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Dr. C's Ear Blog
Dr. Sujana Chandrasekhar, otologist-neurotologist, ear and skull base surgeon, discusses her thoughts on hearing, balance, acoustic neuromas, cochlear implants, baha implants, sudden hearing loss, Meniere's disease, otitis media, cholesteatoma, and any and all other ear-related topics. |
Thursday, October 2, 2008
Tinnitus and Hyperacusis
Dear readers, Last night there was a show on TV with a subplot about one of the main characters having tinnitus (ear noise) and hyperacusis (exquisite sensitivity to sound). There were some mischaracterizations which I'd like to address. Tinnitus (often called 'ringing in the ears') is the abnormal perception of sound that is not present in the environment. It can be perceived as a high-pitched whine, a loud hiss, a roar, clanging, crickets, or any other type of noise. The exact mechanism by which tinnitus occurs is not known, however, our theories in 2008 are significantly more scientifically exact than they were previously. We know that our inner ears produce their own sounds. These 'cochlear microphonics' are used when we test newborn babies for hearing loss by measuring otoacoustic emissions. In general, our inner ear's sounds are masked by environmental sounds and we do not perceive the cochlear microphonics. However, when a large group of young people were tested in a very quiet environment with no other stimuli, nearly all of them perceived their own tinnitus after a period of 30 to 45 minutes. Transient tinnitus is a frequent phenomenon and poses no danger. Tinnitus becomes a problem when it is persistent or interferes with work or sleep. It is often perceived after there is some level of hearing loss, either through aging or noise trauma or other mechanism. The brain then picks up the cochlear microphonic and proceeds to perceive it as sound. Disabling tinnitus can result in severe depression and anxiety and must be attended to as aggressively as possible. It activates the limbic system in the brain, which is the 'fight or flight' response system, and that causes even more anxiety. Hyperacusis is often considered the flip side of tinnitus, as the two often go together. In this condition, loud sounds are perceived as painful, and, in severe cases, even relatively soft sounds become intolerable. Tinnitus is one of the top 3 problems affecting our returning soldiers from Iraq and Afghanistan. Treatment of tinnitus and hyperacusis rests primarily with understanding the underlying process. This is of great help in alleviating the attendant anxiety and depression. Dietary modification is relatively easy and very effective. You should avoid drugs that constrict blood vessels, such as caffeine and nicotine. You should avoid dehydration by drinking enough water and minimizing alcohol intake. Emotional and muscular stress and tension will make your underlying tinnitus worse and should be minimized as much as possible. At bedtime, listening to white or pink noise or pleasant music can help mask the tinnitus. Hyperacusic patients often wear ear plugs or noise cancellation head phones, which are very effective. There are several medications that have some degree of success in managing these conditions, and this avenue should be explored with your otologist if the above methods do not work. Tinnitus retraining treatment (TRT) has been used for years. It is effective in some people. There are newer devices to counteract the limbic system effects. Some are implanted; others are not. I have a great deal of experience with the Neuromonics device, which initially masks the tinnitus but primarily works to alter the anxiety response to the tinnitus. It is very effective in both tinnitus alone as well as tinnitus with hyperacusis. You will not go deaf from tinnitus or hyperacusis. Avoidance of noxious noise stimuli must be stressed. Please do not accept any 'just live with it' advice. Seek help from a qualified otolaryngologist or otologist/neurotologist. You'll be happy that you did. Sincerely, Dr. Chandrasekhar Labels: head noise, hyperacusis, ringing in the ears, tinnitus
Saturday, September 6, 2008
Dear reader, New guidelines were just released a week ago for the management of cerumen (ear wax). A panel of very respected health care providers, including ear-nose-and throat specialists, audiologists, internists, pediatricians, family practitioners, geriatricians, and nurses, was convened to look into the incidence and prevalence of ear wax, how often it becomes a problem to treat, and various methods of treatment for it. The bottom line is that your grandmother was right - don't put anything smaller than your elbow in your ear. For people who need something that sounds more scientific, read on! Yours, Dr. Chandrasekhar Here is my summary of the data: [I've only interjected my opinion once - imagine that!] 1. About 12 million people a year in the U.S. seek medical care for impacted or excessive cerumen, leading to nearly 8 million cerumen removal procedures by health care professionals. 2. Earwax is not really a "wax" but a water-soluble mixture of secretions produced in the outer third of the ear canal, plus hair and dead skin, that serves a protective function for the ear. Cerumen is a natural product that should not be routinely removed unless it becomes impacted. 3. Cerumen impaction occurs when enough earwax accumulates to cause symptoms (pain, fullness, itching, odor, tinnitus, discharge, cough, or hearing loss), or to prevent proper medical assessment of the ear. The problem affects 1 in 10 children, 1 in 20 adults, and more than one-third of the elderly and cognitively impaired. 4. Removing cerumen from the ears is a favorite hobby of many people - who employ cotton-tipped applicators, hair pins, and other such implements. This unnecessary manipulation of the ear canal, far from 'fixing' this problem (that doesn't exist), can, in fact, result in further impaction and other complications to the ear canal, such as infection, bleeding and pain. 5. Cerumen is a beneficial, self-cleaning agent, with protective, lubricating (emollient), and antibacterial properties. 6. Cerumen becomes a problem when: a. the patient wears hearing aids because it may cause feedback, reduce sound intensity, or damage the hearing aid; b. it blocks 80 percent or more of the ear canal diameter and may cause hearing loss. 7. Appropriate options for cerumen impaction are: (1) cerumenolytic (wax-dissolving) agents (2) irrigation or ear syringing, and (3) manual removal with special instruments or a suction device, which is preferred in general, and in particular for patients with narrow ear canals, eardrum perforation or tube, or immune deficiency. [I have to interject here. I am quite opposed to ear syringing and would not recommend it.] 8. Inappropriate or harmful interventions are cotton-tipped swabs, oral jet irrigators, and ear candling. ### "Clinical Practice Guideline on Cerumen Impaction" will appear as a supplement to the September 2008 issue of Otolaryngology – Head and Neck Surgery, the peer-reviewed scientific journal of the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) and the American Academy of Otolaryngic Allergy. The guidelines will also be presented in a seminar during the 2008 AAO-HNSF Annual Meeting & OTO EXPO in Chicago, September 21 – 24, 2008. Reporters wishing to receive the full text of the guidelines should contact Jessica Mikulski at 703-535-3762 or 703-657-9715, or via email at newsroom@entnet.org. Beginning September 1, 2008, the guidelines will be posted on the AAO-HNS website at http://www.entnet.org. Labels: cerumen, outer ear problems
Sunday, August 3, 2008
Swimmer's Ear (Otitis Externa)
Dear reader, Summer is in full swing, and many of you may be beset by external ear infections (otitis externa [OE]), also known as 'swimmer's ear.' This condition is a skin infection limited to the external ear canal, and can be caused by swimming or other ear water exposure, scratching the ear with a cotton-tipped applicator or other device (such as a hair pin), or something foreign entering the ear canal - dirt, sand, even small bugs. It manifests with pain, ear drainage, and sometimes hearing loss. Treatment is straightforward, but if not treated early or correctly, things can of course get complicated. The vast, vast, vast majority of patients with OE do not need oral antibiotics at all. OE is correctly treated by cleaning the ear under otoscopic or microscopic guidance, i.e., by a physician, and then having the patient apply ear drops once or twice daily for several days. During and immediately after treatment, the patient should prevent any water (shower, lake, pool, ocean) from entering the ear by using commercially available 'water protection' ear plugs or by using cotton balls in the ear coated with petrolatum jelly to make them waterproof. Dry cotton in the ears will very effectively wick the water into the ear canals, accomplishing exactly the opposite of the goal. If the ear is infected for too long or the patient has an underlying serious medical problem that interferes with wound healing (such as bad diabetes), the surrounding tissues can get infected, and then the treatment would include oral antibiotics. Sometimes, the initial bacterial infection in the ear canal is overrun by a fungus. Fungal OE itches like crazy. Regular antibiotic ear drops are not the correct treatment for fungal OE. Your doctor should clean the ear very carefully and thoroughly in these cases, and then particular medications that are effective for fungal organisms are applied to the ear, either by the doctor and/or by the patient at home. Water protection is very important in these cases, as fungi love a moist, dark, warm environment! If you or your child do not have OE but are predisposed to it, you should wear ear plugs and perhaps even a bathing cap or neoprene ear band (these are all available commercially) to protect your ears when you swim or bathe. You should also 'shake' any water that has entered the ear canal out, and can use either a hair dryer - on low, cool (don't burn yourself!) - or you can buy a commercially available 'ear dryer' to gently dry up any droplets. Additionally, if your ear drum is fine - no perforation or hole or tube - you can put a drop or two of rubbing alcohol in your ear to eliminate any remaining water droplets. If your ear hurts or burns when you put in the alcohol, STOP! and go see an ENT specialist right away. Have a great rest of the summer! Dr. Chandrasekhar Labels: summer ear problems
Saturday, December 22, 2007
The Gift of Hearing
Dear readers, It turns out I chose a very emotionally rewarding profession. The other day I received a letter from a patient of mine who had had a cochlear implant. She was writing to tell me that she was blowing out the 5th anniversary candles of her surgery - her 'rebirth' as a hearing person. Another patient of mine, who became progressively deaf with each pregnancy, told me that she was able to hear her son's voice for the first time ever after receiving her cochlear implant when her son was 8 years old! Her implant surgery was done nearly 10 years ago, and she loves dancing to Christmas music. I saw a little boy in the office whom I implanted several months ago. It's a good thing I keep tissue boxes in the rooms, since his new amazing speech and conversation brought tears of joy to my eyes! Cochlear implants are for patients who have severe to profound hearing loss in both ears, and cannot benefit from hearing aids. Until relatively recently, those patients had no chance of entering the hearing world. They either joined the Deaf world and became fluent in sign language, and/or they became great face readers and used a variety of different visual cues in order to participate in Hearing life. Then, in the 1960s, two brilliant and forward thinking pioneers of hearing restoration, Dr. Graeme Clarke in Australia and Dr. William House in Los Angeles, CA, decided to change that. Apparently they were almost considered heretics at the beginning - imagine thinking you could stick an electrode in the inner ear and the patient would hear! - but those initial naysayers were proven wrong. About 100,000 people around the world have received cochlear implants, enabling these profoundly deaf people to hear. But it's not just the miracle of cochlear implants that I can use to help people to hear. There's a disease called otosclerosis that causes the third tiny bone in the middle ear (the stapes or stirrup) not to move properly. Most of these patients can benefit from stapedectomy surgery that restores normal middle ear bone functions and restores hearing over 95% of the time. This is, I must say, one of the most fun and challenging operations that I perform. In under 45 minutes, I can take someone from being hearing-impaired to normal hearing! I had one patient undergo stapes surgery in October one year, and that year for the holidays she was inundated with hearing-themed presents - an ipod, CDs, etc. A number of my stapes surgery patients have commented that they didn't realize how much they were missing due to their hearing loss, until after their surgeries! There's something called Idiopathic Sudden Sensorineural Hearing Loss (ISSHL or SSNHL) which is a sudden loss of nerve hearing in one or (rarely) both ears with no clear cause. You might imagine how devastating this would be to someone. I became very interested in the treatment of this problem many years ago, after reading Dr. Lorne Parnes of Canada's research on the subject. Since you have to be an expert at something, I guess this is one of my claims to fame.... Over the past decade or so, a number of physicians (myself included) have seen that we can restore full or at least partial hearing in a large percentage of patients with SSNHL if we treat them aggressively early on. The treatment involves at least oral steroids, and often an injection of steroids into the affected ear, and may be some other medications. I consider SSNHL a true otologic (ear-related) emergency and am really aggressive about treating it. It is really an amazing feeling to have helped someone regain this vital sense! There are other things that are done for hearing restoration - surgical, medical, and device-related. You can read about them within my website under the Symptoms tab. The more I do this, the more I realize how important a gift hearing is. So, as this year winds down, I urge you to protect your hearing. Avoid loud noise exposure: wear ear plugs if you're going to a concert or using power tools. If you use a personal music device such as an ipod, turn the bass up and the volume down. You'll still enjoy the vibrations of the music without hurting your delicate inner ear hair cells. Avoid toxins that can cause or increase hearing loss, such as many illegal drugs as well as caffeine and nicotine. Antioxidants, such as are found in fresh vegetables and at health food stores, are hearing-protective. Exercise well - it helps your ears too! Please accept my wishes for a melodious holiday season and a new year filled with health and happiness. Sincerely, Sujana Chandrasekhar, MD
Saturday, November 17, 2007
Meniere's Disease and Politics
Dear reader, As Thanksgiving Day approaches, I thought I'd give some advice to those out there with Meniere's disease. MD is a disorder of the balance of the fluids of the inner ear. It can be devastating, as it causes hearing loss, tinnitus (roaring in the ears), and spinning vertigo. Luckily, the symptoms are episodic and the patient is usually fine between episodes. Classically, MD affects young women starting in their 20s or 30s, but it can affect both genders and all ages. The first episode of classic MD (with all three of the symptoms of hearing loss, tinnitus and vertigo) is terrifying for the patient and anyone who happens to be around. It's often immediately followed by a trip to the ER. Once the patient gets to an otolaryngologist (ear-nose-throat specialist) or an otologist (ear specialist), appropriate targetted treatment can be started. This involves strict dietary restrictions of (1) salt to less than 2000 to 2500 mg of Sodium per day, (2) caffeine to no more than 1 or maximally 2 cups or cans per day, (3) nicotine to none, and (4) alcohol to minimal, with one glass of water to be consumed per alcohol equivalent [one beer, one wine, or one mixed drink] consumed. Patients should also try to drink a good amount of water (4 to 6 glasses per day) and minimize internalization of external stressors. Some MD patients respond to reduction in certain types of carbohydrates as well as sugars and/or artificial sweeteners. I take umbrage (isn't that a neat phrase?) with some of my colleagues who make dire predictions of the future to MD patients. No, this disease does not have to be quality of life-ending. The vast majority (over 80%) of MD patients have very nice control of their symptoms with the dietary and attitudinal changes described above, and perhaps with some medications taken either daily or when the symptoms crop up. Very few patients need injections into their ears of either steroids or gentamicin, or surgery. A very small minority of patients end up with disabling MD. Holiday time is tough for anyone following a diet. As stress is a major factor in bringing on MD attacks, the holidays can offer a double whammy, with pressure placed to present the perfect holiday family and friends tableau. SO, here's some advice: 1. Start this season by increasing your average water consumption. Water will flush away many of your upcoming dietary indiscretions! 2. Don't overdo it. If you're in charge of the giant Thanksgiving day feast, break the work up into manageable pieces and/or delegate some of the tasks. Make sure you get adequate rest. 3. Make wise choices. Often, the MD attack occurs in a 'perfect storm' of just a little too much salt PLUS a little too big a piece of chocolate cake [caffeine] PLUS an extra cup of tea or coffee PLUS a glass of wine PLUS your brother-in-law just saying the wrong thing about your child. Therefore, if you decide to eat the more salty option, hold off on the caffeine and/or alcohol, and develop a thick enough skin that your relatives can't penetrate with foolishness. And add water. It works. 4. Listen to your ears. Long-term MD patients know when they're prone to an episode by the funny feeling they get in their ears (doctors call it aural fullness). At the first sign of this, really pay attention to your diet, take your diuretic if you haven't that day, and do whatever you need to do to alleviate stress. 5. If you experience an MD attack, lie down, put your head into a position where the spinning is minimal, open your eyes and focus on a point so that your eyes can tell your brain you're not spinning and override the wrong message being sent from your ear. As soon as you can, take a vestibular suppressant such as Meclizine. Call it a day. You'll be much better the next day. Meniere's Disease, in my mind, is not so much a disease as a liveable condition. Once you understand it a bit, the fear of vertigo loses much of its power over you. Patients rather quickly figure out how much they can 'cheat' on their diets and still be comfortable. Medications go from daily to only as needed. You might be happy to know that many prominent figures in science, politics, entertainment, etc. have MD and are managing pretty well! I hope this helps, and I wish you and yours a very happy and healthy Thanksgiving. Sujana Chandrasekhar, MD
Tuesday, November 6, 2007
Welcome
Dear reader, I would like to use this blog to discuss news, publications, and other matters of interest that relate to the ear, hearing, balance, lateral skull base and facial nerve. My hope is that in this type of forum topics can be discussed in greater depth than is usual. I am known to be quite opinionated, especially on subjects that I hold dear, like the ear, so expect some fireworks! Sujana Chandrasekhar, MD
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