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VOICE DISORDER (HOARSENESS OF VOICE)

Prof. Kamrul Hassan Tarafder

 

Voice is the sound made by air passing from lungs through larynx or voice box.

A disordered voice can be define as one that has one or more of the following characteristics

 

  • it is not audible, clear or stable in a wide range of acoustic settings;
  • it is not appropriate for the gender and age of the speaker;
  • it is not capable of fulfilling its linguistic and paralinguistic functions;
  • it fatigues easily;
  • it is associated with discomfort and pain on phonation.

Hoarseness: A perceived rough harsh or breathy quality to the voice.

Aetiology

1. Inflammatory;

2. Structural or neoplastic;

3. Neuromuscular

4 . Muscle tension imbalance.

VOICE DISORDER (Hoarseness of voice)

ORGANIC:

Structural disorders are caused by some lesion (physical abnormality) of the larynx.

       •     Contact Ulcers

       •     Cysts

       •      Granuloma

       •      Hemorrhage

       •      Hyperkeratosis

       •      Laryngitis

       •      Leukoplakia

       •      Nodules (nodes)

       •      Papilloma

       •      Polyps

       •      Trauma

       •      Miscellaneous

       •      growths

 

NEUROGENIC:

Neurogenic Voice Disorders are caused by some problem in the nervous system as it interacts with the larynx.

       •      Paralysis/Paresis

       •     Spasmodic      Dysphonia

       •     Tremor (Benign   Essential Tremor)

       •     Voice problem caused by another   neurological  disorder (e.g. Parkinson's disease, myasthenia

              gravis,) 

 

FUNCTIONAL:

Functional disorders are caused by poor muscle functioning. All functional disorders fall under the category of muscle tension dysphonia.

 •    Muscle tension dysphonia (general)

 •    Anterior-posterior    constriction

                       Hyper abduction

                       Hyper adduction

 •    Pharyngeal  constriction

 •    Ventricular phonation

 •    Vocal fold bowing
 

 

Psychogenic disorders exist because it is possible for the voice to be disturbed for psychological reasons. Conversion dysphonia or aphonia ,  Puberphonia

 

Patient assessment  :

Patient should be assessed  in a voice clinic where should be available following

-Diagnosis

  • history 
  • Examination
  • Investigations

-treatment options

-prognosis

03. Voice therapist assessing-

                -voice production,

-breathing patterns,

-posture,

              -disorders of articulation,

-fluency

- communication

-psychologically related issues.

 

History:

A detailed history is required to determine:

• the nature and chronology of the voice problem;

• exacerbating and relieving factors;

• lifestyle, dietary and hydration issues;

• contributing medical conditions or the effects of their treatment;

• the patient's voice use and requirements;

• the impact on their quality of life, social and psychological well-being;

• their expectations for outcome of the consultation and treatment.

 

The patients' complaints are most frequently related to:

 

• changes in voice quality (hoarseness, roughness and breathiness) ;

• a pitch that is increased or decreased which is not appropriate for their age and sex;

• an inability to control their voice as required (pitch breaks, voice cutting out);

• an inability to raise the voice or make the voice heard in a noisy environment (reduced loudness);

• an increased effort and/or reduced stamina of the voice or one that tires with use;

• difficulties or restrictions in the use of their voice at different times of the day or related to specific

    daily, social or work-related tasks;

• a reduced ability to communicate effectively;

• difficulty in singing;

• throat-related symptoms (soreness, discomfort, aching,dryness, mucus), particularly related to voice 

    use;

• the consequent emotional, psychological effects caused by the above.

Many of the patient self-report questionnaires that have been developed to measure the impact of the voice problem on the quality of life are concerned with these areas of voice complaint .

Examination

Examination should include –

  • oral cavity,
  • oropharynx,
  • nasal cavity,
  • lower cranial nerves,
  • neck for

-          lymphadenopathy,

-          masses and

-          signs of increased muscle tension,

-          external laryngeal skeleton and position,

-          posture,

-          breathing pattern and

-          general affect.

Endoscopic evalutation :

01.Nasopharyngolaryngoscopy

02.Videolaryngostroboscopy

Microscopic evaluation

Diagnostic microlaryngoscopy

Investigations:

01.Laryngeal electromyography

02.twenty four hour pH monitoring

 

May also need further assessment by other collogues like-   

-          clinical psychologist,

-          specialist singing teacher(familiar with voice problems in singers),

-          neurologist,

-          respiratory physician,

-          gastroenterologist or upper gastrointestinal surgeon.

                Treatment Overview:

 Not all patients presenting with a voice disorder want treatment and some may be happy being given a diagnosis, an explanation of their voice problem and be reassured there is no serious underling condition present. If treatment is required, it will usually consist of one or more of the following options depending on the patient's symptoms, vocal requirements and clinical findings:

• vocal hygiene, lifestyle and dietary advice;

• voice (speech) therapy;

• specialist therapy, for example singing therapy,

• medical treatment;

• phonosurgery.

 

 

Vocal hygiene, lifestyle and dietary advice:

Depending on the relevance to the patient this may consist of a discussion or video presentation either in individual or group sessions.Additional material is usually given in patient information leaflets. The areas covered may include:

• an explanation of how the voice works;

• the links between lifestyle, phonatory and nonphonatory vocal activities and stress on voice disorders;

• the potentially traumatic effects to the vocal folds of 'vocally abusive behaviors’ such as talking or singing too loudly, talking too fast, shouting, throat clearing and harsh coughing;

• communicating effectively without raising or straining the voice, for example using a whistle in the school playground or using amplification devices where practical and conserving the voice where possible or in extreme situations discussing the possibility of changing jobs;

• the importance of adequate hydration for vocal fold function, i.e. by drinking water, use of steam inhalations and avoiding excessive amounts of drinks containing caffeine, i.e. coffee, tea and colas;

• smoking cessation, reducing alcohol and social drug consumption (particularly spirits, cannabis and cocaine) and avoiding exposure to fumes, dust and dry air;

• diet and reflux reduction, for example avoiding eating late at night, large or fatty meals.

 

 

 

Voice therapy:

TIPS ON VOICE CARE

  1. Avoid clearing your throat.
  2. Avoid coughing whenever possible.
  3. Speak in a clear tone.
  4. Avoid talking above loud noise.
  5. Keep volume level low on audio sets.
  6. wear earplugs at music concerts.
  7.  Keep airflow smooth during exercise (especially weight lifting)
  8. Drink plenty of water to avoid vocal cord dehydration (at least 8 glasses per day)
  9. Do not smoke and avoid smoky environments.
  10. If your voice quality changes suddenly, rest your voice and consult your physician or laryngologist.
  11. If your voice loss is gradual, but does not improve within 2 weeks, consult your physician or laryngologist.
  12. If you are speaking or singing in a way that makes you hoarse or causes discomfort, STOP!

 

 

 

ADDITIONAL TIPS FOR THE PERFORMER

 

  1. Always warm-up before a performance.
  2. Rest the voice when you do not need to use it.
  3. Get formal voice training if you have not already.
  4. Be careful with “character” voices and “emotional” releases. Always  use good technique.
  5. Career longevity is dependent on maintaining a healthy voice. Make wish decisions and protect yourself.
  6. Come in early to be evaluated for any voice problems.

 

 

 

 

    • to help the patient find a better voice quality which is stable, reliable and less effortful to produce;

    • to make better use of vocal resonance and tonal quality;

    • to increase the flexibility of the voice by improving the pitch range and loudness without undue     

       effort;

    • to increase the stamina of the voice.

       Techniques:

    • vocal exercises with the aim of tar getting and strengthening specific muscle groups and

       improving glottal closure and efficiency;

    • increasing awareness of and reducing excessive tension in the muscles around the larynx, neck 

        and shoulders;

    • advice on posture and improving breathing during  speech;

    • laryngeal massage;

    • general relaxation exercises and stress management;

    • psychological counseling;

    • remedial singing lessons.

    •  Some techniques may need additional specialist input  from clinical psychologists, singing

        teachers and osteopaths,

 

 

 

Medical treatment

This mainly includes treatment for -

-          acid reflux 

-          upper respiratory tract infections

-           allergies.

-          change medication for  asthma inhalers, diuretics and other antihypertensive medication.

 

Phonosurgery:

Phonosurgery refers to any surgery designed primarily for the maintenance, restoration or enhancement of the voice .It encompasses the following-

 

• Microlaryngoscopic surgery:

The vocal folds or occasionally false cords are inspected and lesions removed using a microscope and endoscope. The aim is usually to remove pathological tissue and attempt to restore the normal surface contour and layered structure of the vocal fold.

• Laryngeal injection techniques:

Various synthetic,biological and autologous materials are usually injected laterally into the muscle of deep layers with a view to augmenting the vocal fold.

• Laryngeal framework surgery: 

Transcutaneous surgery performed on the cartilaginous skeleton of the larynx, for example, laryngoplasty (thyroplasty), arytenoid adduction and cricothyroid approximation with a view to improving glottic closure and body cover differential tone.

• Nerve-muscle pedicle graft techniques:

Nerve-muscle pedicle graft techniques are used for bulking out or restoring tone to the vocal fold.

• Reinnervation and electrode pacing techniques:

Reinnervation and electrode pacing techniques are used for restoring tone to the vocal fold or

stimulating contraction of specific muscles.More information can be obtained .

NOISE POLLUTION

Prof. Abdullah A Haroon, FRCS, FCPS

Noise pollution is the disturbing or excessive noise that may harm the activity or balance of human or animal life. The source of most outdoor noise worldwide is mainly caused by machines and
transportation system like motor vehicles, air craft and train.

Outdoor noise is summarized by the word environmental noise. Poor urban planning may give rise to noise pollution, since side by side industrial and residential buildings can result in noise pollution in the residential areas.

Indoor noise is caused by machines, building activities, music
performance, specially in some work places. There is no great
difference whether noise-induced hearing loss is brought about by outside (e.g. trains) or inside (e.g. music) noise.

High noise levels can contribute to cardiovascular effects in humans, a rise in blood pressure and an increase in stress and
vasoconstriction, and an increased incidence of coronary artery
diseases. In animals, noise can increase risk of death by altering predator or prey detection and avoidance, interfere with reproduction and navigation, and contribute to permanent hearing loss.

Noise pollution affects both health and behavior. Unwanted sound can damage psychological health.  Noise pollution can cause hypertension, high stress levels, tinnitus, hearing loss, sleep disturbances and other harmful effects. Further more stress and hypertension are the leading causes to health problems.

Sound becomes unwanted when it either in interferes with normal
activities such as sleeping, conversation or disrupts or diminishesone's quality of life.

Hearing loss associated with exposure to excessive noise can be
divided into two groups- 1. Acoustic trauma, and  2. Noise induced hearing loss.

Acoustic trauma: Permanent damage to hearing can be caused by a single brief exposure to very intense sound, e.g. In explosion, gunfire or a powerful cracker. Sound Levels in rifle or a gunfire may reach 140-170 db SPL. Sudden loud sound may damage outer hair cells, disrupts the organ of Corti and ruptures the Reissner's membrane in the inner ear. A severe blast may concomitantly cause a rupture in tympanic membrane/ear drum and disrupts ossicular chain (a chain of small bones for conduction of sound) in the middle ear situated between the ear drum and inner ear.

Nose included hearing loss (NIHL): Hearing loss in this case follows chronic exposure to less intense sounds than seen in acoustic trauma and is mainly a hazard of noisy occupation.
The damage caused by noise trauma depends on several factors-
a)    Frequency of noise- A frequency of 2000 Hz to 3000 Hz causes more
damage than lower or higher frequencies.
b)    Intensity and duration of noise- As the intensity increases, the, permissible time for exposure is reduced.
c)    Continuous Vs interrupted noise- Continuous noise is more harmful.
d)    Susceptibility of individual.
e)    Pre-existing ear diseases.
The audiogram in NIHL shows a typical notch at 4 KHz both for air and bone conduction; it is usually symmetrical in both ears. At this stage patient complains of high pitched tinnitus and difficulty in hearing in noisy surroundings.

Wild life:
Noise can have a detrimental effects on wild animals, increasing the risk of death by changing the delicate balance in predator or prey detection and avoidance, and interfering the use of the sound in communication, especially in relation to reproduction and in navigation.

An impact of noise on wild animals is the reduction of usable habitat that noisy areas may cause, which in the case of uncommon species may be part of the path to extinction.

SINUSITIS

Professor S.M. Khorshed Mazumder

Patients come to ENT specialists invariably coin the term “Sinus” to narrate some common ENT problems like headache, nasal discharge & nasal stuffiness. But actually sinuses are air-containing cavities in certain bones of skull. They are four on each side. Clinically, paranasal sinuses have been divided into two groups:

Anterior group: this includes maxillary, frontal & anterior ethmoidal.

Post Group: This includes post ethmoidal sinuses.

And, the inflammation of the above mentioned sinuses is called sinusitis.

On the basis of duration of inflammation, sinusitis is divided into acute & chronic sinusitis.

Acute inflammation of sinus mucosa is called acute sinusitis. The sinus most commonly involved is the maxillary sinus followed inturn by ethmoid, frontal & sphenoid. Very often, more than one sinus is infected (multisinusitis). Sometimes, all the sinuses of one or both sides are involved simultaneously (Pansinusitis Unilateral or bilateral). Sinusitis may be ‘open’ or ‘closed’ type depending on whether the inflammatory products of sinus cavity can drain freely into the nasal cavity through the natural ostia or not. A ‘Closed’ sinusitis causes more severe symptoms and is also likely to cause complications.

 

AETIOLOGY OF SINUSITIS IN GENERAL:

  1. Common cold or influenza
  2. Dental infection or extraction
  3. Swinning or diving
  4. Fracture of sinuses due to trauma
  5. After nose operation.

 

PREDISPOSING FACTORS:

  1. Local:
    1. Allergic Rhinitis, Vasomotor Rhinitis
    2. Nasal Polyps
    3. Deviated nasal septum, abnormal uncinate process Bulla
    4. Foreign body in nose
    5. Nasal tumour (Benign or malignant)
    6. Enlarged Adenoid
    7. Choanal atresia
    8. Cystic fibrosis

 

  1. General:
    1. Environmental: sinusitis is common in cold & wet climate.

Atmospheric pollution, smoke, dust & overcrowding also predispose to sinus infection.

  1. Poor general health:-

Diabetes

AIDS

Karta gener’s Syndrome

 

 

PATHOLOGY OF SINUSITIS:

Most cases of acute sinusitis start as viral infections followed soon by bacterial invasion. The bacteria is most often responsible for acute suppurative sinusitis. such infection causes oedema of the mucosa which blocks osteum of sinuses. There is cellular infiltration and increase mucous production.
Infection also paralyzes the cilia, leading to stasis of secretion.

 

CAUSATIVE ORGANISM:

  1. Streptococcus pneumoniae
  2. Haemophilus influenzae.
  3. Moraxella catarrhalies
  4. Streptococcus pyogens
  5. Staph. aureus
  6. Klebsiella Pneumoniae
  7. Anaerobic organism & mixed infections are seen in sinusitis of dental origin.

 

 

CLINICAL FEATURES:

Symptoms:

  1. Severe pain across the affected sinuses with fever & malaise. The pain may increase in bending forwards. Pain in cheek or upper teeth indicates maxillary sinusitis.

Pain in the forehead & tenderness below the eyebrows indicates frontal sinusitis.

Frontal headache & pain between the eyes indicates ethmoidal sinusitis.

Retro-orbital pain or pain at the top of the head indicates sphenoidal sinusitis.

  1. Nasal blockage, nasal discharge & disturbance of smell.

SIGNS:

  1. Congested nasal mucosa
  2. Oedematous turbinates
  3. Pus in middle meatus or spheno ethmoid recess
  4. Tenderness over the infected sinus
  5. precussion over the upper teeth may elicit tenderness in maxillary sinusitis

 

INVESTIGATIONS:

  1. X-ray paranasal sinuses occipito mental view or water’s view will show either an opacity or a fluid level in the involved sinus.
  2. CT scan of paranasal sinuses coronal section is the preferred imaging modality to investigate the sinuses.

 

TREATMENT:

  1. MEDICAL:
    1. Nasal decongestant drops:

Oxymetazoline 0.05% or

Xylometazoline 0.1%

4 drops in each Nostril Thrice daily for 7-10 days

  1. Antibiotics:

Tab Cefuroxine 250/500mg twice daily for 10-14 days

  • or

Tab Ciprofloxacin 500mg twice daily for 10-14 days

  • or

Tab Co-amoxyclav 375/625mg thrice daily for 10-14 days

  1. Analgesics:

Paracetamol or any other suitable analgesics

  1. Steam Inhalation:

Steam alone or medicated with menthol or Tr. Benzoin-Co provides symptomatic relief & encourages sinus drainage. Inhalation should be given 15-20 min after nasal decongestion for better penetration.

  1. Hot fomentation:

Local heat to the affected sinus after soothing & helps to reduce inflammation.

 

 

  1. Surgical:

If medical treatment fails then one of the following surgical procedures may be needed to resolve the condition.

  1. Antral Puncture & washout
    If acute sinusitis fails to resolve within 24-48 hours then the antral puncture is needed. The maxillary sinus is the most important of the orchestra. If this sinus settles, oedema of the middle meatus will disappear & permits adequate drainage of the frontal & ethmoid sinuses.
  2. FESS or Functional Endoscopic sinus surgery is the classical treatment of choice.
    With this procedure any sinuses can be explored.
  3. Correction of any precipitating factor like septoplasty, polypectomy should be organized.

 

 

CHRONIC SINUSITIS IN GENERAL:

Sinus infection lasting for months or years is called chronic sinusitis. Most important cause of chronic sinusitis is failure of acute infection to resolve.

PATHOPHYSIOLOGY:

Acute infection destroys normal ciliated epithelium impairing drainage from sinus. Pooling & stagnation of secretions in the sinus invites infection. Persistence of infection causes mucosal changes such as loss of cilia, oedema & polyp formation, thus continuing the vicious cycle.

 

PATHOLOGY:

In chronic infection, process of destruction and attempts at healing proceed simultaneously. Sinus mucosa becomes thick and polypoidal or undergoes atrophy. Surface epithelium may show desquamation; regenerates or metaplasia. Submucosa is infiltrated with lymphocytes & plasma cells & may show micro abscesses, granulations, fibrosis or polyp formation.

 

BACTERIOLOGY:

Mixed aerobic & anaerobic organisms are often present.

 

CLINICAL FEATURES:

Often vague & similar to those of acute sinusitis but lesser severity.

Purulent nasal discharge is the commonest complaint.

Foul- smelling discharge suggests anaerobic infection.

Local pain & headache are often not marked except in acute exacerbations. Some patients complain of nasal stuffiness and anosmia.

INVESTIGATIONS:

  1. X-Ray paranasal sinuses occipitomental view shows varying degrees of opacification, mucosal thickening & polypoidal changes etc.
  2. CT scan of PNS is useful in ethmoid & sphenoid sinus infection.

 

TREATMENT:

Aims to correct the predisposing causes to ventilates the sinus & to restore normal sinus lining.

  1. Medical:
    Antibiotic, nasal decongestant should be tried.
  2. Surgical:
    Following options are available for chronic maxillary sinusitis.
    1. Functional Endoscopic sinus surgery (FESS)
    2. Antral lavage puncturing info meatus
    3. Intra nasal antrostomy through inf. meatus
    4. Cald-well-luc operation

 

SURGICAL OPTIONS FOR OTHER SINUS INFECTION:

  1. Chronic Ethmoid Sinusitis
    1. FESS
    2. External ethmoidectomy (howarth incision approach)
    3. Internal ethmoidectomy
    4. trans antral approach
    5. Chronic Frontal Sinusitis
      1. FESS
      2. External frontoethmoidectomy (howarth incision approach)
      3. osteoplastic flap operation (MacBeth)
      4. Chronic Sphenoiditis
        1. FESS
        2. External frontoethmoidectomy approach
        3. Trans septal trans sphenoidal approach

 

COMPLICATIONS OF SINUSITIS:

Usually uncommon, complications may follow an acute infection but are common during an acute excarbation of chronic sinusitis. Orbital complications are the commonest & mostly found in children.

  1. ORBITAL COMPLICATIONS:
    Orbital Cellulitis
    Orbital abscess
  2. Osteomyelitis
    Maxilla of Children
    Frontal sinus in Adult
  3. MUCOCELE
    Frontal Sinus
    Ethmoid, maxilla & sphenoid
  4. LOCO REGIONAL COMPLICATIONS:
    Pharynagitis
    Larynagitis
    Otitis Media
  5. INTRACRANIAL COMPLICATIONS
    Meningitis
    Brain Abscess
    Cavernous sinus thrombosis
ORAL AND THROAT CANCER

Dr. Belayat Hossain Siddiquee

FCPS, FICS

drbelayat@gmail.com

 

Oral cancer and throat cancer are similar group of diseases both aetio-pathologically and from the management point of view. In global perspect these constitutes 10 percent of the incidence of all cancer but in Bangladesh the incidence is higher. In general all the head-neck cancers including cervical oesophagus are responsible for 35% to 40% of all cancers in Bangladesh. One hospital based study shows (Siddiquee B.lt, et al, 2006) overall incidence of head-neck cancer is 150 per lac population and among them 85 percent were oral and throat cancer.

 

 

The main etiological factor for these grave diseases is tobacco. Tobacco is consumed in our society in different forms e.g cigarate smoking, reverse smoking (hukkah), pipe smoking, bidi and shada etc. Indirect smoking is also important as because lack of consceiousness, people often smoke in public spaces. But the senerio is improving by the campaign of many social organizations. Other important causative agents are habit of chewing betel quide, consumption of alcohol. Pan which combine tobacco with betel leaf, slaked lime and areca nut are widely consumed in our rural areas. Besides these iron and Vit A deficiency have important role in precipilating these cancer. Injudicious use of chemicals in the food and heavy environmental pollution also might have role.

 

 

The early symptoms of oral cancer is a swelling or ulceration some where in the oral cavity. This may or may not be painful. In case of throat cancers food sticking in the throat or foreign body sensation are the synptoms which draw attention of the patient. Gradually there develop difficulty in swallowing, change of voice, occasionally breathing difficulty. One or more swelling may develop in the neck which is persistant hard may or may not be painful.

 

This type of symptoms do not always indicate malignancy but must be evaluated properly by an ENT specialist. After thorough clinical examination, should be examined by endoscopes and if necessary biopsy should be done for confirmation of tissue diagnosis. Other investigations like CT Scan/ MRI, some biochemical investigations may be required for clinical staging of the tumour and treatment planning.

 

 

The mainstay of treatment are Surgery and Radiotherapy. These may be used singly or combindly. Combination may be done concurrently or sequentially. These again may be combine with chemotheraphy to increase efficacy of treatment and survival rate.   

 

Overall prognosis of oral and throat cancers are not bad. In early stage tumours even 80%-90% patients may survive for more than 5 years. But the prognosis drops with the advancement of the disease process.

 

In Bangladesh the treatment is readily available in old medical colleges. A specialized head-neck surgery division is also established in Bangabandhu Sheikh Mujib Medical University for better management of these patients.

TINNITUS/ RINGING IN EAR

Prof. Khabiruddin Ahmed

What is tinnitus?
Tinnitus is a sound sensation perceived by the patients . A sensation of noises in the ear or head. The term tinnitus is derived from the Latin word tinnier, meaning to ring.
It may be felt like ringing , buzzing, clicking or escaping of steam like that from a pressure cooker. The term does not include hallucinations of voices, which are of psychogenic origin. Tuneful or rhythmical sounds may indicate temporal lobe epilepsy or other focal lesion. Tinnitus is usually subjective, but occasionally objective clicks or buzzing may be heard by the observer. Vascular bruits must be excluded.

Types:

  1. 1.     Type I: Subjective tinnitus (Heard by the patient himself) -
    This is the most common variety of tinnitus. Only patient can hear the sound. These include the sounds of crickets, roaring, buzzing, and hissing, whistling and high-pitched ringing.
  2. 2.     Type II: Objective tinnitus (May be heard by examiner if amplified sufficiently) -
    This sound can be heard by patient as well as the doctor. It is less common and makes up less than 5% of cases.

Prevalence
Tinnitus is very common and many people will experience it at some point. Studies show that up to 10-15% of if the population suffers tinnitus severe enough to seek medical attention. The prevalence increases with age. More men than women are affected. Both adults and children report experiencing tinnitus.




Nature:
- continuous:  Otosclerosis, acoustic neuroma, acoustic noise trauma.
- Intermittent and fluctuant: Meniere’s disease
- Pulsatile:  Glomus tumors, strychnine poisoning.
- Factors:
- Relieving factors: By putting pressure at the side of the neck in vascular causes.
- Aggravating factors:
  By smoking-
cochlear pathology, ototoxicity. Yawning and blowing- Eustachian   
  dysfunction.

Causes:

Hearing loss is the common cause of tinnitus. Hearing loss can be due to normal ageing or trauma to the cochlea (the hearing organ) through noise, drug, or chemicals.
It has been suggested that because the cochlea is no longer sending normal signals to the brain, the brain develops its own noise to make up for the lack of normal sound signals. This is interpreted as sound – tinnitus.
Loud noise exposure damages the hearing and is a common cause of tinnitus. Many people are unaware and unconcerned about the harmful effects of excessively loud noise at discos or from using earphones.
Anything that affects hearing, such as an ear infection or excess wax in the ear can make tinnitus worse.

Subjective tinnitus :

Meniere’s disease is a common cause of subjective tinnitus. Someone suffering from this complains of fullness in the ear or hearing loss, roaring tinnitus and dizziness that can last for hours.

Acoustic neuroma is a rare cause of subjective tinnitus. It is a tumor that grows on the nerve that leads from the brain to the inner ear. The affected person usually notices the tinnitus and hearing loss in one year, unlike the more common type caused by hearing loss that is usually felt in both ears.

 

Other causes of tinnitus
-Toxic cause:
      Aspirin, Salicylates, Quinine,  Streptomycin, Neomycin, Ibuprofen,  
      Imipramine, Heavy metals.

-Head Injury (labyrinthine concussion).

-Ischemia ( Caused by hypertension, Arteriosclerosis).

- Endocrine disturbance ( Hypo thyroidism, Diabetes, Premenstrual tension).

- Cerebral Atherosclerosis (Presbyacusis).

- Secretory otitis media.

- Otosclerosis.

- Severe Anaemia.

- Hypotension.

- Muscular Contraction of tensor tympani & stapedius.

 - Psychogenic causes
        Depression
        Anxiety

Objective Tinnitus:

Blood flow, either through normal or abnormal blood vessels near the ear is usually the cause of objective tinnitus. Causes of pulsatile tinnitus (tinnitus that corresponds to the heartbeat) include pregnancy, anaemia, an overactive thyroid gland, or tumors involving blood vessels near the ear (glomus tumor and arteriovenous malformation).

The narrowing of the carotid artery (a major blood vessel to the brain) can also cause pulsatile tinnitus.

Benign intracranial hypertension, a condition where an increase in the pressure of the fluid surrounding the brain causes pulsatile tnnitus.

Jaw joint misalignment problems or muscles of the ear or throat `twitching’ can cause clicking types of tinnitus.

Evaluation:
Tinnitus is not a disease in itself but rather a reflection of underline disease, so it must be evaluated properly.

  1. History taking.
  2. Clinical examination.
  3. Audiometric testing.
  4. Radiological investigations.
  5. Laboratory studies.

History taking:
The evaluation of a patient with tinnitus should start with a careful taken history.

  1. The patient’s description of the tinnitus is very important.
    - The quality of the sound especially whether it is pulsatile or nonpulsatile.
    - The perceived location.
    - The pitch.
    - The loudness.
    - Constant or episodic.
    - Onset.
    - Alleviating/ aggravating factors.
  2. History of infection.
  3. History of trauma, noise exposure, medication usage.
  4. Medical history – hypertension, diabetes.
  5. Associated hearing loss, vertigo, pain.
  6. Family history of hearing loss.

Clinical examination:

  1. Complete head & neck examination.
  2. General physical examination.
  3. Otomicroscopy to look for a middle ear mass or motion of the tympanic membrane with respiration. A glomous tympanicum can be seen as a radish mass in the middle ear or a dehiscent jugular bulb may be seen as bluish mass.
  4. History of pulsatile tinnitus.

Investigations:

  1.  Audiometric testing :
    - Pure tone audiometry
    - Tympanometry
    - Specch discrimination
    - Acoustic reflex measurement
  2. Radiological investigation :
    - CT scan of CP angle
  3. Laboratory studies
    - complete haemogram / Blood count
    - Thyroid studies
    - Lipid profile

Treatment:
Treatment for tinnitus depends on the underlying cause. In most cases, tinnitus is caused by damage to the cochlea. There is normally no need for treatment in such cases other than reassurance.
If the patient is extremely bothered by the tinnitus, there are a number of treatment options.
Relaxation
exercises help to control muscle groups and circulation throughout the body. This may reduce the intensity of tinnitus in some individuals.
Masking
of the noise with a competing sound at a constant low level, such as a ticking clock, radio static (white noise) or soothing sounds (rain, running water) may make it less noticeable, Since tinnitus is usually more bothersome in quiet surroundings.
A tinnitus masker is a small electronic generator that provides noise that is used to mask out a patient’s tinnitus. Most maskers are similar in design to a `behind the ear’ hearing aid and deliver their sound into an ear mould. The power source is a hearing aid battery.
The criteria for optimum performance are not yet defined and each patient has to be fitted individually. Generally a pure tone or narrow band of noise is selected in consultation with the patient which is just loud enough to make the tinnitus inaudible.
 
A few fortunate patients find that tinnitus suppression occurs and that this continues even after the device is removed; sometimes relief obtained lasts all day. Some find the masking noise worse than the tinnitus. Computer-assisted characterization and masking of tinnitus allows a wide range of sounds to be scanned in search of the most effective. A pillow radio may help the patient to get to sleep.

Hearing aids may reduce tinnitus while the patients are wearing them.
Medication that can be prescribed include tricyclic antidepressants and betahistine. Tricyclic antidepressants may have a role especially in patients with concomitant depression. Betahistine is a vasodilator that may improve blood circulation in the cochlea. Herbal medications and vitamins that have been advocated are ginko biloba and Vitamin B.

Tinnitus Retraining Therapy (TRT)
is a multimodality therapy that incorporates counseling, patient education and the use of low level white noise tinnitus maskers. This therapy has shown significant promising result in certain studies.
Where the tinnitus is caused by other rare problems (such as a tumor or aneurysm), treatment of the tinnitus involves fixing the main issue.

Surgical treatment depending upon the cause:
  - Endolymphatic Sac decompression.
  - Intratympanic injection of alcohol.
  - Cryotherapy for cochlear destruction.
  - Cochlear nerve section if no hearing.

Prevention/ lessen the intensity of tinnitus :
     - Avoid exposure to loud sounds & noises.
     - Control blood pressure.
     - Decrease salt intake.
     - Avoid nerve stimulants such as Coffee, Caffeine & Tobacco.
     - Reduce anxiety.
     - Stop worrying about the tinnitus.
     - Get adequate rest & avoid fatigue.
     - Exercise regularly.
     - Utilize a masking noise (tickling clock, radio , fan, white noise machine).
     - Bio feedback.
     - Avoid aspirin.  

What is an Otolaryngologist?

We're usually called "ear, nose, throat" doctors and we specialize in treating and operating on the ears, nose, throat and related areas of the head and neck.

What are the most common disorders treated in otolaryngology?
  • Cosmetic tumors on the head, neck and face
  • Ear disease, including ear infections and ear tubes
  • Hearing impairment, including hearing loss
  • Sinus, thyroid and larynx problems (throat and voicebox)

We offer special expertise in pediatric airway disease, sinusitis, all types of pediatric otologic and hearing conditions, obstructive sleep apnea, and tumors (both benign and malignant) of the head and neck:

  • Laryngology: laryngomalacia, subglottic hemangiomas, subglottic stenosis, vocal cord paralysis, laryngeal webs, laryngeal cysts, and recurrent respiratory papillomatosis; croup, stridor, chronic cough, hoarseness.
  • Bronchoesophagology: gastroesophageal reflux, treatment of other breathing and swallowing disorders, and foreign body removal.
  • Rhinology: Medical and surgical management of allergic rhinitis, chronic and recurrent sinusitis.
  • Otology/Neurotology: congenital and acquired hearing loss, cholesteatoma, tympanic membrane perforations, otosclerosis, congenital aural atresia, balance disorders, facial paralysis, and cochlear implantation.
  • Communication Disorders: speech and language problems, velopharyngeal insufficiency.
What is sinusitis and endoscopic sinus surgery?

The sinuses are bony hollows in the head. When the lining of the nose and sinuses becomes swollen with allergies or infections, the sinuses can become obstructed. If they stay obstructed long enough, the mucus in the sinuses can become infected. When this occurs, patients typically experience facial pain in the distribution of the sinuses, as well as thickened, often yellow or green, nasal discharge, as well as nasal congestion.

A variety of other symptoms can occur with sinusitis, including runny itchy eyes, cough, ear symptoms including discomfort or a sense of fullness in the ears, hoarseness, and a bad smell in the nose. Sinus swelling can lead to the formation of nasal polyps. Nasal polyps, in turn, tend to obstruct sinuses and lead to sinusitis.

Facial pain, in isolation, can have other causes, including temporomandibular joint syndrome (TMJ), dental disease and non-sinus headache.

Since infection can block the sinus chambers, initial treatment generally includes antibiotics to fight infection and medicines to encourage the sinuses to open and drain. Typically these include oral and/or topical decongestants. Other treatments may include steroid nasal sprays and antihistamines. Patients who smoke will benefit from suspending smoking, permanently if possible – but at minimum during medical treatment.

When medical management is ineffective and sinusitis becomes recurrent, a thorough ENT evaluation is warranted. The initial evaluation includes a thorough history and physical exam, which often involves a telescopic exam of the nasal cavity. This provides the otolaryngologist (ENT doctor) with detailed intranasal information regarding septal deviations, nasal turbinate abnormalities and areas of abnormal drainage or polyp formation.

CT scanning of the sinuses after medical management may be recommended for patients with chronic symptoms to allow documentation of chronic sinusitis. CT is also a valuable tool for planning when surgery is warranted.

Patients may require sinus surgery if all medical management has failed – typically endoscopic sinus surgery. With endoscopic surgery, the doctor can examine and make repairs to the nasal cavity through a nasal telescope, without external incisions.

Occasionally this surgery will be performed with a state-of-the-art CT guidance system, which allows the surgeons a whole new level of information for safe sinus surgery. The surgery is typically performed under general anesthesia, but can be performed under local anesthesia and usually takes about 90 minutes. Patients may go home the same day or may stay overnight. Patients post-operatively will have generally mild discomfort and some nasal congestion. Surgery patients are directed to limit strenuous activitiy for about a week or two after surgery.

One or two post-operative visits are required within the first two weeks after surgery, during which the nasal cavity and sinuses are cleaned. The endoscopic sinus surgery philosophy used at the Mass.  Eye and Ear is that limited surgery in key areas of the sinuses allows improved aeration and drainage, often giving dramatic improvement. This sinus surgery is generally very well tolerated.

What is snoring and obstructive sleep apnea?

Often regarded humorously, snoring can be a difficult problem – both for patients and their bed partners. It is the sound made by the soft palate and uvula during inhalation. It occurs during sleep because of the way the throat muscles relax. Although snoring does come from the mouth, it can be made worse with nasal obstruction as this limits inward airflow. Patients are at risk if their oral cavity is small and crowded, if their uvula and palate are long, if they have large tonsils, or are obese.

Depending on the amount of redundant tissue, the throat may actually close during sleep, rather than just reverberate with snoring. We call this obstructive sleep apnea. In obstructive sleep apnea, oxygen levels fall. This can lead to significant strain on the lungs and heart, and may generate heart arrhythmias.

The evaluation of snoring related to obstructive sleep apnea starts with a full office otolaryngology head and neck exam with focus on the upper airway and digestive tract. Usually formal sleep study is recommended, which can offer definitive diagnosis of obstructive sleep apnea a measure of its intensity.

The treatment of snoring and obstructive sleep apnea includes a variety of interventions. Weight loss is generally recommended. In addition, there are a variety of nasal and oral airflow devices, including CPAP, BI-PAP masks to reduce obstruction during sleep.

A variety of surgical options are available for snoring and obstructive sleep apnea, all of which either scar or shorten the palate and uvula. These include radiofrequency treatment, CO2 laser palate and uvula treatment (LAUP), or standard surgical uvulopalatopharyngoplasty (UPP).

Typically, during surgery for snoring and obstructive sleep apnea, any areas of nasal obstruction are corrected at the same time. In select patients, mandibular procedures may be included to increase the chance of surgical cure. Generally these procedures are well tolerated, but involve a sore throat that lasts for typically seven to 10 days after surgery.

What is a thyroid nodule and how is it evaluated?

Nodules within the thyroid gland are very frequent in the adult population. Some studies suggest up to 50 percent of the adult population have thyroid nodules. They are commonly benign but may represent thyroid cancers. The risk of thyroid cancer is higher in the elderly, and is higher with a past history of radiation therapy. The larger the nodule, the higher the risk of cancer.

Thyroid nodules may be identified during routine physical exams by general medical physicians, or may be identified by the patient during a shower or during shaving. When large enough they can also be sensed as a lump in the neck, especially noticeable during swallowing.

The evaluation of the thyroid nodule involves a complete history and head and neck physical exam, including evaluation of vocal cord function. The nerve to the vocal cord travels in close proximity to the thyroid and can occasionally be affected by nodules. This requires a vocal cord evaluation after a complete history and physical exam.

Testing is typically recommended, usually a blood test to measure thyroid function and often a thyroid ultrasound to determine the exact nature and size of the nodule. This is painless and involves no radiation.

The central test for work-up of the thyroid nodule is a fine needle aspiration. Fine needle aspiration can be considered a microscopic needle biopsy. This often allows definitive diagnosis. Surgery is typically reserved for lesions that are identified as cancerous or suspicious on fine needle biopsy. Other treatment options are available for tumors confirmed to be benign after biopsy.

For large thyroid masses or goiter, additional evaluation is often necessary, and may include CT scanning, MRI scanning, or barium swallow. These tests measure the relationship of the thyroid mass to the adjacent swallowing tube (esophagus) and breathing tube (trachea).

At Mass. Eye and Ear, surgery of the thyroid and parathyroid glands at the Massachusetts Eye and Ear Infirmary is performed with an advanced recurrent laryngeal nerve monitoring system. This new technology allows real-time vocal cord monitoring to help in identification and preservation of this important nerve during thyroid surgery. The system may decrease the rate of vocal cord nerve injury and may reduce the incidence of voice and swallowing problems after thyroid surgery.

What does the evaluation of a neck lump entail?

A complete head and neck exam is essential to view the entire upper airway and digestive tract. It is important to assess a history of smoking in a patient with a neck nodule.

During the ENT office exam, the location of the nodule can often given a clue as to its identity. CT and MRI scanning and other imaging evaluation is sometimes necessary. Fine needle aspiration and biopsy is an important test and usually provides a definitive diagnosis without surgery.

What are common causes of nasal obstruction?

Common causes of nasal obstruction include a deviated nasal septum, nasal turbinate enlargement and nasal polyps (benign growths).

Deviated nasal septum:
The midline of the nose consists of a cartilage and bony nasal septum that separates the two sides of the nasal cavity. A deviation or bend in this structure can be present at birth or can occur following a nasal fracture. The obstruction caused by such a deviation can be corrected by surgically straightening the septum, called a septoplasty. A septoplasty is a commonly performed outpatient surgery done through incisions within the nasal cavity, removing the obstructing portion of bone and cartilage.

Nasal turbinate enlargement:
The nasal turbinates are three bony and soft-tissue structures lining the sides of the nasal cavity. As part of the normal nasal cycle, the turbinates alternately swell and enlarge. In some persons, the turbinates can be excessively large, resulting in significant nasal obstruction. Allergy treatment, typically with nasal steroid sprays, may help to decrease this swelling. When allergy management does sufficiently relieve nasal obstruction, the inferior turbinates can be surgically reduced. In many cases this can be done as an office procedure.

Nasal polyps: 
Nasal polyps are a type of inflammatory tissue that can grow in the nasal cavity and sinuses. They occur more frequently in persons with allergies and/or asthma. Nasal obstruction is the most common symptom. The sinus drainage tracts may also be blocked, resulting in chronic sinus disease. Nasal polyps are controlled with steroid sprays as well as removal by endoscopic surgery. Persons whose polyps arise from asthma may have serious allergic reactions to aspirin.