- Ear Wax / Blockage:
The sensation of ear blockage can be due to either foreign body material in the outer ear canal or due to either the presence of fluid in the middle ear or obstruction of the eustachian tube. A build of wax is by far the commonest cause which can be made worse if the patient uses cotton buds to try and clear the ears. In rare instances, a feeling of fullness can be described as a blockage sensation which occurs in Meniere’s disease, usually associated with dizziness.
- Ear Infections:
Any discharge from the ear should be a reason to visit your Doctor. The commonest causes are ear infection either due to the outer or middle ear causation and are usually associated with pain in the ear as well as the presence of a perforation of the ear drum depending on the exact cause. Copious clear discharge could be fluid arising from the brain compartment and is seen following severe head injury. It is occasionally a complication of ear or brain surgery. Management of this symptom is to determine the cause and to treat with medications which usually involves both oral and topical treatment. Removal of debris from the ear canal is important as this allows examination of the ear more thoroughly especially using a microscope. Hearing tests are also required in order to determine the possibility of hearing loss as a consequence of the infection.
In rare instances imaging of the ear is required with either CT or MRI particularly in the presence of the condition mentioned above called cholesteatoma. Cholesteatoma is a condition that invariably requires surgical management in order to prevent any deeper erosion into the middle ear or indeed into the brain compartment. It is not unusual for episodes of ear discharge to come and go and can be made worse for example after allowing water to get into the ear. Occasionally the ear discharge can be blood stained and this usually implies an acute infection of the ear and is often associated with a polyp formation.
- Hearing Loss:
Hearing loss can either be congenital or acquired following birth. It can either be caused by problems of the outer ear, the middle ear or the inner ear. It can also be divided into the speed of onset of symptoms.
- Sudden sensorineural hearing loss:
This is a rare condition but can be quite devastating. The patient has sudden onset of hearing lose usually on one side and can be associated with a ringing tone in the ear. Although the cause has not yet been determined the cause is likely to be due to a virus. Other possible causes are a cessation of blood flow due to blockage of the feeding artery to the inner ear. This diagnosis requires urgent attention and the sooner treatment starts with high doses of oral steroids the more chance there is of recovery of hearing. The diagnosis and treatment is best made by an ENT Specialist.
Other causes of sudden onset of hearing loss include the impaction of a foreign body into the ear canal. The patent usually presents with a history of using either an implement or inserting a foreign body into the ear canal and this is usually visible. Other causes for sudden gearing loss include a stroke or head trauma.
- Dizziness / balance disorders:Many different balance disorders makes you feel unsteady or dizzy, as if you are moving, spinning, or floating, even though you are standing still or lying down. Balance disorders can be caused by certain infections, medications, or a problem in the inner ear or the brain.Diagnosis of a balance disorder can be difficult. Dr Alam Hussain is an expert in balance and hearing disorders and at The London ENT Clinic we have highly specialised technology and experience to diagnose and formulate your balance disorder treatment plan.
- Functional & Cosmetic Rhinoplasty:
A rhinoplasty is a form of facial plastic surgery that aims to resolve cosmetic and functional issues with a person’s nose. Rhinoplasty is also commonly called a “nose job”. Rhinoplasty can be performed to meet aesthetic goals or for reconstructive purposes to correct trauma, birth defects or breathing problems.Mr Patel is a rhinoplasty expert with more than 15 years experience in the field. If you would like to know more about rhinoplasty please visit our website www.londonrhinoplasty.com
- Deviated Nasal Septum:
The septum is the thin piece of cartilage and bone in the nose which separates the 2 nostrils. The septum may be deviated and cause blockage on one or both sides. Septal deviation can also result in external deformity of the nose. Although septal deviation can result from injury, in the majority of patients it is due to the way the septum has grown relative to the rest of the nose. Similarly the nasal bones too can be deviated and this is usually evident from just looking at the nose. In some patients the cause of nasal blockage is due to collapse of what are called the nasal valves. There are thin strips of cartilage in the fleshy part of the nose whose purpose it is to prevent inward collapse of the nostrils during inspiration. These cartilages can weaken with age or be deficient after excessive surgery and result in what is called “Alar Collapse”.
In all of these scenarios, there are structural factors which need correcting with a surgical procedure. A septoplasty is a relatively simple operation done through an incision within the nostrils. When the nasal bones need to be re-set in the midline or other changes need to be made, the operation is called Septo-Rhinoplasty.
- Acute/Chronic Sinusitis and Endoscopic Sinus Surgery:
- Nasal Allergy:
This can cause both acute and long term nasal blockage symptoms. Allergy causes swelling of the lining (mucosa) of the nose and after a long period of allergen exposure, the lining can become permanently enlarged. The mucosal swelling can result in secondary drainage problems of the sinuses which in turn can result in infection. In some patients it may contribute to the development of nasal polyps which further obstructs the nasal airway.
Patients with severe allergies may develop acute nasal blockage symptoms together with sneezing, itchy feeling in the nose, watery nasal discharge, and associated eye and throat irritation. Common allergies include those to grass pollens, house dust mites, and animal dander. Diagnosis can be made on the history but skin prick testing with RAST blood testing usually confirms the nature and extent of allergies. Treatment involves allergen avoidance, oral anthistamines, topical steroid sprays and more recently consideration of immunotherapy options.
- Nasal Polyps:
Nasal polyps occur when the lining of the sinuses swell and thereafter protrude through the natural ostia. This then results in prolapsing of swollen mucosal tissue into the nasal cavity which has the appearance of a bunch of grapes. A number of conditions are associated with the development of nasal polyps. One example is Samter’s triad, which is a condition associated with nasal polyps, Aspirin sensitivity and asthma. Many patients with nasal polyps also have underlying allergies and as a result, it is not uncommon for nasal polyps to recur after surgery, making medical management a more useful option in the long term.
In vast majority of cases, nasal polyp is a bilateral condition affecting both sides of the nose. Any patient presenting with a polyp on one side only will invariably require a biopsy of the polyp to ensure that it is entirely benign. Any patients who have nasal polyps with bleeding or offensive discharge should also be seen as a matter of urgency to rule out a malignant diagnosis.
- Nose Bleeds:
These are due to bursting of blood vessels in the front of the nose (anterior part). It is by far the most commonly seen in young children. There is an area just inside the nostril along the septum (Little’s area) where there is a confluence of four different blood supplies to the nose forming a plexus of veins which are very near the surface. In addition to this, young children often have a mild infection in the nasal cavity called vestibulitis. Any minimal trauma can therefore set off nosebleeds. This can be made worse by associated conditions such as allergy or a viral infection. Hot weather can also precipitate nose bleeds. In many instances, application of antibiotic ointments such as Bactroban on a twice daily basis for two weeks can resolve nosebleeds in a significant proportion of children.
However in those in whom it is persistent, cauterisation of the blood vessels is a successful technique in the outpatient setting using silver nitrate. This is done following application of a local anaesthetic nasal spray. Usually, both sides of the septum are not cauterised at the same time in order to avoid the small risk of septal perforation. It is also often the case that cauterisation needs to occur on at least three separate occasions spaced up by six weeks for the best long term outcome.
- Nasal Tumours:
Fortunately nasal tumours are relatively uncommon. The vast majority are benign and presents with symptoms of nasal blockage or bleeding from the nose. Obstruction of the nasal passage can also result in stagnant mucus and secondary infection. Probably, the commonest nasal tumour is called an inverted papilloma. This arises from the lining of the maxillary sinus usually and presents with unilateral flat fleshy polyp. A small percentage of these tumours can progress to malignant transformation and for this reason the condition was usually treated in the form of a lateral rhinotomy where incision was made between the inner aspect of the eye down the side of the nose between the cheek and along the nostril of the nose, thereby allowing access to the sinus through the front of the face. The middle part of the maxillary sinus was then removed and the tumour scooped out in its entirety. However, recent advances in endoscopic techniques can now allow this to be carried out endoscopically in the majority of cases. This condition requires long term surveillance and any recurrences need to be proactively removed and assessed for malignant change.
Malignant tumours can occur in the ethmoid sinuses. A classic one was seen in those who worked in the woodworking industry. It is thought that some of the resins found particularly in hardwoods such as mahogany can give rise to malignant changes in the ethmoid sinuses. Such conditions when diagnosed can require extensive cranio facial operations to ensure complete removal of the disease but involvement of the surrounding tissues, such as the eye and brain, are not uncommon making this condition quite difficult to manage.
Hoarseness is a symptom of a rough or gravely voice. It occurs as a result of pathology involving the larynx (voice box). The vocal cords come together during the act of speech and undulation of the lining of the vocal cords give rise to audible sound. Therefore, any abnormality of the coating of the vocal cords can give rise to change in the pitch and quality of the voice. Common causes include viral laryngitis, vocal cord nodules, polyps of the vocal cord and in rare instances, paralysis of the vocal cord itself. The vocal cord can also be affected by cancer and this is almost exclusive to smokers. Any unexplained hoarseness for more than 3 weeks is an indication to seek medical help. During the assessment at the ENT Clinic, the larynx is examined with a fibre optic camera and the nature of the cause for the problem can usually be identified.
- Persistent Cough:
Cough is one of the most common reasons for people to seek medical attention. Although most episodes are short lived and require over the counter medication only, there are instances where the symptom of cough persists for more than 8 weeks. This is called chronic cough. It can be very debilitating and have secondary effects such as cracked ribs, backache or chest muscle strain, not least the embarrassment of appearing ill in front of family and friends. It can also interfere with your professional life. There are many causes for persistent cough but 3 main groups of conditions will account for 90% of cases.
These conditions are
1.Upper airway inflammation e.g. sinusitis with post-nasal drip.
2.Laryngopharyngeal (acid) reflux.
3.Lower airway cases such as asthma related cough or bronchial hyper reactivity syndrome.
At the London ENT Clinic, we are able to diagnose the cause of cough in most instances and start investigations and definitive therapies.
- Lumps in the Head & Neck:
Any persistent lump in the head and neck region for more than three weeks needs to be investigated as to the possible cause. In the vast majority of cases, these are benign causes but cancer needs to be excluded. There are many different causes for lumps in the head and neck region and the descriptions below will be divided based on which types of glands or structures from which they arise.
- Salivary Gland Tumours:
We have three pairs of main salivary glands which are the parotid glands, situated below the ear and behind the jawbone, the submandibular gland under the horizontal part of the jawbone and tongue, and lastly the sublingual gland which is in the floor of the mouth just below the mobile part of the tongue. The salivary glands can be affected by growths which are in the main benign but can also be malignant in nature. Tell-tale signs of malignancy include paralysis of the facial nerve which travels through the parotid gland and supplies the muscles of the face. Again, ultrasound and needle biopsy are mainstays of diagnostic tests to assess nature of the problem. Occasionally, the parotid and submandibular glands can increase in size itself due to the presence of a stone in the duct giving rise to a backlog of saliva and swelling with meals.
- Thyroid Tumours:
The thyroid gland is situated at the lower part of the neck and its purpose is to produce thyroxine and parathormone, which are essential hormones that regulate various activities of the body. They can be both benign and malignant tumours involving the thyroid gland. This can usually present as a firm lump in the neck which may or may not cause any particular symptoms. Occasionally, when the tumour is very large, it can cause a compression feeling but this is uncommon. The thyroid gland can become diffusely enlarged as part of a multicystic disorder. In some cases, thyroid disease is part of an autoimmune condition where the body attacks its own tissues. Any lumps in the thyroid gland can be easily determined by ultrasound examination and this allows the radiologist to perform a needle biopsy. This can give rise to an accurate diagnosis in most cases and can help the attending surgeon plan the best treatment.
During the development of the foetus, the thyroid gland starts at the base of the tongue and makes its way down the neck during the first few weeks of development. Sometimes, this developmental process can be affected and result in the presence of a cyst in the midline of the neck which can lie dormant until adulthood. It then presents with a swelling in the midline which can be completely asymptomatic. However, it can also develop into an infection. This is called a thyroglossal cyst. Treatment is usually by excision of the cyst and associated tract including the middle third of the hyoid bone (Sistrunk’s operation).
- Tonsil & Adenoid Surgery:
The tonsils are thought to have an immunological function in the first 18 months of life but thereafter have no useful function and are surplus to requirement. Seen under the low-power microscope, the tonsil has deep clefts which reach to the inside of the tonsil and harbour numerous bacteria. Every now and again, these bacteria can become virulent and give rise to an episode of tonsillitis. The bacteria invade the surrounding tissues and give rise to sore throat and associated symptoms can include fever, general malaise and inspection of the tonsils reveals white spots with sometimes pus-like material emanating from the crypts of the tonsils. As a result of the acute episode, the body builds up a defence with an increase in white blood cells and together with treatment with antibiotics, the acute infection usually settles after seven to ten days. However, the bacterium may then reside dormant in the depths of the tonsil until the next occasion. In some patients, the bacteria remain quite active and give rise to persistent sore throat symptoms with acute exacerbations (chronic tonsillitis). The common organisms causing this infection are Streptococcus and Staphylococcus. Treatment of these infections is with appropriate antibiotics. In an ideal world, a throat swab would be taken in the outpatient setting but a course of broad-spectrum antibiotics such as Penicillin V is started pending the throat swab result.
There are now guidelines as to the surgical management of recurrent tonsillitis and usually if a patient has a history of four or more episodes in a 12-month period for two consecutive years, then this fulfils the criteria for tonsillectomy. However, this guideline is not set in stone and patients with very mild symptoms but frequent episodes can sometimes be observed whereas patients with few episodes but are more severe and result in much time loss from work or school may benefit from tonsillectomy.