HILANG DERIA BAU (HYPOSMIA)

Deria bau adalah salah satu fungsi hidung. Di kawasan langit hidung terdapat saraf-saraf halus (olfactory nerves) yang dapat menghasilkan deria bau. Molekul-molekul bau dari pelbagai punca dapat merangsang saraf-saraf halus tersebut.
Pesakit boleh mengalami masalah kurang deria bau sekiranya hidung sumbat atau kerosakan pada saraf deria bau tersebut. Masalah deria bau terbahagi kepada separa atau kurang deria bau (hyposmia) atau kehilangan seluruh deria bau (anosmia).
Kebanyakan pesakit yang mempunyai masalah deria bau juga mengalami masalah deria rasa. Ia seringkali berkaitan tetapi ada juga pesakit yang mempunyai masalah deria rasa tetapi deria bau adalah normal.

Sistem deria bau (olfaktori) manusia terletak di bahagian atap hidung. 

Punca-punca kurang deria bau

• Alahan hidung (allergic rhintis)
• Polip hidung
• Radang pada sinus (rhinosinusitis)
• Ketumbuhan atau tumor di dalam rongga hidung
• Toksin seperti kokain, asap rokok
• Radang pada saraf deria bau (olfactory nerve) yang disebabkan oleh jangkitan virus, sarcoidosis, Wegener's granulomatosis
• Masalah endokrin seperti penyakit diabetes/kencing manis, tiroid etc
• Trauma kepada kepala
• Proses penuaan
• Masalah degeneratif seperti Parkinson's disease, Alzheimers
• Sindrom Kallman

SEPTOPLASTY AND TURBINATE SURGERY

Septoplasty is a surgical procedure to correct a deviated or crooked nasal septum. Patients often complain of nasal block and congestion, which can disturb their sleep. They may also have symptoms of rhinitis such as runny nose, sneezing and postnasal drip. Some patients have a deviated nasal septum as a result of trauma or blow to the nose. 

Turbinate surgery refers to a procedure performed to reduce the size of the enlarged nasal turbinates, which often contribute to the nasal block and congestion. There are many methods how the ENT surgeon reduce the size of the turbinates. Regardless of the surgical method used, the turbinates may slowly increase back in size if patients do not take care of their allergies.

The ENT surgeon may put the patient on a trial of medication which include nasal sprays and antihistamine to control their allergies. If the nasal block is still not relieved or minimally relieved with medication then septoplasty and turbinate surgery should be considered. However in severely deviated nasal septum especially post trauma, medication often bring little improvement. Septoplasty can also be indicated for recurrent epistaxis.

Complications of septoplasty and turbinate surgery are uncommon however patients should be aware of the possible complications including bleeding, infection, nasal crusting, numbness and septal perforation.

General care after septoplasty and turbinate surgery

The nose may be packed after surgery and patients are warned to breathe through their mouth upon waking up from surgery. The nasal pack is usually removed the following day after surgery. Following nasal pack removal, patients should expect bloodstained nasal secretions for a few days. Patients should not blow their nose for about 10-14 days. When sneezing, patients should keep their mouth open to reduce built-up pressure in the nose.

Patients may also experience swelling and pain around the nose including numbness of the upper teeth; which usually resolve in a few weeks. 

Patients are advised to take light soft cool diet when awake after surgery. Hot food and drinks are to be avoided for a few days after surgery.

Patients should rest with their head elevated on 2-3 pillows to reduce swelling around the nose area. Patient should also avoid straining and lifting heavy objects to reduce risk of bleeding.

Medications that can thin the blood, such as Aspirin and Warfarin, should be avoided until advised by the ENT surgeon.

The ENT surgeon would often prescribe nasal douching where patients will flush the nasal cavities using saline irrigation for a few weeks. This will ensure good healing and prevent formation of dried crusts or blood clots. Patients will also be prescribed with a course antibiotic that should be completed.

Patients are also expected to take some time off until the doctor says it is safe to return back to work. Patient should refrain from smoking or exposure to smoky areas as this can impair healing and cause further irritation to the nose.

When should you see your ENT surgeon urgently?

• Continuous bleeding despite nasal compression and ice
• Increasing swelling over the nose and eyes 
• Persistent high grade fever >38 Celcius
• Severe pain or headache not relieved by the pain medication given.

Q&A on RAPI magazine Sept 2012

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.

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.

NASAL POLYPOSIS

Nasal polyps are growths or masses in the nasal cavity which is not cancerous. It usually arises due to chronic inflammatory process and will continue to increase in size if not treated. It can even cause distortion in the shape of the nose and eventually bulge out through the nostrils in severe cases.

Nasal polyps usually occur in young and middle aged adults. It is uncommon in children. Nasal polyps are often bilateral (both nasal cavities involved). A unilateral polyp is called an antrochoanal polyp which usually arises from the maxillary sinus and affects teens and young adults.

The cause of nasal polyps is open to much debate but it is agreed that an ongoing inflammatory process is the main pathophysiology. There are however certain associated conditions which increase the risk of developing polyps.

These conditions include asthma which is an inflammatory condition of the airways triggered by allergens, chronic rhinosinusitis which is a chronic infection of the sinuses, aspirin sensitivity, allergic fungal sinusitis which is an allergy to airbone fungi, cystic fibrosis especially suspected in children with nasal polyps (rare disease in Malaysia) and other less common syndromes such as Churg Strauss syndrome, Kartagener’s syndrome and Young’s syndrome. Recent understandings have also shown the relevance of family history and certain genetic predisposition to nasal polyps.

SYMPTOMS

The symptoms or nasal polyps are similar to other inflammatory conditions of the nose such as runny nose, post nasal drip and pressure around the face. However when there is persistence in the symptoms especially when associated with unrelenting nasal block/stuffiness, loss of sense of smell or taste, headache, pain around face and teeth and snoring then possibility of nasal polyposis should be considered.

HOW TO DIAGNOSE NASAL POLYPS?

Diagnosis of nasal polyposis can only be confirmed with an endoscopic examination of the nose. A small rigid or flexible scope is inserted into the nose to fully inspect the nasal cavities. It is a simple procedure performed in the ENT clinic. Polyps appear as grapelike structures protruding into the nasal cavities.

Imaging studies are also performed to see the origin of the polyps and extent of the disease. A computed tomography (CT) or magnetic resonance imaging (MRI) is usually requested. The imaging studies can also reveal possible fungal disease or complications.

Other tests such as allergy test, test for cystic fibrosis or others may be indicated depending on a patient to patient basis.

TREATMENT

The treatment of nasal polyps is long term suiting its nature; underlying chronic ongoing inflammatory process. The aims of treatment are to shrink the size of polyps and prevent complications. Most polyps would respond to medical treatment however some would require surgical intervention.

Medical treatment would consist of topical intranasal steroids, oral corticosteroids, antihistamines and antibiotics in various combinations.

Endoscopic sinus surgery is considered when the polyps do not respond to optimal medical treatment. Surgical intervention is also recommended earlier if patients present with complications. Large nasal polyps often may not shrink considerably with medication alone. However patients have to be aware that nasal polyps do recur after surgery. Therefore adequate followup care and ‘maintenance’ medication is necessary to prevent recurrence.

NASOPHARYNGEAL CARCINOMA

Nasopharyngeal carcinoma (NPC) is a tumour of the nasopharynx which is situated at the deep end of the nose. It has the highest incidence amongst the Chinese of Southeastern region and Hong Kong.  It is one of the top 5 cancers affecting both male and female in Malaysia apart from breast, colorectal (bowel), lung and cervical cancer. The Malaysian National Cancer Registry in 2006 noted an incidence of 7.5 per 100,000 for males and 2.4 per 100,000 for females. Chinese men had the highest incidence rate of 15.9 per 100,000. The age specific incidence increased after 30 years old. 

The nasopharynx is situated at the deep end of the nose which makes it a blind spot to normal clinical examination. Tumors or the nasopharynx also often present late because of this anatomical position.

This disease has a multifactorial origin and is a result of interplay between genetic susceptibility, environmental factors and Epstein Barr virus. There is evidence to suggest that abnormalities in specific chromosomes may play a role in the pathogenesis. Cultural factors linked to NPC which have been observed include consumption of dried salted fish in childhood.

CLINICAL FEATURES

The symptoms of NPC are usually non obvious and only apparent when the tumor has spread, due to the anatomical location of the nasopharynx. More commonly patients present with neck swelling in 50-70% of cases followed by unilateral ear block or tinnitus and nasal obstruction. Other less common symptoms include blood stained nasal discharge or saliva and headache. Advanced disease may present with cranial nerve palsies, altered conscious level or distant tumour spread.

DIAGNOSIS

The diagnosis of NPC requires visualization of the nasopharynx region using nasal endoscopy. This endoscopic facility is readily available as an outpatient procedure in ENT clinics. The neck is also palpated to assess for enlarged lymph nodes. Patients with neck swelling and unilateral ear symptoms coupled with high risk ethnicity should always be examined with nasal endoscopy. Endoscopic examination findings in NPC would show as a growth/mass, swelling or obliteration of the Fossa of Rosenmuller. The diagnosis of NPC is confirmed by biopsy and examination of the tissue in the histopathological laboratory. In rare instances, nasal endoscopy may be normal. In these highly suspicious cases the ENT surgeon may suggest examination under general anaesthesia with deep multiple biopsies.

TUMOR STAGING

When diagnosis is confirmed, the tumour is then staged by imaging studies. The rationale for tumour staging is to give a true picture of the tumour extension and its related prognosis. Imaging studies include computed tomography (CT) scan of the head and neck area, chest radiograph, abdominal ultrasound and bone scan.

TREATMENT

The mainstay of treatment for NPC is radiotherapy with without concurrent chemotherapy.  Early small tumours will do well with radiotherapy alone. Often the radiotherapy is combined with chemotherapy. The oncologist will devise the treatment plan after discussing with the patient.

Nowadays advanced forms of radiotherapy such as intensity modulated radiation therapy (IMRT) can better target the tumour volume thus reducing radiation exposure to normal tissues. The side effects that patients may experience with radiotherapy include skin pigmentation and desquamation, oral ulcers and dryness, tiredness, restricted mouth movements, taste disturbance and hearing changes. These side effects would gradually occur during the course of the treatment and will slowly get better. However some of the side effects such as dry mouth and hearing changes are long term.

FOLLOW UP AFTER TREATMENT

After completing the treatment for NPC, the patient is reassessed to ensure good response to the treatment given. Patient is again reviewed by medical history, physical examination along with nasal endoscopy and imaging studies are performed to make sure that the tumour has been eradicated. These clinic reviews are also important to assess for tumour recurrence (return of the tumour), metastasis (distant spread of the disease) and any ongoing problems that the patient may have following treatment. The follow up consultation may be frequent, 3-4 monthly, in the first 2 years and then becomes a 6-12 monthly visit after that.

Useful links

National Cancer Society Malaysia 

National Cancer Registry 2006 

MENGATASI MASALAH ALAHAN (RESDUNG)

Masalah resdung seringkali berkaitan dengan gatal hidung, bersin, hingus cair dan hidung sumbat. Dalam bahasa perubatan ia lebih sesuai dipanggil sebagai ‘Allergic Rhinitis’ atau alahan hidung. Pesakit juga boleh mengalami simptom gatal pada bahagian mata dan kulit muka. Gejala ini berlaku kerana pesakit alah kepada pelbagai bahan terutamanya hama, makanan laut, belacan dan sebagainya.

Perkara utama dalam menangani masalah alahan hidung adalah untuk mengelak dari bahan yang menyebabkan alahan atau ‘alergen’. Salah satu cara untuk mengenalpasti alergen adalah dengan mencatatkan dalam diari makanan yang diambil setiap hari dan juga keadaan persekitaran. Seringkali apabila diimbas kembali pesakit mungkin dapat meneka alahan mereka dengan tepat.

Selain daripada usaha pencegahan, para doktor mungkin mengesyorkan pengambilan ubat anti-alahan hidung samada dalam bentuk pil antihistamin atau pam/spray hidung. Ubat ini dapat membantu mengawal simptom alahan hidung dengan lebih berkesan, terutamanya bagi pesakit yang mengalami alahan yang teruk atau yang terpaksa terdedah kepada alergen seperti mereka yang bekerja di gudang yang berhabuk.

Langkah- langkah mengatasi alahan

Elak dari terdedah kepada alergen Pengambilan ubat yang disyorkan doktor apabila mengalami kes alahan teruk

Mengatasi masalah alergen utama iaitu HAMA

Ramai pesakit alahan hidung mempunyai alahan terhadap hama. Hama adalah binatang yang hanya dapat dilihat melalui kanta mikroskop. Sebenarnya alahan itu adalah terhadap najis hama tersebut. Hama hidup dengan memakan sel kulit mati yang terdapat pada katil dan perabot di dalam rumah kita. Ia suka kepada keadaan yang panas dan lembab.

Selain dari alahan hidung, alahan kepada hama juga boleh menyebabkan sakit asma (lelah) atau gatal kulit (eczema). Ciri utama dalam mengatasi alahan hama adalah pencegahan dan kebersihan.

Cara mengatasi hama

1. Elak penggunaan permaidani di dalam rumah terutamanya di bilik tidur
2. Elak mengunakan terlalu banyak kusyen atau perhiasan rumah yang dapat mengumpul habuk
3. Alat mainan seperti patung beruang seharusnya jenis yang boleh dibasuh dengan senang dan kerap
4. Basuh cadar dan selimut sekurang-kurangnya dua kali seminggu
5. Elok basuh cadar dan selimut dengan menggunakan air panas 60⁰C
6. Menggunakan hampagas untuk mengurangkan habuk. Penggunaan hampagas yang mempunyai filter yang bagus (high efficiency filter, HEPA) dapat mengurangkan habuk dan hama dengan berkesan
7. Mengelap perabot dengan kain lembap lebih berkesan dari menggunakan bulu ayam/plastik
8. Memakai 'face mask' terutamanya semasa mengemas rumah ataupun di tempat kerja yang berhabuk
9. Mengelakkan haiwan peliharaan seperti kucing atau anjing dari kawasan bilik tidur
10. Penggunaan lapik katil dan bantal yang anti-hama (anti-dust mite covers) juga dapat membantu

Apa yang boleh berlaku sekiranya masalah alahan hidung (resdung) tidak dikawal?

• Boleh menyebabkan masalah infeksi atau jangkitan kuman pada rongga hidung dan sinus (sinusitis)
• Boleh menyebabkan masalah polip hidung
• Gejala hidung yang sentiasa sumbat boleh mengurangkan daya konsentrasi dan menyebabkan pesakit merasa lesu
• Hidung tersumbat boleh mengganggu tidur yang berkualiti
• Alahan hidung juga berkait rapat dengan penyakit asma/lelah yang sukar dikawal
• Alahan hidung juga boleh menyebabkan pesakit mengalami masalah jangkitan telinga ‘otitis media’ terutamanya pada kanak-kanak

CARE AFTER ENDOSCOPIC SINUS SURGERY

Endoscopic sinus surgery is a procedure that is performed to open up blocked sinuses. It entails using scopes which provide good visualization of the nasal cavity structures without having to make any external skin incisions. Compared to yesteryears of open sinus surgery, endoscopic sinus surgery allows shorter hospital stay and faster recovery.

Endoscopic sinus surgery is recommended when there is failure of medical therapy in treatment of sinus infections.  It is also performed when there are polyps or tumours within the nasal cavity. Correction of deviated nasal septum causing nasal blockage can also be performed by endoscopy.

What to expect when you wake up from the surgery?

Usually the nose will be blocked with nasal packing and a gauze dressing is placed at the front of the nostril to absorb any blood stained discharge and changed whenever soaked. There are two types of nasal packing; dissolvable and non-dissolvable. The non-dissolvable nasal packing which looks like nasal tampon is usually removed 24-48 hours after the operation. The dissolvable nasal packing is left in place and will dissolve within few days.  Patients may have to breathe through their mouth because of the nasal pack.

Patients will experience some pain over the nose area and mild headache is expected. Analgesics are prescribed for pain relief. Inform the surgeon if you still experience considerable pain.

Once the nasal pack is removed, the patient is advised to pinch the nose for at least 15 minutes to stop the bleeding. The patient is also propped up in a sitting forward position and a kidney dish/basin is placed in front so that the patient can spit out any blood discharge trickling at the back of the throat.

The patient is then observed for any serious bleeding before allowed home. A small amount of blood stained discharge is expected for the next few days.

Post op advice for patients

• When lying in bed, keep the head elevated to reduce bleeding from the operated site.
• Patients should not blow their nose for 1 week after surgery. When they sneeze, make sure the mouth is open to reduce pressure in the nasal cavity and prevent bleeding.
• Nasal douching will be prescribed by the surgeon using pre-prepared salts which are dissolved into cooled boiled water. Patients are expected to perform the douching twice a day until healing is complete. The nasal douching will prevent dry crusting in the nasal cavity and allows easy dislodgment of blood clots.
• Patients should also avoid straining, heavy lifting, swimming and flying for a few weeks.
• Patients should avoid allergies and any food known to cause an allergic reaction. Reduce intake of dairy products which can increase mucous production. Refrain from smoking and exposure to secondhand smoke. Patients should also avoid crowded places in case they may catch an infection.
• Patients must comply with the medications prescribed by the surgeon which often includes antibiotics.
• Patients are required to come for follow-up at 5-7 days post operation. During the follow-up visits, the surgeon will monitor the recovery process by endoscopic examination in the clinic and suction removal of blood clots or secretions will be performed.

What next?

The recovery period can take between 2-4 weeks. Patients are often given at least 1 week home rest after the operation. The recovery process varies from patient to patient.

Some patients require long term medication after the endoscopic sinus surgery to prevent recurrence of the disease such as polyps.

Follow up is necessary until the recovery is complete and in patients with polyps they may still need a 6-12 monthly checkup to monitor for recurrence.

NOSEBLEEDS: WHAT TO DO?

Most of us would have had a nosebleed, especially during childhood. However it can still occur in adults. It is usually incited by trauma such as nose digging and upper respiratory tract infection. Sometimes the amount of bleeding can be alarming. Doctors would refer nosebleeds as epistaxis in its medical term.

What to do during nosebleeds?

mypregnancycalendar.blogspot.com

1.       Sit down calmly.

2.       Bend upper body and head forwards, this will prevent swallowing of the blood which can upset the stomach and cause vomiting.

3.       Use a tissue paper of soft towel to pinch the soft part of the nose using the thumb and index finger.

4.       Breathe through the mouth and spit out any blood trickling down the back of the throat.

5.       Continue to pinch the nose between 5 to 15 minutes. Check after first 5 minutes to see if the bleeding has stopped.

6.       It may help to gargle with ice water or to suck on an ice cube.

7.       Once the bleeding stops, do not pick the nose or blow harshly to remove the blood clots. Avoid straining and lifting heavy objects.

8.       If it continues to bleed, please seek medical help.

allaboutathletictraining.blogspot.com

When to seek medical treatment?

·         If the bleeding does not stop despite the above measures after 15-20 minutes

·         Nosebleeds following trauma to the nose or head/face area

·         Repeated episodes of nosebleeds

·         When you feel faint, dizzy or appear pale

·         Large amount of bleeding especially with blood clots

·         If you are taking medications that thin the blood such as Aspirin or Warfarin

·         Nosebleeds associated with bruising on other parts of the body

What are the causes of epistaxis?

• Upper respiratory tract infections
• Nose digging or vigorous nose blowing
• Dry, low humidity air
• Trauma to face or nose
• Allergic and non allergic rhinitis
• Foreign objects inserted into the nose
• Use of medications such as Aspirin and Warfarin
• High blood pressure
• Tumours

The nasal cavity is well vascularized.
Epistaxis commonly occurs from the Little area.
Posterior epistaxis is often more serious.

Printable leaflet

http://www.entheadandneckclinic.com/web_documents/leaflet__epistaxis_.pdf

§  

SNORING AND OBSTRUCTIVE SLEEP APNEA

Snoring occurs due to narrowing of the airway causing vibration of the soft tissues of the throat during sleep. It is more common in men generally whereby 45% of men and 30% of women snore on a regular basis.

Risk factors for snoring include overweight, increasing age, nasal blockage, sedating medications, alcohol, sleeping position and thick neck. It is important to recognize if snoring is related to an underlying medical problem such as obstructive sleep apnea (OSA) or is an isolated problem


What is obstructive sleep apnea (OSA)?
It is a severe form of snoring which has serious health consequences. OSA occurs due to complete collapse or obstruction of the upper airway, at one or a combination of these levels:

• Nasal Airway  

• Soft Palate/Tonsils

•  Tongue Base 

• Pharyngeal Walls

Symptoms of OSA

• Loud, irregular snoring
• Daytime tiredness and sleepiness
• Early morning headaches
• Poor concentration
• Deterioration of intellectual capabilities
• Mood swings

Diagnosis of OSA

A complete ear, nose and throat examination by endoscopy is performed in the clinic to assess the possible sites of airway obstruction during sleep. The body mass index is measured.

Sleep study is often recommended to confirm and determine severity of OSA
OSA severity is indicated by the Apnea / Hypopnea Index (AHI)
· Mild: 5 – 15 events / hour
· Moderate: 16 – 30 events / hour
· Severe: > 30 events / hour
(events is when there is almost or total obstruction of the airway causing a drop in oxygen blood saturation)

Consequences of OSA
It is very important to recognize and treat OSA because if left untreated it can lead to serious health consequences:
Hypertension
Myocardial infarction
Stroke
Type II diabetes
Depression
Cognitive dysfunction
Impotence, sexual dysfunction, or reduced libido
Morning headaches

General preventive measures for snoring
§ Sleep hygiene
     - Regular sleep-wake times
     - Peaceful surroundings
     - Moderate room temperature
     - Avoidance of night shift and changing work shifts
§ Reduction of weight
§ Exercise
§ Avoid alcohol and sedatives before bedtime


Treatment options for OSA



APAP (Automated Positive Airway Pressure) with Mask
It is the Gold Standard treatment for Sleep Apnea. Patients are required to wear a face or nasal mask which blows in humidified air. This will help to ‘splint’ the airway open during sleep.

Oral appliance
Oral Appliance Therapy is a suitable front-line treatment option for mild to moderate OSA sufferers and simple snorers. The Oral Appliance is worn during sleep to maintain the patency of the upper airway.


Surgical treatment options for OSASurgery is aimed to relieve the obstruction. Therefore the type(s) of surgery recommended varies between patients.

The surgeries that can be performed include
· Tonsillectomy and adenoidectomy
· Septoplasty and turbinate surgery
· Soft palate surgery
· Base of tongue surgery
· Surgery to facial bones in selected cases

OSA in children 

The symptoms may differ from adults as children with OSA can present with mouth breathing, behavioural problems/ irritability, learning difficulties, hyperactivity and bedwetting. Often these children have large tonsils and adenoids which cause the airway obstruction and snoring. Obesity is a less common reason for OSA in children.

ALLERGY AND ALLERGIC RHINITIS

What is allergy?

Allergy is the body’s reaction to certain substances (allergen) that brings about symptoms of itchiness, rash and swelling. The symptoms are commonly mild but rarely can be life threatening (anaphylaxis). Allergic reaction is unique to each person. Conditions such as asthma, frequent upper respiratory tract infection, nasal polyps, eczema are commonly associated with allergy.  

Risk of developing allergy

The development of allergy is a complex interaction of genetic factors and environmental factors. The increasing rise of pollution has been associated with increased risk of developing allergies. Family history of allergies will also put a person at risk. On the other hand, breastfeeding has been associated with reduced incidence of developing allergies.

Diagnosis of allergies

A full history of allergy is obtained to ascertain the diagnosis. Diagnostic tests which can help to determine the allergens include skin prick test, contact patch testing and RAST blood test.

Allergic rhinitis

Allergic rhinitis is one of the manifestations of allergy. The main symptoms are stuffy blocked nose, sneezing, runny nose and itchiness. The itchiness can also affect the eyes. It is commonly associated with asthma. Patients often notice that the asthma symptoms improve when there is better control of rhinitis symptoms. Common triggering factors (allergens) include house dust mite, cockroaches, pet dander, mould and certain seafood.

Treatment of allergic rhinitis

First and foremost is AVOIDANCE. Avoiding the triggering factors will ensure better control of allergy symptoms. However some patients require medical treatment depending on the severity of the symptoms. Treatment which may be suggested by your doctor would include antihistamines and nasal sprays. The response to treatment should be closely monitored.

How to get rid of house dust mites?

	House dust mites are everywhere especially in mattresses, pillows, carpets and upholstered furniture. It thrives in humid environment and warm temperatures. They are too small to be seen with the naked eye and feed on dead human shedded skin.

Suggested ways to get rid of them:

·         Use allergy proof mattress and pillow encasings

·         Wash sheets, pillows, blankets, soft toys once a week in hot water and dry in a clothes dryer

·         Vacuum regularly with vacuum cleaners with HEPA filter

·         Dust furniture with damn cloth