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Otolaryngology (Ear, Nose, Throat)

WHAT IS TRIGGERING YOUR ALLERGIES

Things that make allergies or asthma worse are called triggers. Dr. Hetherington at Bozeman Deaconess Ear, Nose & Throat can help with all types of allergies including seasonal allergies,...

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ALLERGIES
Allergies
Respiratory allergies affect approximately 20 percent of the population. They can contribute to many other disorders of the ears, nose, throat and respiratory system. Symptoms can include: Nasal drainage, usually clear Stuffy nose Sneezing Watery, itchy eyes Chronic cough Headache Asthma Ear infections What causes allergies? Airborne pollens produced by trees, grasses, and weeds usually cause seasonal hayfever symptoms.  Year round symptoms can be caused by pets, dust and insects such as cockroaches and dust mites.  Molds are frequently an under recognized and therefore under treated source of allergies.  Recent studies have demonstrated that even low level mold allergies may be a significant cause of chronic sinus disorders.Allergies are caused by tiny particles called antigens which react with our immune systems.  Antigens are found on pollens, pet dander, dust, molds and other substances.  The immune system may react by producing a variety of antibodies.  IgE antibodies are the most relevant to allergies.  In allergy, an abnormal quantity of IgE antibodies are produced in response to common antigens.  This results in an abnormally reactive immune system.  When an antigen attaches to an IgE antibody, inflammatory mediators are released.  These inflammatory mediators cause localized reactions such as swelling, irritation, inflammation and wheezing.  If the allergic reaction is severe enough, life threatening systemic anaphylactic reactions can occur which require immediate medical attention.Treatment options:AvoidanceAntihistaminesNasal SpraysLeukotriene InhibitorsImmunotherapyTypes of tests for allergies include:Prick testingIntradermal testingSkin endpoint titration (SET)Blood testing
EAR INFECTIONS
Ear Infections
Ear infections commonly occur in either the middle ear or in the ear canal. Otitis Media The middle ear is located behind the eardrum and contains a chain of tiny bones which connects the eardrum to the inner ear. This space normally contains air. The presence of fluid can interfere with hearing. Middle ear infections are very common in small children. The peak incidences are at ages 2 and 5 years. The air containing middle ear space is ventilated by the eustachian tube. The eustachian tube connects the middle ear with the throat. Its function is to ventilate the middles ear space and equalize the pressure with the outside. When this tube is obsructed, a vacuum develops in the middle ear. The vacuum is then replaced by fluid. This fluid frequently interferes with hearing. The fluid also may become infected. If the infection is not treated, the eardrum will usually rupture, thus allowing the ear to drain. Once the pus drains, the immune system will usually resolve the infection. Occasionally, complications such as facial paralysis, neck abscess or even brain abscess may result from untreated infections. Most middle ear infections are treated with antibiotics. If the infections are frequent or if fluid does not clear from the middle ear after an infection and interferes with hearing, placement of tubes may be considered. In children this operation is done under a light general anesthesia. In adults, it is frequently done as an office procedure under local anesthesia. An incision is made in the eardrum and a small tube is inserted into the incision. Without the tube, the eardrum would heal within a day or two. Depending on the design of the tube, it may stay in several months to several years before the eardrum heals underneath it and extrudes the tube. The tube functions to bypass the eustachian tube and ventilate the middle ear space preventing the accumulation of fluid and the ensuing infection. The tube mimics the body’s natural process of perforation of the eardrum to ventilate the middle ear and drain the infection. Otitis Externa The ear canal which extends from the opening down to the eardrum is occasionally infected. This is usually associated with the prolonged presence of moisture in the ear canal. It is more common in diabetics or in immunocompromised patients. Careful cleaning of the ear canal and antibiotic ear drops usually suffice to clear the infection
SINUSITUS
Sinusitus
Sinusitis is a leading health care problem. It is believed to be increasing in both incidence and prevalence. It has been estimated that bacterial sinusitis complicates 0.5 to 2% of viral upper respiratory infections (colds). This translates to 20 million cases of bacterial sinusitis in the U.S. every year. The chronic form, lasting more than 12 weeks, has been estimated to affect more than 31 million individuals. This makes it the most common chronic health problem in the United States. The disease frequently presents as "the cold that won't go away."What are the sinuses? The sinuses are cavities inside the head, which are connected to the nose. They are lined with a mucus membrane. The mucus membrane has mucus glands, which secrete mucus. The mucus membrane is also covered with tiny hairs, which actively push the mucus from the sinuses into the nose through tiny openings known as ostia. The mucus contains antibodies and other infection fighting substances. It is also sticky and its function once inside the nose is to trap particles in the inspired air and thus it forms part of the nose's filtration system. What causes sinusitis? Sinusitis is caused by obstruction of the ostia. When the ostia become obstructed, the mucus backs up in the sinus. When mucus collects it easily becomes infected since there is a large variety of bacteria, which colonize a normal nose. Things, which can cause sinus outflow obstruction, include allergies, viral upper respiratory infections ("the common cold,") and non-specific nasal irritants such as dust and noxious chemicals. In addition, an individual may be predisposed to sinus infections because of anatomic obstructions such as a deviated septum or enlarged turbinates. What are the symptoms of sinusitis? Primary: * Facial pain and pressure in the sinus area * Facial congestion and fullness * Nasal or postnasal drainage, usually yellow or otherwise discolored * Nasal obstruction and blockage * Loss or reduced sense of smell * Fever Secondary: * Headache * Bad breath * Ear pain, pressure or fullness * Sore throat * General malaise or fatigue * Dental pain * Cough Any of these symptoms may be present however; it usually takes at least one primary and at least two secondary symptoms to consider the diagnosis. They may be quite severe or relatively mild and may be mainly a nuisance. In chronic sinusitis, these symptoms may be present for years. Frequently, chronic sinusitis is described as "the cold that won't go away." How is sinusitis diagnosed? The history of the disease process is the most important factor in making the diagnosis. Physical examination may reveal the presence of nasal discharge, nasal polyps, inflammation of the throat, tenderness of the sinuses and swelling of the lymph nodes in the neck. In chronic cases, nasal endoscopy (looking up the nose with a special scope) is usually performed to fully evaluate the deeper passageways of the nose and look for the presence of contributing factors such as polyps, tumors and anatomic abnormalities. Computerized tomography or CT scanning is used to define the anatomy and help determine the extent of disease. How is sinusitis treated? In most cases, a ten-day course of antibiotics will clear up a sinus infections. If the infection does not clear with a short course of antibiotics, or if the symptoms have been present a long time, a longer course of antibiotics of four to six weeks may be used. Frequently, steroid nasal sprays and systemic corticosteroids are used in conjunction with the antibiotics to reduce the inflammation and swelling in the nose and sinuses. This is frequently successful in opening up the sinus drainage pathways and restoring normal ventilation of the sinuses. Decongestants are often used for similar reasons. The key to restoring the sinuses to health is to unblock the drainage pathways. Allergies and other medical problems may contribute to recurrent and chronic sinusitis.  Appropriate testing and treatment should be pursued if allergies are suspected to be a contributing factor.   When medical treatment is unsuccessful in clearing the sinus infection or when the infections become so frequent, protracted or severe that they affect the individuals quality of life then surgical treatment is considered. Surgery is aimed at making the sinus drainage pathways larger to eliminate obstruction. Any anatomic factor, such as deviated nasal septum, which may contribute to sinus obstruction, is corrected also. Sinus surgery Sinus surgery is performed as an outpatient. The procedure is called endoscopic sinus surgery. It is technically demanding and very precise work. The surgery is performed in close proximity to the eyes, optic nerves, brain and carotid arteries. The procedure is quite safe however when performed by an experienced surgeon.  At Bozeman Deaconess Ear, Nose & Throat, we have successfully performed over a thousand sinus operations. After surgery, packs are left in the nose for a variable period of time depending on the extent of the surgery. The purpose of the packs is to control bleeding and to stent the sinus outflow passages open during the initial phase of healing. During the post-operative period, debris and crusting must be cleaned from the sinus passages. This is to prevent recurrent infection, prevent scarring with closure of the drainage pathways, and it also makes the patient more comfortable. This is performed in the office on several occasions over the initial four to six weeks after surgery. It is important to realize that sinus surgery is only part of the process to rehabilitate the sinuses. By the time most patients undergo surgery, the sinus mucus membranes have been sick a long time. Continued medical management after the surgery is very important. Underlying problems such as allergies must be treated to prevent the infections from recurring. In addition, any recurrence of the sinus infection, which occurs, must be promptly treated to prevent it from becoming chronic.
SLEEP APNEA & SNORING
Snoring and sleep apnea are common problems. They are both caused by excess tissue in the throat. The primary obstructed areas are the soft palate and the base of the tongue. A long palate vibrating while breathing causes most snoring. Apnea is the cessation of breathing and may be due to an obstructive cause or to a central cause. Central sleep apnea results when the brain fails to tell the body to breathe. Obstructive sleep apnea results from excess soft tissue in the palate, base of tongue, and rarely, the sides of the throat collapsing in and blocking breathing. Obstructive sleep apnea occurs in the deeper stages of sleep when the body becomes very relaxed. Both types of apnea are relieved when the oxygen concentration in the blood drops low enough that the person feels starved for air and wakes up to breath. These brief waking episodes may occur hundreds of times a night and are not usually remembered by the patient. The result is a poor night's rest. Symptoms include daytime sleepiness, morning headaches, falling asleep at the wheel, irritability and short temper, and problems with concentration and memory. There is also an association with health problems such as high blood pressure, heart attack, and stroke. Treatment Options Medical Treatment Medical treatment is generally recommended as the initial treatment for all but the most severe cases of sleep apnea. For obstructive sleep apnea, continuous positive airway pressure (CPAP) is used as the initial treatment. In this form of treatment, a mask is worn at night and a machine blows air into it. This creates pressure in the airway thus supporting the tissues and preventing blockage. CPAP is an effective treatment for those patients who tolerate it. If CPAP is not effective or if the patient does not tolerate it surgery may be considered. LAUP The laser-assisted uvulopalatoplasty is an office procedure performed under local anesthetic. It is a highly effective treatment for snoring. At this time, it does not have a role in the treatment of sleep apnea. In this procedure, excess tissue is trimmed off the soft palate and uvula with a laser. This reduces or eliminates snoring by reducing the amount of tissue, which can vibrate. This procedure is repeated in the office until the desired result is obtained. It may take from two to five treatments to alleviate the problem. The treatments are spaced 6 to 8 weeks apart. It is performed in a serial fashion to avoid taking to much palate. This increases the safety of the procedure.  In our practice, this procedure has been replaced by injection snoreplasty. Injection snoreplasty This is the latest procedure used to treat snoring.  It is performed in the office using local anesthesia and results in minimal discomfort after the procedure.  A small amount of sclerosing solution (sodium tetradecyl sulfate) is injected into the soft palate.  This causes scarring and stiffening which in turn results in less noise being produced. UPPP Uvulopalatopharyngoplasty is also an operation to trim excess tissue from the palate and also from the tonsil area. It is similar to the LAUP except that tissue is also removed from the sides of the throat. The tonsils are removed in conjunction if they are still present. This is an effective operation for snoring and is effective for obstructive sleep apnea resulting from obstruction at the level of the palate. This operation requires overnight hospitalization. Tongue base advancement In cases where collapse of the tongue base is obstructing breathing, operations may be performed to pull the tongue forward. The tongue is attached to the lower jaw in the midline just below and behind the front teeth. If this attachment is separated or loose, the tongue can flop backwards and block the airway. The genioglossus advancement is a surgical procedure designed to pull the tongue forward towards its attachment to the lower jaw.  The very lowest part of the base of tongue is pulled forward in a procedure known as the hyoid suspension. In this procedure, the base of the tongue is pulled forward and suspended over the top of the voice box. This prevents collapse of the base of the tongue. These two procedures are usually performed together to maximize suspension of the tongue. Bimaxillary Advancement This procedure pulls both the upper and lower jaw forward, thus pulling both the tongue and the palate away from the back of the throat. It is a very effective procedure for sleep apnea however it is quite extensive and is usually reserved for those cases which fail more conservative approaches. In this procedure, the teeth bearing portions of the upper and lower jaws are cut free and surgically suspended in a more forward position.  Evaluation and management protocol The patient with a snoring and/or sleep apnea problem is evaluated in a systematic fashion. The patient's history is the most important indicator of problems. A complete ear, nose and throat examination is performed. A sleep study, also known as a polysomnogram, is usually obtained. The sleep study may be screening test which can be done at home if the suspicion of sleep apnea is low and treatment of snoring is all that is desired. A more detailed sleep study, performed in a sleep lab may be required if the screening test is abnormal or if sleep apnea is strongly suspected. Once sleep apnea is ruled out in the snoring patient, an injection snoreplasty may be performed for snoring. Sometimes chronic nasal obstruction contributes to snoring and/or sleep apnea and may require medical or surgical treatment. Once sleep apnea is documented to exist with a sleep study the initial treatment is usually medical. This treatment takes the form of Continuous Positive Airway Pressure (CPAP). If CPAP is not effective or if the patient does not tolerate it surgery may be considered. When surgery is considered, the object of the evaluation is to determine the level where the obstruction is occurring. A complete head and neck examination is performed. In addition, a small flexible scope is passed through the nose to evaluate the base of the tongue. An x-ray is also obtained of the base of the tongue region.
THROAT & VOICE BOX PROBLEMS
Throat & Voice Box Problems
Swallowing and breathing problems, infections, tumors, birth defects, speech and voice diagnostics and therapy.
TONSILS & ADENOID DISORDERS
Tonsils & Adenoid Disorders
The tonsils and adenoids are a normal part of the immune system.  Large numbers of white blood cells which fight infections are located there.  They are located in the throat so that they can respond to infectious agents entering the body by priming the immune system.  Fortunately, there are redundant systems which can take over if the tonsils become chronically infected or enlarged and need to be removed. The tonsils and adenoids can become chronically infected and themselves become a source of recurrent infections.  The tonsils and adenoids can become can also enlarge to the point that they obstruct normal breathing, swallowing and speech.  Enlarged tonsils and adenoids are the most common cause of obstructive sleep apnea in children. The initial treatment for tonsillitis is antibiotics.  If the tonsils become chronically infected or are constantly becoming reinfected tonsillectomy is usually recommended.  The adenoids are usually removed at the same time. 

 

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