Nasal turbinates

The nasal passages are lined in the middle with what is called the nasal septum. On the side walls on each side, there are three sets of turbinates: The upper (superior), the middle, and the lower (inferior). The turbinates are bony projections with mucous membrane lining that provide additional surface area to the air that we breath. It is believed that turbinates function to modify the air before it reaches our lungs: the air is moisturized, cleaned from any debris, and optimized for temperature.

The inferior turbinate is the largest of the turbinates, and it can be seen by simply looking into the nostrils. Some people have mistaken the inferior turbinates for polyps or other growths within the nasal passages. The inferior turbinates do the majority of the function of the turbinates. If the inferior turbinates are otherwise big and bulky, they can conversely cause quite a bit of obstruction of the nasal passages.

The middle turbinates can only be seen by endoscopy in most cases. They usually cover the sinus drainage pathways, and provide the layer of protection. The superior turbinates are very small, and we are not sure if they serve any function.

During sinus or nasal surgery, it might become necessary for the turbinates to be addressed as well. Typically, when I perform septoplasty to provide additional room for the breathing, I also use a coblation device to shrink the bony component of the inferior turbinates while preserving the integrity of the membranes for future function. The middle turbinates might need to be pushed more towards the center to allow more access for the sinuses to drain more spontaneously.

Quite a few decades ago, the function of the turbinates was not certain. It was common practice to remove portions or entire turbinates in order to make more room for the breathing and for the drainage. The patients who had this kind of surgery subsequently went on to suffer from dryness of the nasal membranes as well as frequent nosebleeds. It is no longer standard practice to remove the turbinates for routine breathing or sinus issues. We now prefer to address the bulkiness of the bony component and preserve the membranes as much as possible in order to have ongoing normal functioning of the turbinates.

Vertigo may have various different presentations. Some people may experience vertigo specifically from certain positioning of the head or the body that triggers the onset of the symptoms, while some people may have it occur spontaneously. In some cases, the symptoms may last a few seconds, in other instances it may last few hours to a few days.

In general, symptoms of vertigo are believed to be from diseases of the inner ear (vestibule). Conversely, symptoms of dizziness that do not include a true sensation of room rolling around you are believed not necessarily to be from the inner ear. One of the more common reasons for people to have vertigo is benign paroxysmal positional vertigo (BPPV). Most people in this situation experience the onset of the vertigo from rolling around in the certain direction, or from certain motions. The symptoms generally last less than one minute, and they are repeatable every time the patient engages in the same type of activity. The baseline reasoning for this kind of dizziness is due to crystal formation in the inner ear where the inner ear liquid chambers would be normally responding to positional changes of the body. A consultation with your ENT specialist and performing of the Epley maneuver can remedy the situation in the majority of the patients. A second reason for people to have vertigo is an entity called labyrinthitis or vestibular neuritis. This usually refers to viral infection of the inner ear or the nerve communicating from the inner ear to the brain. Most people describe acute symptoms of vertigo that last hours to days, and they are generally completely debilitated from engaging in normal activities. This is usually a self-limiting process, and most patients get better with a few days of bed rest. Additional anti-dizziness medicines as well as antiviral antibiotics could be used to make the recovery faster.

Sometimes, when a specific reason for the patient’s symptoms of dizziness is not able to be confirmed by physical examination or additional testing, vertigo is used as a diagnosis name. However, be aware that vertigo is not the name of a disease; it is name of a symptom.

The patients with vertigo are best served by getting immediate attention from a specialist. This could be from your ear, nose, and throat specialist, or from a neurologist. Additional testing may become necessary to make a correct diagnosis.

Patients often contemplate if their tonsils are problematic enough to consider tonsillectomy. A few decades ago, tonsillectomy procedures were very common. Many pediatric patients had their tonsils taken out at the slightest sign of sore throats or strep throats. Later, the pendulum swept the other way, and a recommendation was made by most doctors to have a watch and wait attitude for the tonsils. Many patients who perhaps should have had their tonsils taken out did not have the procedure due to the prevailing attitude of conservative management.

There are currently two reasons for most patients to consider tonsillectomy. The first is relating to repeated bouts of infection. Severely frequent infections in the past year or otherwise frequent infections for few years are indications to consider tonsillectomy. The numbers recommended by medical guidelines are exactly that: guidelines. No patient is forced to have their tonsils out the minute they meet those guidelines, and conversely patients don’t necessarily have to wait and suffer multiple times if it looks like they will eventually meet the guidelines for tonsillectomy.

The second reason for people to consider tonsillectomy is issues relating to obstruction. Many patients, pediatric and adult, have rather large tonsils which give them issues with breathing as well as snoring and possible sleep apnea. Removing the tonsils, as well as possible adenoidectomy in the pediatric population, can open up the airways and allow for more smooth breathing during the course of the night.

It is best to consult with an ear, nose and throat specialist to review your symptoms and to determine together if this procedure would be helpful in your particular situation. Most ear, nose and throat surgeons are capable of discussing the benefits and the expectations with you before undertaking any kinds of procedure.

The basic underlying pathology for this kind of condition is an injury to the membranes of the inside of the nostril, which in medical terminology is called the nasal vestibule. Accordingly, the condition is called nasal vestibulitis. The injury to the membrane could be self-induced, such as cases of clipping hair or scratching the inside of the nostril with a fingernail. Alternatively dry nasal passages, which is more common in winter, can also lead to a breakdown of the usual defense barriers of the skin and result in an injury. Once these defense barriers are compromised, bacterial infection can penetrate deep into the nasal membranes and give rise to chronic infection. The usual bacteria that is implicated in these kinds of infections is Staphylococcus aureus.

The treatment for nasal vestibulitis is first and foremost to avoid any further injury to the area. The patient is strongly discouraged from picking the scabs and irritating the area repeatedly. At the minimum, application of Vaseline ointment with the help of a Q-tip can remedy some of the dryness effect. However, due to the deep nature of the infection, treatment with antibiotic ointment as well as oral antibiotic is frequently recommended. Both of these need to be by prescription and you need to see your doctor to make an accurate diagnosis and get appropriate prescription.

Diagram of the ear and the Eustachian Tube

The eustachian tubes are very small structures within the head that can often cause big problems. In simple terms, the eustachian tube is a very narrow and short mucosa-lined tunnel that connects the back of the ears to the back of the nose. This is the part of the body that needs to open itself up to equalize the pressure with in the ears after diving, going in an elevator, or going on a flight. The inside of the eustachian tube is typically no bigger than the size of a pin, and any slight variations of your overall health such as sinusitis, allergies, or a cold can block the eustachian tube.

In an ideal situation, the eustachian tube should be able to open and close on demand to meet whatever activity you happen to be engaged in and whatever pressure changes are necessary. However, patients suffering from any degree of nasal stuffiness due to recent cold symptoms or sinusitis may have an extra challenge with this. If there is a sudden demand of pressure changes such as a flight, many patients may not be able to pressurize the ears as comfortably as possible.

Additionally, some patients have scarring of the eustachian tube or are otherwise born with a smaller eustachian tube or one that does not respond as effectively. These patients suffer more from symptoms of eustachian tube dysfunction.

If the eustachian tube is not able to pressurize the ear as effectively, patients suffer from sensation of fluid in the ears accompanied with occasional sound of the fluid moving around, as well as issues with reversible type of hearing loss. If the eustachian tube has caused some prolonged period of blockage, the fluid trapped in the ear can otherwise also lead to an ear infection making the symptoms much worse.

The treatment for eustachian tube disorder could involve watchful waiting until the body’s natural immune system mechanisms take over, versus trial of medicines to assist in more rapid decongestion of the eustachian tube, or surgical intervention in the form of myringotomy (making an incision into the ear drum) in order to more expeditiously drain the ears. Patients with a long history of eustachian tube disorder typically could benefit from a long lasting myringotomy tube, called a T-tube, for ongoing drainage.

Self-adhesive Provent valves

The field of sleep apnea has seen numerous innovations in the past few years, aimed at achieving better results and making the treatment much more comfortable on the patients. While some therapies focus on devices and machines, others focus on surgical intervention. Each type of therapy has its own pros and cons, and your best bet is to consult with your physician to better understand the most appropriate treatment in your individual case.

Recently, there has been some information in the media about a new treatment modality called Provent. The Provent device is two individual disc-like adhesives with a central air valve. These discs need to be applied to the nostril nightly before going to sleep, and they need to stay on all through the course of the night. The idea behind the valves is that it creates expiratory positive airway pressure. In simple terms, it means that the valves only allow so much air out at a given time, and retain some extra pressure within the airways of the sleeping patient. This positive pressure is ideal to prevent any collapse of the airway, that otherwise would lead to obstructive sleep apnea.

Each set of discs is designed to be used once only. The patient who opts to undergo this kind of treatment is usually given a 30-day supply with multiple refills. Most patients start with a 10-day supply just to make sure that they are comfortable with use of the device before long-term commitment.

Provent is currently available by prescription only. It is recommended for the patient to be examined by a sleep specialist and determine if they are good candidate for this kind of treatment. Once this is established, the patient can obtain the prescription and then get the supply through various different vendors of the device. Again, the device may not be optimal in every single case, and the best way to find out is to have a thorough examination with a sleep specialist.

In order for the membranes to be able to keep up with this demand, the nasal passages have a very rich supply of blood vessels.  This supply is much richer than most other organs in our body.  In fact, there are three main arteries that supply either side of the nasal passages.  Additionally, the blood vessels of the nasal membranes happen to be much more superficial than most other places accessible to the outside world.  Therefore, any slight scraping or dryness can lead to exposed blood vessels.

During the winter, the air around us is much colder and much more dry.  Basically, as the temperature around us drops, the moisture in the environment drops as well.  In addition, most of us are exposed to central heating, which is a dry heating mode (as compared to the old style fireplaces that used to be the main heating elements in most houses).

The combination of cold weather and dry heat is very damaging to the nasal membrane.  Frequently, the membranes cannot stand up to their demand, and they start having superficial cracks.  These can lead to nosebleeds of capillary, vein, or artery origin.

The best way to improve the hygiene of the nose in order to prevent any unnecessary bleeding is to give it extra moisture.  Over-the-counter saline sprays can be used periodically throughout the day to keep the moisture up in the nose.  Rhinaris® is the only over-the-counter nasal spray that in addition to saline contains an emollient designed to further soothe the dry nasal membranes.  You can also put a small amount of Vaseline on a Q-Tip and gently rub on the inside of the nostrils to provide extra moisture to the membranes couple of times a day.  Make sure you keep up oral intake of liquid in order to keep up the hydration of the body as a general principle.

Another important element is to provide environmental humidification.  Using a cold mist humidifier can replace the missing moisture in environment around you.  The optimal place for use of the humidifier is in your bedroom in a location near the head of the bed.  This will make sure that the air that you breathe all night is optimally moisturized, and you will avoid a dry nose as you wake up in the morning.  I recommend that you have the humidifier working in your bedroom all nights, every night.  Ideally, in climates similar to New York, this should be done from November until April.

Technically, this is more of a nuisance than a medical problem. However, the tonsils crypts could trap food particles or prevent the normal shedding of the superficial lining from being discarded.  Often, these particles stay in the crypts and irritate the surrounding tissue.  The particles can also form concretions, knows as “tonsil stones”.  The medical term for these concretions is tonsilliths.

The most simple way of dealing with this problem is to chew carefully and thorougly, and to avoid foods with small particles (sesame seeds, etc.).  It is ideal to gargle with saline rinse right after meals, so that any trappped material could be washed out right away.  Occasonally, various procedures or even tonsillectomy might be recommended, depending on the severity of the symptoms.

I am not opposed to holistic or alternative methods of medical therapy.  In fact, I have supplemented my Western medical education by learning acupuncture for physicians.  I frequently use acupuncture techniques in order to better help my patients in any way possible.

However, there are several drawbacks to using the candling technique in the ear.  First, the candling is done “blindly.”  By this I mean that there is usually an assumption that there is earwax in the ear that needs to be removed, and therefore the candling should be used.  Not all cases of fullness in the ear are due to earwax build-up.  Other reasons for blockage of the ear could be due to ear infection or water stuck in the ears.  Therefore, when candling is used by lay persons without first examining the ear for the actual cause of the fullness of the ear, one might not treat the correct problem.

Secondly, not looking into the ear with an otoscope, a lay person can never determine what is the endpoint.  Simply because the ear feels less clogged does not mean that all of the earwax that was present came out successfully.  Only with direct visualization with an otoscope one can determine if the earwax problem is completely resolved or if there is still remnants present in the ear canal.

My third concern with the procedure is that the device is in fact shaped like a cone.  The fire is burning at the wider end, which is typically held in the upright position.  From time-to-time the paraffin can melt from the heat and come down through the cone in reverse and actually enter the ear canal.  I have occasionally seen instances of the hardened paraffin that had entered the external ear canal and caused a superficial burn and additional blockage of the ear.  I have also seen instances of paraffin dust scattered through the ear, and it takes months for the natural cleaning mechanisms of the ear to eradicate this.

Therefore, as much as I am not opposed to any holistic measures of eradicating the earwax problem effectively, I do not think that using candling without proper medical supervision and equipment is advised.  In an ideal setting, a trained professional should first inspect the ear to determine what is the nature of the blockage.  If the blockage is in fact due to earwax build-up, various different techniques could be applied to remove this earwax.  Only through a second inspection can determination be made if all the earwax came out successfully.

Many general care practitioners feel comfortable removing most instances of earwax build-up in their office.  Occasionally, the texture or the amount of earwax is beyond the capacity of a general practitioner, and the patient needs to be referred to an ear, nose, and throat specialist for expert care.  Most ear, nose, and throat specialist have all the necessary equipment (and skill) in the office to successfully remove earwax or other reasons for the blockage.

Let’s also review the basic physiology of the ear canal and earwax production.  In other parts of the body, as we take a shower, the dead skin sheds off and new skin is generated from the bottom up.  Since the skin of the ear canal is not generally accessible to typical cleaning during a shower, the ear has adopted other mechanisms for cleaning itself.  The center of growth of the ear canal skin is actually on the eardrum itself (this is how most perforations of the eardrum can generally heal themselves spontaneously).  As the ear skin grows from the center of the eardrum, older skin slowly migrates towards the outside of the ear, and it stops at the junction of the entrance of the ear canal to the outside world.  This growth of skin typically carries any earwax or any other particles with it.  The earwax and particles are then deposited right at the entrance of the ear canal.

Many people have the misconception that a good way to clean the ears is to use cotton tip swabs (Q-tips®).  These cotton swabs are generally the same size as the ear canal, and with inserting them into the ear canal you might actually push in the earwax deeper.  If this is done repeatedly over a period of time, the earwax can become impacted into the ear canal and make the cleaning worse.

Ideally, the best way to clean the ears on a regular basis is to simply use a finger wrapped with tissue.  After taking a shower, when everything is moist, wrap a tissue around your small finger.  Then use the finger to grab whatever you can from the entrance of the ear canal.  This is as deep as one should go, and any attempt at going deeper with a Q-tip might make matters worse by pushing the earwax back in.

Over-the-counter ear drop preparations for removal of earwax are also available.  These generally have a peroxide-based solution, which is designed to loosen any earwax accumulation.  Some people might use it preventively every few weeks to remove any residual earwax that might have accumulated over a period of time.  Additionally, if one has a sensation of excessive buildup, the ear drops might make the earwax softer and thus making it easier for the earwax to drain out spontaneously.  One general misconception is that by applying those eardrops to the ear, the earwax is going to simply disappear.  This is not the case.  The eardrops are simply designed to make the earwax softer.  Any residual softer earwax still needs to be physically removed either by a bulb syringe that comes with over-the-counter kits, or by a physician in office setting.

Alternatively, the patients with known history of recurrent earwax production and blockage should see their ear, nose, and throat specialist on a routine basis for preventive cleaning.  This will assure that the earwax is removed safely with full inspection.  Please make an appointment to see your ear, nose, and throat specialist on a regular basis for this purpose if you are affected with excessive earwax.