring infections in the tonsils can lead to chronic tonsillitis. Symptoms include fever, persistent sore throat, redness of the tonsil area, yellow discharge on the tonsils, and tender lymph nodes on both sides of the neck.

It is common for patients who have undergone Coblation Tonsillectomy to feel better than expected following their surgery, with most patients resuming a normal diet and activities within just a few days.

In addition to blocking the throat, enlarged tonsils may interfere with normal breathing, nasal sinus drainage, sleeping, swallowing and speaking. They may also aggravate snoring and can even cause an alarming condition called sleep apnea which involves an occasional stoppage of breathing.

  After the procedure

Your doctor or nurse will provide postoperative instructions, which may include antibiotics and other medicines for up to 1 week. Some minor pain medication may also be prescribed.

  How long will my child be in hospital?

  In our hospitals, tonsil surgery is done as a day case, so that he or she can go home on the same day as the operation. Rarely, we may keep children in hospital for one night. It may depend on whether your child has their operation in the morning or the afternoon. Either way, we will only let him or her goes home when he or she is eating and drinking and feels well enough.

Can there be problems?

Tonsil surgery is very safe, but every operation has a small risk.

The most serious problem is bleeding. This may need a second operation to stop it. but only 1 child out of every 100 will need a second operation.

Your child’s throat will be sore

Your child’s throat will get better day-by-day. Give him or her painkillers regularly, half an hour before meals for the first few days. Do not give more than it says on the label. Do not give your child aspirin - it could make your child bleed.

Eat normal food

Eating food will help your child’s throat to heal. It will help the pain too. Always give him or her a drink with every meal. Chewing gum may also help the pain.

Your child may have sore ears

This is normal. It happens because your throat and ears have the same nerves. It does not usually mean that your child has an ear infection. The removal of enlarged tonsils like this can relieve airway obstruction.

Your child’s throat will look white

This is normal while your throat heals.

This is normal while your throat heals. You may also see small threads in your child’s throat – sometimes these are used to help stop the bleeding during the operation, and they will fall out by themselves.

Some children get a throat infection after surgery, usually if they have not been eating properly. If this happens you may notice a fever and a bad smell from your child’s throat. Call your hospital doctor for advice if this happens.

Keep your child off school for 7 days

Make sure he or she rests at home away from crowds and smoky places. Keep him or her away from people with coughs and colds. Your child may also feel tired for the first few days.

Bleeding can be serious

If you notice any bleeding from your child’s throat, you must see a doctor. Go to our hospital casualty department which is 24 hrs.

What are the adenoids?

Adenoids are small glands in the throat, at the back of the nose. In younger children they are there to fight germs. We believe that after the age of about 3 years, the adenoids are no longer needed.

Do we need our adenoids?

Your body can still fight germs without your adenoids. They probably only act to help fight infection during the first three years of life; after then, we only take them out if they are doing more harm than good.

Why do adenoids cause problems?

• Sometimes children have adenoids so big that they have a blocked nose, so that they have to breathe through their mouths.
  
  
• They snore at night.
  
  
• Some children even stop breathing for a few seconds while they are asleep. The adenoids can also cause ear problems by preventing the tube which joins your nose to your ear, from working properly.
  
  

  Some benefits of removing adenoids

For children with glue ear

For children over three years of age, removing the adenoid at the same time as putting grommets in the ears seems to help stop the glue ear coming back.

Reduces colds

Removing the adenoid may reduce the problem of a blocked nose when your child has a cold

Is there an age limit for adenoidectomy?

Adenoidectomy is generally avoided in children under 12 kgs, approximately 2 and a half years of age, because of the small risk of blood loss during or after the operation. There is no upper age limit, but the adenoid has usually shrunk to almost nothing by the teens.

How are the adenoids removed in the 21st century?

The traditional technique is to use a curette, which is a special type of surgical cutting device. This is a safe technique, although a consideration for small children having the operation is that the blood loss may be higher at the time of surgery.

Other techniques are becoming more popular.

• Electric diathermy and Coblation dissection have the advantage of less blood loss at the time of surgery. At our hospital, we are using coblation and microdebrider.
  
  
• The laser has fallen out of favor because of the much higher levels of pain after the operation.
  
  

Is it true that the adenoid may grow back?

This is possible but uncommon.

Who is suitable for day case surgery and who would require inpatient stay?

Generally, children who are fit and well with no bleeding or bruising disorders are fit for day surgery.

What is the recovery time after surgery?

It is wise to allow a one week convalescence period.

Is there any long-term risk to having your adenoids removed (e.g. reduced immune function)?

There is no good evidence that adenoidectomy reduces immune function or makes people more prone to chest infections. If possible, it is probably wise to avoid adenoidectomy in children less than 2 and a half years of age as the adenoids may be helping develop their ability to fight off infections.

What makes you decide to remove the tonsils at the same time?

If your child gets lots of tonsillitis (sore throats) or has difficulty breathing at night then we may decide to take out the tonsils at the same time as the adenoids.

Preparing for your child’s operation or things to do before your child’s operation

Arrange for a week at home or off school after the operation.

Things we need to know before the operation

Let us know if your child has a sore throat or cold in the week before the operation - it will be safer to put it off for a week. It is very important to tell us if your child has any unusual bleeding or bruising problems, or if this type of problem might run in your family.

How is the operation done?

• Your child will be asleep.
  
  
• We will take his or her adenoids out through the mouth, and then stop the bleeding. This takes about 20 minutes.
  
  
• Your child will then go to a recovery area to be watched carefully as he or she wakes up from the anesthetic.
  
  
• He or she will be away from the ward for about an hour or two in total.
  
  

How long will my child be in hospital?

In our hospitals, adenoid surgery is done as a day case, so that he or she can go home on the same day as the operation. Some surgeons may prefer to keep children in hospital for one night. Either way, we will only let him or her go home when he or she is eating and drinking and feels well enough.

Most children need no more than a week off nursery or school. They should rest at home away from crowds and smoky places. Stay away from people with coughs and colds.

Can there be problems?

• Adenoid surgery is very safe, but every operation has small risks.
  
  
• The most serious problem is bleeding, which may need a second operation to stop it. However, bleeding after adenoidectomy is very uncommon. It is very important to let us know well before the operation if anyone in the family has a bleeding problem.
  
  
• During the operation, there is a very small chance that we may chip or knock out a tooth, especially if it is loose, capped or crowned. Please let us know if your child has any teeth like this.
  
  

After the operation

• Some children feel sick after the operation. This settles quickly.
  
  
• A small number of children find that their voice sounds different after the surgery. It may sound like they are talking through their nose a little. This usually settles by itself within a few weeks. If not, speech therapy is helpful.
  
  
• Your child’s nose may seem blocked up after the surgery, but it will clear by itself in a week or so.
  
  

Your child’s throat may be a little sore

• Give painkillers as needed for the first few days.
  
  
• Prepare normal food. Eating food will help your child’s throat to heal.
  
  

Your child may have sore ears

• This is normal. It happens because your throat and ears have the same nerves. It does not usually mean that your child has an ear infection.
  
  

Your child may also feel tired for the first few days

• This is normal.
  
  

Keep your child off school for 2 to 7 days

• Make sure he or she rests at home away from crowds and smoky places.
  
  
• Keep him or her away from people with coughs and colds.
  
  

  ABOUT HOARSENESS &  MICROLARYNGOSCOPY

  What is Hoarseness?

Hoarseness or Dysphonia means a change in the sound of someone’s voice. People suffering from hoarseness can experience a strained, husky or breathy voice.

• They may also notice a difference in loudness and/or changes in how high or low their voice sounds (Pitch).
  
  
• Changes in voice pitch are common in young children as they grow through puberty (voice ‘breaking’).
  
  
• A complete loss of voice, resulting in only a whisper, is called Aphonia.
  
  

What causes Hoarseness?

Normally when we talk/sing the vocal cords come together and vibrate. This creates a sound which we know as the voice. Hoarseness results from the vocal cords in the voice box (Larynx) not working properly. There are several causes of hoarseness, fortunately most are not serious and tend to go away after a short period of time. Common causes are:

• A viral upper respiratory tract infection, causing the voice box lining to swell (Laryngitis)
  
  
• Stomach acid/enzymes irritating the throat (Laryngopharyngeal Reflux)
  
  
• A build-up of soft tissue (polyps) or thickenings (nodules) on  the vocal cords. These can develop when the voice is used too much or too loudly for long periods of time (Singer’s Nodules). Vocal cord polyps are often related to smoking.
  
  
• Problems with the strength of the lungs can also lead to a change in voice
  
  
• Rarely a growth or tumour develops on the vocal cords and or voice box. These may be noncancerous (benign) or cancerous (malignant).
  
  
• Problems with movement of the vocal cords (paralysed vocal cords). One or both of the vocal cords may be paralysed if it’s nerve is affected by infection or tumour.
  
  

How is Hoarseness treated?

A key question here is whether the hoarseness is constant or getting worse or does it come and go with periods of “normal” voice in between.

Intermittent mild episodes of hoarseness: In most cases this will settle by itself. To help relieve the symptoms one can:

• rest the voice (but don’t resort to whispering which can make matters worse).
  
  
• drink plenty of fluids (avoid too many fizzy drinks).
  
  
• avoid alcohol.
  
  
• avoid cigarette smoke.
  
  
• take Antacids if you get a buildup of acid in the throat.
  
  

Persistent and / or worsening hoarseness

People suffering from the following symptoms should seek urgent medical advice from a doctor:

• Prolonged hoarseness for more than four weeks
  
  
• repeated spells of hoarseness without reason
  
  
• Prolonged sore throat or difficulty swallowing for more than two weeks
  
  

It is particularly important to see the doctor with these symptoms if the person is a smoker or drinks more than the recommended amount of alcohol.

What will the ENT surgeon do?

The surgeon will examine the throat to help identify the cause of the hoarseness. This is done by passing a flexible telescope through the nose (Fibreoptic Endoscope). This examination is done at the time of your outpatient visit and does not require hospital admission. Depending on the clinical findings, the following treatments may be recommended:

Simple advice:

As described above for intermittent mild hoarseness.

Voice therapy (Speech and Language Therapist):

The majority of patients will have no structural abnormality identified. The problem with their voice will be related to the way they are using their voice i.e. they are ‘straining’ it in some way. In this case a voice therapist will be able to give advice or suggest exercises that might help the quality of the voice. Voice therapy may require more than one visit to the therapist.

Microlaryngoscopy

An operation to remove nodules, polyps and non cancerous (benign) tumors may be recommended if these are identified at the outpatients visit. This type of operation is usually done under general anesthetic using a rigid telescope (Endoscope) and a microscope (to provide magnification). It can remove the problem in the case of polyps, nodules or cysts and will provide a piece of tissue for laboratory analysis (a biopsy). If a malignant (cancerous) tumor of the larynx is diagnosed by biopsy then further treatment will be planned at a cancer team meeting and discussed with the patient.

What is Microlaryngoscopy?

Microlaryngoscopy is the examination of your larynx (voice box) while you are under a general anaesthetic.

Why do you need the operation?

Microlaryngoscopy is done to find and treat problems of the voice box, such as hoarseness. Your surgeon will put a short metal tube (laryngoscope) through your mouth into your voice box. A microscope is then used to look into the voice box to find the problem. If needed, surgery on your voice box can also be done through the laryngoscope with very fine instruments.

If there are any problem areas, a small part of the lining of the voice box is taken away for laboratory examination. This is called a biopsy. Depending on the type of problem a laser might be used. Microlaryngoscopy is quite a short operation and usually takes less than 30 minutes.

How will I feel after the operation?

You may find that your throat hurts. This is because of the metal tubes that are passed through your throat to examine the voice box. Any discomfort settles quickly with simple painkillers and usually only lasts a day or two. Some patients feel their neck is slightly stiff after the operation.

After microlaryngoscopy, you should be able to use your voice as normal after the procedure. If the surgeon has taken a biopsy from your voice box, he may advise you to rest your voice for a short period. Your voice may sound worse, especially if any biopsies have been taken. This should be temporary until the lining of the voice box heals. You can usually eat and drink later the same day

Possible complications

Microlaryngoscopy is very safe. You may have a slightly sore throat afterwards. Very rarely, there is a risk that the metal tubes may chip your teeth. Your surgeon uses a gum guard to help prevent this happening.

Things to think about before your operation

If you have a history of neck problems, you should inform the surgeon about this before your operation. Please also advise your surgeon of any loose or capped teeth before the operation.

When will I know whathappened?

Your surgeon will usually be able to tell you what was found, and what they did to help you, on the same day as your operation. If any biopsies were taken, these normally take a few days to process in a laboratory. Your surgeon will arrange to see you again for your results.

When can I go home?

Usually you can go home the same day as the operation, as long as you have someone with you. Depending on how you feel afterwards, you may need to stay overnight for observation.

When can I go back to work?

You may be advised to stay off work for a few days to rest your throat, depending on your job.

Is there any alternative treatment?

There is no alternative to microlaryngoscopy to achieve a detailed examination of the voice box.

Summary

Hoarseness is very common and usually due to simple problems that get better quickly with simple painkillers, drinking water and rest. Very occasionally however it can be a warning symptom that something more serious is wrong with the throat or voice box. This is especially important to remember in people who smoke and if the hoarseness persists or seems to get worse over a period of several weeks.