SUSAH BERNAFAS SEBAB HIDUNG TERSUMBAT

Hidung tersumbat boleh menyebabkan seseorang merasa sesak nafas, tidur berdengkur, bernafas melalui mulut, suara sengau, sakit kepala, berat kepala, letih dan lesu. Seringkali hidung menjadi tersumbat oleh sebab jangkitan virus atau bakteria semasa demam selsema dan ia akan pulih dalam masa yang singkat. Walaubagaimanapun ada sesetengah pesakit gejala hidung tersumbat ini berlaku pada bila-bila masa atau berpanjangan.

Ruang hidung manusia terbahagi kepada dua; belah kanan dan kiri. Ia dipisahkan oleh tulang tengah iaitu ‘septum’. Masalah hidung tersumbat boleh disebabkan oleh bentuk septum yang bengkok atau bengkakan pada selaput dalam hidung. Selaput hidung boleh menjadi bengkak disebabkan jangkitan kuman, alahan (alergi), polip hidung (nasal polyposis) atau ketumbuhan hidung (tumour). Pada peringkat umur kanak-kanak tisu adenoid yang besar seringkali menjadi punca hidung tersumbat. Terdapat juga insiden di mana bendasing menyebabkan sebelah hidung tersumbat dan berair pada kanak-kanak.

Apa lagi gejala lain berkaitan dengan hidung tersumbat?

Doktor akan bertanya beberapa soalan seperti berikut:

• Berapa lama masalah ini berlaku?
• Hidung sebelah mana atau kedua-duanya yang tersumbat?
• Adakah masalah ini semakin serius dalam jangka masa terdekat?
• Adakah tuan/puan mengalami sentiasa bersin, hidung gatal, hidung berair?
• Adakah tuan/puan mengalami masalah sakit kepala, tidur berdengkur?
• Bagaimana dengan deria bau dan rasa? Adakah ia berkurangan?
• Pernah mengalami hidung berdarah?
• Pernah mengalami trauma pada hidung?
• Adakah tuan/puan menggunakan ubat sembur hidung yang mengandungi pseudoephedrine atau mengambil ubat aspirin?
• Adakah tuan/puan mengalami masalah kesihatan yang lain seperti lelah, darah tinggi, masalah tiroid etc?

Bagaimana doktor pakar ENT mengenalpasti punca hidung tersumbat?

Setelah mendapat riwayat penyakit dengan teliti, pakar ENT akan memeriksa bahagian ruang hidung dengan menggunakan skop di klinik. Ini membolehkan pakar tersebut melihat dengan lebih jelas ruang dalam hidung dan mengenalpasti punca hidung tersumbat. Selalunya imej skop tersebut disambung kepada kamera dan dipaparkan di atas skrin TV agar pesakit juga dapat melihat dengan sendiri.

Kadangkala doktor akan mengesyorkan pemeriksaan lanjutan seperti ujian darah, ujian alahan atau CT scan. Tetapi ini bergantung kepada setiap kes pesakit dan bukan semua pesakit perlu pemeriksaan lanjutan tersebut.

Rawatan bagi hidung tersumbat

Rawatan hidung tersumbat bergantung kepada puncanya. Sekiranya ia berkaitan demam selsema, rawatan perubatan dapat memulihkan keadaan yang selalunya bersifat sementara.

Rawatan perubatan yang sering disyorkan termasuk ubat sembur hidung (intranasal steroids, nasal decongestant, saline wash/spray) dan pil (antihistamine, decongestant) dalam pelbagai kombinasi. Antibiotik juga perlu sekiranya ada jangkitan bakteria. Ia adalah penting bagi pesakit menggunakan ubat seperti yang disarankan oleh doktor yang merawat. Kadangkala ia mengambil masa beberapa minggu untuk hidung tersumbat menjadi lega.

Sekiranya rawatan perubatan gagal untuk memulihkan masalah hidung sumbat, pakar ENT mungkin mengesyorkan pembedahan (surgeri). Jenis pembedahan bergantung kepada punca masalah hidung tersumbat. Contohnya pembedahan septum (septoplasty) dinasihatkan sekiranya pesakit mengalami tulang septum yang bengkok. Ada juga pembedahan turbinat hidung untuk mengecutkan selaput yang bengkak. Endoscopic sinus surgery pula disyorkan bagi mereka yang bermasalah polip hidung dan sinusitis. Tisu adenoid yang bengkak juga boleh dibedah sekiranya rawatan perubatan gagal. Perlu diingatkan bahawa ada beberapa cara untuk mengatasi masalah hidung tersumbat dan doktor pakar akan menasihatkan rawatan yang paling sesuai bagi setiap pesakit.

Laryngopharyngeal reflux- the chronic cough

Have you experienced an irritating cough that doesn’t get better despite cough mixtures and antibiotics? If yes, then you may be suffering from laryngopharyngeal reflux (LPR); also known as ‘silent reflux’. Most patients may not have the typical symptoms of gastroesophageal reflux (GERD) such as heartburn.

LPR occurs when the acid contents of the stomach is washed up (refluxed) all the way up to the throat (larynx) and even the back of the nose. It may be due to laxity of the muscle sphincter or gatekeeper between the oesophagus and stomach. The mucosal lining of the throat gets inflamed when exposed to the acid.

Symptoms of laryngopharyngeal reflux (LPR)

• Chronic cough
• Frequent throat clearing
• Feeling of mucous at the back of the throat
• Hoarseness
• Foreign body sensation or feel of a ‘lump’ in the throat
• Difficulty swallowing
• Sore throat
• Difficulty breathing

Diagnosis of laryngopharyngeal reflux

Most of the time the ENT Surgeon would make a diagnosis of LPR from the medical history and throat examination with a 70 degree scope or flexible nasopharyngolaryngoscope. This will allow visualization of the larynx, showing inflammation of the vocal cord and surrounding areas.

Sometimes a double probe pH monitoring may be required. This involves inserting a small tube through the nose into the oesophagus to record the frequency and severity of the acid reflux. This would have to be worn for 24 hours. However this test is only necessary for certain cases.

Treatment of laryngopharyngeal reflux

The inflammation of the larynx due to acid reflux may take weeks to months to recover. The doctor would recommend some medication such as proton pump inhibitors, antacids, prokinetic agents.

However it is also important that the patient adhere to some lifestyle changes for better recovery and control of the reflux in the long run. Smoking habit and some food can aggravate the condition. Patients who are obese and overweight are also prone to LPR.

Most patients respond well to medication and lifestyle modification/ dietary change. Some may require prolonged treatment. Only a few patients may not respond to the above measures and require surgery; which involves wrapping around the muscle sphincter to improve its strength.

Home care measures for LPR

• Stop smoking
• Lose weight
• Avoid alcohol
• Avoid caffeinated drinks such as coffee, tea including cola fizzy drinks
• Avoid acidic fruit juices such as orange, grapefruit, tomato
• Avoid spicy and fatty foods such as curry, tomyam even tomato based sauces
• Do not wear tight fitting cloths especially at the waist
• Stop eating at least 3 hours before going to bed
• Elevate the head of the bed at least 4-6 inches
• Take the medications prescribed according to instructions. Proton pump inhibitors are taken 30 minutes before meals and most are given for twice a day.

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SINUSITIS

Article published in KPJ Klang Specialist Hospital website
Link to article Sinusitis authored by Dr Mazita Ami

Sinuses are air-filled spaces located within the skull bones.  These sinuses are situated behind the forehead, cheek, around the eyes and nasal bones. Sinusitis occurs when there is inflammation of the sinuses due to viral, bacterial or fungal infection.

These sinuses (frontal, maxillary, ethmoid and sphenoid) are usually lined with mucosal membranes and drain into the nasal cavities. The mucous clearance from the sinuses occurs by the sweeping mechanism of small hair like structures called cilia. This ciliary mechanism can be affected by certain medical conditions such as cystic fibrosis and Kartagener’s syndrome. Upper respiratory tract infection, allergies and deviated nasal septum can also cause blockage of the sinuses. Chronic smoking can also affect the ciliary function

and lead to sinusitis.

Symptoms of sinusitis

Sinusitis usually follows a cold that does not improve after 5-7 days. The symptoms include

• Nasal block
• Post nasal drip
• Nasal drip (rhinorrhoea)
• Headache
• Cough
• Bad breath or loss of smell
• Fever
• Fatigue

How is sinusitis diagnosed?

The doctor would obtain a complete medical history and ask for the above symptoms.

Nasal endoscopic examination can be performed which enables close inspection of the nasal cavities and the sinus openings. Features of sinusitis would include inflamed turbinates and nasal mucosa with yellowish discharge (mucopus). Presence of nasal polyps would also be inspected.

Computed tomography (CT scan) of the sinuses can further confirm the diagnosis and will show the extent of the sinuses involved. It can also show the anatomy of the sinuses and determine if surgery is necessary. Magnetic resonance imaging (MRI) may also be performed if there is suspicion of tumour or fungal infection.

Treatment

Treatment of sinusitis would be directed at decongesting the nose and treating the infection.

Broad-spectrum antibiotic is prescribed for 10-14 days. Oral decongestants are also given to help open up the blocked sinus openings. Nasal decongestant sprays are also beneficial. However caution is taken that it is not used for more than 3-5 days as it cause worsening of the nasal congestion. Other medications would include analgesics (painkillers), nasal saline sprays and mucolytics. Nasal corticosteroid sprays have also been shown to be beneficial in acute sinusitis, more so in patients with allergies and nasal polyps.

If fungal infection is suspected, treatment is more intensive and often surgery is advised. Invasive fungal infection is life threatening and would require inpatient treatment and immediate sinus surgery.

Is sinusitis a serious condition?

Sinusitis especially when acute can lead to life-threatening complications. Because of the close proximity of the sinuses to important structures, infections can easily spread with devastating effects. The complications include eye infections, eye abscess, blindness, meningitis, brain abscess and encephalitis.

Symptoms of possible complication are swelling or redness around the eyes, headache not relieved with over-the-counter medicine, nausea, vomiting or changes in vision. These symptoms require immediate medical attention.

Does sinusitis require surgical treatment?

Most cases of acute sinusitis would resolve with adequate medications. However patients with nasal polyps, anatomical blockage of sinuses and allergies are prone to get recurrent or chronic sinusitis. This category of patients would often require sinus surgery.

How is sinus surgery performed?

Sinus surgery is performed with the use of nasal endoscopes (Endoscopic sinus surgery). This enables the ENT Surgeon to perform the surgery via the nostrils without any external skin incisions. The surgery is aimed to open the blocked or narrowed sinus openings, correction of deviated nasal septum, removing nasal polyps and drainage of the sinuses.

Nowadays, balloon sinuplasty is also being performed to widen the narrowed or blocked sinus openings. The ENT Surgeon would be able to advise if this type of sinus surgery is suitable for the patient.

CHRONIC OTITIS MEDIA

Article published in KPJ Klang Specialist website
Link to website article: Chronic Otitis Media authored by Dr Mazita Ami

Chronic otitis media occurs due to chronic inflammation or infection of the middle ear mucosa and mastoid air cells.

It can occur from an acute otitis media infection that does not resolve completely or repeated infections. It usually presents as persistent ear discharge, reduced hearing and a perforated ear drum. Pain and fever are less common symptoms compared to patients with acute otitis media.

How does it occur?

It starts with an upper respiratory tract infection that causes nasal congestion and blockage of the Eustachian tube. This will lead to poor equalization of pressure in the middle ear thus causing fluid accumulation in the middle ear.

This fluid may get infected with bacteria and cause an acute infection.

If the Eustachian tube is continuously blocked or the infection not adequately treated the middle ear infection persists and lead to ear drum perforation and damage to the ossicles.

Treatment for chronic otitis media

Ear care is very important and patients are advised to prevent water entering the ears whilst bathing. Swimming is also discouraged when there is ongoing infection and perforated ear drums. This is to prevent the vicious cycle of repeated infections.

Antibiotic ear drops and oral antibiotics are prescribed. Nasal decongestants are often given to help alleviate the underlying nasal congestion.

If the infection resolve and the patient is left with a dry perforated ear drum, surgical repair of the ear drum (myringoplasty) can be performed. Sometimes there is need to repair the damaged ossicles at the same time.

However if the ear discharge and infection persists despite adequate medical treatment, mastoid surgery is advised to rid of the diseased mastoid bone and achieve a healthy ear.

When is it not just a ‘simple’ ear infection?

Otitis media or infection of the middle ear can spread to surrounding structures and cause complications. These complications include meningitis, brain abscess, inner ear infection and facial weakness. Symptoms to look out for are severe headache, nausea, vomiting, dizziness/spinning sensation with hearing loss.

HEARING LOSS

The ear is divided into three parts that is the external ear, middle ear and inner ear. The external ear consists of the pinna and external ear canal limited by the ear drum. The middle ear is an air-filled space deep to the ear drum which houses the ossicles, facial nerve and connected to the Eustachian tube and mastoid air cells. The inner ear is a fluid filled labyrinth surrounded by solid bone and contains the organ for hearing (cochlea) and balance (semicircular canals, saccule and utricle).

A person can hear when sound waves travel through the external ear canal and hits the ear drum whose vibrations are transmitted via the ossicles to reach the cochlea. Nerve impulses generated by the cochlea are then transmitted by the cochlea nerve to the brain which interprets the sound. Any disruption along this chain of events can lead to hearing loss.

Types of hearing loss

Hearing loss is divided into three types such as conductive hearing loss, sensorineural hearing loss or mixed hearing loss. The type of hearing loss can be determined by performing a pure tone audiometric test. This test can also assess the degree of hearing loss; mild, moderate, severe or profound. However the ENT surgeon would perform an ear examination to assess the condition of the ear before performing the hearing test.

Conductive hearing loss

Conductive hearing loss occurs when there is disruption of the conducting mechanism in the hearing pathway. It can be due to simple causes such as impacted ear wax, foreign body or external ear infection, otitis externa. Perforated ear drum, middle ear fluid and damaged ossicles due to otitis media or otosclerosis can also cause conductive hearing loss.

Sensorineural hearing loss

Sensorineural hearing loss occurs when there is damage to the inner ear structures such as the cochlea or the cochlear nerve. This often occurs due to aging and is called presbyacusis. It can also occur due to infection or less commonly tumours. If a patient has one-sided sensorineural hearing loss, an assessment by the ENT surgeon is necessary to exclude brain tumour (cerebellopontine angle). Sensorineural hearing loss can also be congenital; present since birth. And it is important to detect this early because it can affect the speech development of the child.

Mixed hearing loss

Mixed hearing loss means there is impairment in both the conductive and sensorineural components of the hearing mechanism. This usually occurs in patients with chronic otitis media which can cause damage to the ear drum, ossicles and cochlea.

Treatment of hearing loss

The treatment would depend on the type of hearing loss and if the cause is reversible. Most conductive hearing loss can be cured by treating the underlying cause. If there is impacted ear wax or foreign body then it only requires removal of the offending objects. Perforated ear drum, damaged ossicles and otosclerosis can be repaired surgically. Middle ear fluid can be resolved with medication and if that fails then myringotomy with grommet insertion is performed. The chances of surgical success of each of the procedures should be discussed with the ENT surgeon.

Patients with sensorineural hearing loss would be advised to use hearing aids. Nowadays, hearing aids are digitalized and can be programmed to the individual needs of patients. However in patients with severe to profound hearing loss, the benefits of hearing aids can be limited. In this group of patients, cochlear implants should be considered in suitable candidates.

On the other hand, patients with mixed hearing loss often have ongoing middle ear infection. The initial step is to treat the infection by medication including antibiotics. If the infection persists, mastoid surgery is performed to eradicate the infection and the perforated ear drum can be repaired at the same time. Often the patient requires hearing aid after surgery to achieve good hearing.