POSITIONAL VERTIGO (BENIGN PAROXYSMAL POSITIONAL VERTIGO)

Benign paroxysmal positional vertigo is a sensation of spinning related to head movement and position. The spinning sensation or vertigo only lasts for brief periods and is not associated with ear fullness or tinnitus. The vertigo experienced can be quite intense and patient may have nausea.
It may occur repeatedly with certain head positions such as tilting the head backwards and forwards, looking to the sides and turning to right or left on the bed. In between episodes, patients are generally well.
BPPV is one of the most common cause of vertigo and it commonly affects those above 50 years of age. Occasionally it can be related to head trauma especially in young adults.

Understanding the disease process of BPPV
BPPV is a condition affecting the inner ear. Each inner ear consists of organs responsible for hearing (cochlea) and balance (utricle, saccule & 3 semicircular canals). The balance organs especially the semicircular canals are responsible to detect angular head movements.
When the head moves, the fluid within the semicircular canal would move in the opposite direction initially due to inertia. This fluid movement is detected by the cupula which contains hair like sensors. These sensors would then produce electrical signals to the brain.
In BPPV there is dislodgement of crystals from the utricle or saccule which then collects within the semicircular canals. Therefore during head movements, these crystals would cause the semicircular canals to send false signals to the brain. And this brain signal misinterpretation would cause the patient to feel the spinning sensation of vertigo.

Diagnosis of BPPV
The diagnosis of BPPV is a clinical diagnosis which the doctor makes from the patient's history and examination. A complete ENT examination should be performed to assess for other causes of vertigo. In BPPV, the ear examination is generally normal.
Sometimes a hearing assessment is also required. If the symptoms are non specific, imaging studies such as MRI (magnetic resonance imaging) may be performed to assess for any intracranial cause.
The doctor would also perform a Dix Hallpike manouvre to stimulate a vertigo episode. This test would be positive in cases of BPPV.

Treatment of BPPV
A canalith repositioning manouvre for BPPV can be performed by the doctor in the clinic. The side of the ear affected will be determined during the Dix Hallpike manouvre. And then the canalith repositioning manouvre will be performed according to the affected ear; right or left.
The canalith repositioning manouvre, also called the Epley's manouvre, involves a series of head movements aimed at bringing the crystals out from the semicircular canals and back into the utricle. This test may need to be repeated several times. It is usually performed twice and may be repeated during the next clinic review if still symptomatic.
In very rare situations that the canalith repositioning manouvre would fail and surgery is recommended. The surgical procedure performed involves plugging the semicircular canal that causes the vertigo.

Home advice after repositioning manouvre
There is no substantial clinical evidence that has shown that the following restrictions are very useful after the clinic canalith repositioning procedure. However doctors often advise patients to avoid lying flat or on the affected ear for 2-3 days after the procedure. Patients are also advised to lay their head on 2-3 pillows on the first night following the procedure.

CHOLESTEATOMA

Cholesteatoma adalah penyakit yang disebabkan oleh gumpalan sel-sel kulit mati dan inflammasi tisu yang mampu menghancurkan struktur-struktur tulang disekelilingnya. Sifat sebegini amat membahayakan sekiranya  ia tidak dirawat dengan segera.

Simptom-simptom yang dialami oleh pesakit adalah jangkitan telinga yang sukar dirawat dengan antibiotik, jangkitan telinga yang berulang-ulang, bau cecair yang amat busuk dan kurang pendengaran. Sekiranya cholesteatoma telah merebak pesakit juga boleh mengalami pening, sakit kepala, bengkak pada bahagian belakang telinga dan kelemahan otot muka.

Pakar ENT akan merawat jangkitan kuman yang berkaitan dengan cholesteatoma dan mengeluarkan cholesteatoma atau gumpalan sel-sel kulit mati tersebut di klinik. Sekiranya ia tidak dapat dirawat kerana kes cholesteatoma yang lebih serius, pakar ENT akan mengesyorkan pembedahan dilakukan untuk membersihkan dan mengeluarkan cholesteatoma tersebut. Sejurusnya mengelakkan daripada komplikasi cholesteatoma seperti lemah saraf muka (facial nerve palsy), jangkitan kuman pada otak (meningitis), nanah pada otak (brain abscess) dan pekak pendengaran. Komplikasi-komplikasi tersebut adalah amat serius.

Imbasan CT telinga perlu dibuat agar pakar ENT boleh menganalisis sejauh mana cholesteatoma itu sudah merebak ke dalam bahagian-bahagian telinga. Ujian pendengaran juga dilakukan sebelum pembedahan untuk mengetahui tahap pendengarn pesakit.

Pembedahan yang dilakukan bergantung kepada sejauh mana cholesteatoma itu telah merebak. Secara amnya, pembedahan yang dilakukan adalah pembedahan mastoid. Di dalam kes terpencil, pembedahan attikotomi boleh dilakukan bagi kes cholesteatoma yang hanya melibatkan bahagian atas gegendang telinga (attic).

PEMBEDAHAN MASTOID

Mastoid adalah bahagian tulang tengkorak yang berkaitan dengan telinga. Ia merupakan sambungan kepada bahagian telinga tengah dan tulang mastoid dipenuhi oleh rongga-rongga udara. Sekiranya terdapat jangkitan kuman pada telinga tengah (otitis media), jangkitan tersebut dapat merebak ke tulang mastoid (mastoiditis). Ini menyebabkan bengkak pada bahagian belakang cuping telinga dan pesakit merasa amat sakit dan demam.

Tulang mastoid terletak di bahagian belakang cuping telinga (anak panah). Ia mempunyai sambungan kepada telinga tengah.. Wikipedia image

Gambarajah di atas menunjukkan sambungan (melalui tympanic antrum) antara telinga tengah dan tulang mastoid. Ia juga menunjukkan bahawa tulah mastoid dipenuhi oleh rongga-rongga udara (mastoid cells). Wikipedia image

Pembedahan mastoid pula merupakan pembedahan yang dilakukan oleh pakar ENT sekiranya ada jangkitan kronik pada tulang mastoid (chronic mastoiditis), cholesteatoma, ketumbuhan (tumor) pada telinga tengah, implan koklear dan lain pembedahan telinga dalam/tengah.

Sebelum pembedahan mastoid, pesakit perlu membuat ujian pendengaran untuk mengetahui tahap pendengaran. Imbasan CT juga perlu agar pakar ENT dapat mengetahui sejauh mana jangkitan atau penyakit tersebut telah merebak.

Pembedahan mastoid dilakukan melalui torehan pada kulit di belakang cuping telinga (postaural). Tetapi kadangkala ia dilakukan melalui torehan di bahagian atas lubang telinga (endaural). Ia melibatkan penggunaan mikroskop dan drill untuk membersihkan tulang mastoid yang tidak sihat atau mengalami jangkitan.

Kenapa perlunya pembedahan mastoid?
Pembedahan mastoid perlu dilakukan sekiranya jangkitan kuman pada tulang mastoid tidak dapat disembuh dengan rawatan antibiotik dan cucian telinga yang dilakukan oleh pakar ENT di klinik. Ia juga perlu sekiranya pesakit mempunyai penyakit cholesteatoma atau ketumbuhan di dalam telinga. Ini adalah kerana sekiranya dibiarkan berlarutan jangkitan atau penyakit tersebut akan merebak ke telinga dalam menyebabkan pekak pendengaran, mengganggu saraf muka dan juga boleh berjangkit ke bahagian otak.

Saranan selepas pembedahan mastoid
Pesakit mungkin berasa pening selepas pembedahan dan disyorkan agar berehat di rumah selama 5-7 hari. Sekiranya pesakit mempunyai pekerjaan berat yang memerlukan banyak pergerakan dan mengangkat benda berat, pesakit mungkin perlu bercuti selama 2 minggu.
Kesakitan pada bahagian pembedahan selalunya dapat dikawal dengan ubat tahan sakit. Tetapi jika masih mengalami kesakitan yang teruk, mungkin ia tandanya jangkitan kuman telah berlaku.
Bahagian torehan akan dijahit dan jahitan ini perlu dibuka selepas 5-7 hari oleh doktor di klinik.
Bahagian telinga yang dibedah pula akan dibalut dengan 'mastoid bandage'. Ia kelihatan seperti serban kepala yang kecil dan ini perlu dipakai selama lebih kurang 24 jam.
Bahagian lubang telinga pula selalunya disumbat dengan kain antiseptik dan ini harus dibiarkan selama 2 minggu. Pesakit tidak boleh sama sekali menarik keluar sumbatan tersebut. Di bahagian luar sumbatan telinga tersebut pula ditutup oleh kapas (cotton ball). Kapas di luar ini perlu ditukar selalu oleh pesakit di rumah, sekurang-kurangnya setiap kali selepas mandi.
Pesakit harus mengambil langkah berhati-hati agar bahagian telinga yang dibedah dan 'dressing' tidak basah atau dimasuki air.

Perkara-perkara yang perlu dielakkan selepas pembedahan mastoid
Jaga kebersihan telinga yang dibedah dan jangan biarkan ia dimasuki air selama 6-8 minggu
Elak dari menghembus hidung dengan kuat. Sekiranya bersin, pastikan bersin dengan mulut terbuka
Elak daripada mengangkat benda berat dan aktiviti fizikal selama 3-4 minggu selepas pembedahan
Elak daripada menaiki kapal terbang selama 3-4 minggu selepas pembedahan
Pesakit disyorkan meminta nasihat pakar ENT sebelum memulakan pekerjaan dan sebarang aktiviti berat

Masalah-masalah yang dijangkakan selepas pembedahan mastoid
Dengan sumbatan di dalam lubang telinga,  pesakit boleh mengalami bunyi air atau buih di dalam telinga dan ini akan hilang apabila sumbatan tersebut dikeluarkan oleh pakar ENT pada masa 2 minggu selepas pembedahan.
Selepas itu tahap pendengaran pesakit bergantung kepada kerosakan yang dialami oleh telinga dalam disebabkan jangkitan kuman sebelumnya (mastoiditis atau cholesteatoma). Ujian pendengaran selalunya dilakukan 3 bulan selepas pembedahan.
Amat jarang sekali ada pesakit mengalami kelemahan otot muka. Ini kerana ada bahagian saraf muka (facial nerve) yang melalui bahagian telinga tengah boleh tercedera/terganggu semasa pembedahan. Dalam kebanyakan kes, kelemahan ini adalah sementara.
Pesakit juga mungkin mengalami deria rasa yang lain pada bahagian lidah dan ini juga bersifat sementara.

Bila pesakit harus mendapatkan rawatan doktor dengan segera selepas pembedahan mastoid
Demam tinggi
Cecair busuk/Nanah yang sentiasa mengalir dari dalam telinga
Sakit pada bahagian pembedahan yang teramat sangat
Bengkak ketara pada bahagian sekeliling telinga yang dibedah
Pening atau rasa kepala berpusing yang menyebabkan rasa loya dan muntah

NOTA:
Cholesteatoma adalah penyakit yang disebabkan oleh gumpalan sel-sel kulit mati dan inflammasi tisu yang mampu menghancurkan struktur-struktur tulang disekelilingnya. Sifat sebegini amat membahayakan sekiranya  ia tidak dirawat dengan segera.

GEGENDANG TELINGA BERLUBANG

Gegendang telinga merupakan selaput nipis yang memisahkan antara telinga luar dan telinga tengah. Ia amat penting bagi fungsi pendengaran yang normal. Ia juga penting untuk melindungi bahagian telinga tengah dengan struktur-strukturnya.

Gegendang telinga (tympanic membrane) memisahkan ruang telinga luar dan telinga tengah 

PUNCA GEGENDANG TELINGA BERLUBANG/PECAH

Gegendang telinga yang berlubang berpunca dari beberapa sebab seperti jangkitan telinga tengah (otitis media) dan trauma. Kebanyakan kes gegendang berlubang berpunca dari jangkitan telinga tengah. Jangkitan menyebabkan tekanan meningkat di dalam ruang telinga tengah dengan adanya cecair nanah. Tekanan tersebut menyebabkan gegendang telinga pecah dan cecair nanah akan mengalir keluar.

Trauma yang dimaksudkan termasuk dengan penggunaan putik kapas atau besi semasa mengorek telinga, tamparan pada bahagian telinga atau pipi, perubahan tekanan mendadak semasa aktiviti menyelam atau naik ke tempat tinggi, bunyi bising melampau seperti bunyi tembakan atau letupan mercun.

APA PESAKIT AKAN RASA?

Simptom gegendang telinga pecah adalah sakit yang teramat sangat dirasai dalam telinga atau pesakit berasa tidak selesa. Pesakit juga merasa seperti telinga sumbat dan pendengaran mungkin berkurangan. Kadangkala terdapat cecair atau darah mengalir keluar dari dalam telinga. Pesakit juga mungkin berasa pening disebabkan oleh gegendang pecah.

RAWATAN GEGENDANG TELINGA BERLUBANG/PECAH

Rawatan bagi gegendang telinga berlubang bergantung kepada puncanya. Sekiranya ia disebabkan jangkitan kuman, pesakit perlu mendapat rawatan antibiotik dan ubat titis telinga. Pakar ENT juga akan mencuci telinga tersebut dengan menggunakan alat sedut di klinik ENT. Setelah jangkitan kuman dirawati, iaitu telinga tengah sudah tidak mengeluarkan nanah, gegendang telinga berlubang dapat ditampal dengan kaedah pembedahan (myringoplasty). Ada kalanya gegendang telinga tersebut dapat pulih dan tutup dengan sendiri jika jangkitan dapat ditangani dengan segera seperti dalam kes otitis media akut (acute otitis media, AOM)

Kadangkala jangkitan telinga tengah sudah berlarutan dan melibatkan mastoid. Ini berlaku sekiranya jangkitan telinga tengah adalah kronik dan melebihi 12 minggu (otitis media kronik atau chronic otitis media, CSOM). Bila ini berlaku jangkitan kuman menjadi sukar untuk dirawat dengan kaedah antibiotik sahaja dan pesakit mungkin memerlukan pembedahan mastoid. Dengan pembedahan ini tulang mastoid yang dijangkiti kuman dapat dicuci dan dinyahkan jangkitan. Gegendang telinga yang berlubang itu ditampal sekali.

Sekiranya gegendang telinga pecah atau berlubang disebabkan oleh trauma, kebanyakan kes gegendang pecah itu dapat pulih dengan sendiri bergantung kepada saiz lubang pada gegendang telinga. Saiz lubang yang kecil kemungkinan besar dapat pulih secara semulajadi adalah tinggi, 80-90%. Tetapi penting bagi pesakit menjaga kebersihan telinga dan mengelak air masuk ke dalam telinga. Ini supaya jangkitan kuman tidak berlaku dan gegendang tersebut dapat pulih dengan eloknya.

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

HOARSENESS

Hoarseness is a symptom when there is change in the voice. The voice may become raspy, strained, unable to reach certain pitch or breathy. Hoarseness happens when there is an abnormality of the vocal cords. The vocal cords act like string instruments that come together and vibrates as we speak. During breathing the vocal cords come apart to allow air to enter the lungs.

CAUSES OF HOARSENESS

Laryngitis

The most common cause of hoarseness is laryngitis; which is inflammation of the vocal cords. It is usually temporary and related to the common cold or upper respiratory tract infection. However voice abuse during bouts of laryngitis can further strain and injure the vocal cords. If the hoarseness lasts for more than 2 weeks the patient should seek the advice of an ENT surgeon who would examine the larynx to confirm the cause. Persistent hoarseness can be an early sign of cancer.

Voice abuse

Excessive straining of the voice can also cause damage to the vocal cords. Habits of screaming, excessive use or shouting in noisy environment can also lead to hoarseness. Public speaking for prolonged periods without use of amplification is also voice abuse.

If the hoarseness happens suddenly after shouting then there is a possibility that the patient has developed vocal cord hemorrhage. This occurs when the sudden increased pressure on shouting causes a blood vessel to rupture at the surface of the vocal cord. An assessment by an ENT surgeon can determine this and treatment is strict voice rest.

Vocal cord lesions

Prolonged hoarseness of more than 2 week should be assessed by an ENT surgeon as it can be an early sign of cancer.

There are also other benign (non-cancerous) vocal cord lesions that can present with persistent hoarseness such as vocal cord polyp and nodules.

Laryngopharyngeal reflux

This is condition when there is stomach acid reflux which goes all the way up till the larynx or vocal cords. The acidic juice will cause inflammation of the vocal cords and result in hoarseness.

Smoking

Both primary and secondary smoking can cause hoarseness. Smokers also have a high risk of developing cancer of the larynx. Therefore they should not delay consulting an ENT surgeon if they develop hoarseness.

Vocal cord paralysis or palsy

Any impairment of the vocal cords movement can result in hoarseness. The vocal cords come in a pair and move synchronously to produce voice, pitch and volume. If one or both the vocal cords are unable to move then the patients will experience change in voice. Depending on the position of the vocal cords patients amy also have difficulty breathing or choking episodes on drinking fluids. Vocal cord palsy/paralysis can occur due to neurological conditions, trauma, thyroid disease and other rare causes such as muscle tension dysphonia or spasmodic dysphonia.

Treatment of hoarseness

The treatment of hoarseness depends on the underlying cause. Usually doctors would advice voice rest, taking lots of fluids, avoid smoking and spicy food. Occasionally the help of a speech therapist would be sought. The therapist is able to teach patients on proper voice usage and how to avoid voice abuse especially for professional voice users such as singers, teachers, telephonists and public speakers.

Vocal cord lesions or vocal cord paralysis often need surgical intervention.

When should patients seek ENT advice?

Since the most common cause of hoarseness is laryngitis then the initial treatment is given by the family doctor or general practitioner when patients come in for their common cold. However there are certain signs and symptoms which should prompt early referral to the ENT surgeon:

1. Persistent hoarseness of more than 2 weeks especially in smokers

2. When there is no associated upper respiratory tract infection

3. Professional voice users

4. Presence of neck swelling

5. When patients experience difficulty swallowing

6. When patients experience difficulty breathing

7. When there is cough with blood stained sputum

Voice hygiene

This term refers to maintaining the health of the vocal cords which is mainly avoiding voice abuse. These measures can be practiced:

• Quit smoking
• Avoid secondhand smoke
• Drink plenty of fluids
• Avoid caffeinated drinks and alcohol which can dehydrate the body
• Avoid spicy and oily food
• Try not to use the voice for too long or too loudly
• Humidify the home
• Use of amplification such as microphones when speaking to a crowd

Useful links:

Guide for Voice hygiene by Marshfield Clinic