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14/Dec/2018

Corticosteroids are used for their anti-inflammatory and immunomodulatory properties to treat a wide spectrum of disease. Indications for use of steroids in otolaryngology include rhinosinusitis, rhinitis, facial nerve paralysis, hearing loss, Menieres’s disease, croup, nasal polyposis, and temporal arteritis.

Complications include disruption of the hypothalamic-pituitary-adrenal axis, hyperglycemia and glucose intolerance, and numerous gastrointestinal and psychiatric effects. Consequences of long-term steroid use include osteoporosis, avascular necosis of the hip, cushingoid body changes, cataract formation, dermatologic manifestations and atherosclerosis. The most dangerous complication is the risk of infection associated with the acquired immunodeficiency of chronic steroid use.

Avascular necrosis of the hip is a devastating complication that occurs in approximately 1 in 300 patients. It has been associated with doses as low as 290 mg of prednisone and durations as low as 6 days.

Severe psyciatric reactions occur 1.3%, 4.6% and 18.4%, respectively with doses lower than prednisone 40 mg daily, prednisone 40-80 mg daily and greater than prednisone 80 mg daily. The severe reactions include mania, depression (suicidal ideations), a mixed state and aggressiveness. The mild effects occur in a range of 13-62% and include agitation, anxiety, distractibility, fear, hypomania, indifference, insomnia, irritability, lethargy, mood lability, pressured speech, restlessness, and tearfulness.

Redistribution of adipose tissue (cushingoid changes) are a common effect of prolonged steroid use. They include truncal obesity, facial adipose tissue (moon facies), and dorsocervical adipose tissue (buffalo hump). These changes occur in 15% of patients in less than 3 months with doses of 10-30 mg daily of prednisone. Higher doses and longer duration increase the frequency.

In addition to the adipose tissue changes, steroids cause cutaneous complications including skin atrophy, striae, ecchymoses, and changes in the mechanical properties of the skin. These skin changes are more commonly found with topical application of steroids.

Corticosteroids inhibit the natural wound healing process in several ways ultimately causing delayed wound healing and decreased tensile strength. epdiermal growth factor, transforming growth factor factor beta, platelet-derived gwoth factor, tetrachlorodecaoxygen, vitamin A and insulinlike growth factor 1 may counter the impact of steroids on wound healing.

Systemic administration of steroids can lead to cataract formation, increased intraocular pressure (glaucoma), myopia, exophthalmos, papilledema, central serous chorioretinopathy and subconjunctival hemorrhages. Doses as low as 5 mg of prednisone for as little as 2 months can lead to cataract formation but most cases involve greater than 10 mg for over a year.

There is a perception that steroids can increase the risk of peptic ulcer disease. However, several large meta-anylsis have failed to show this association. Gastritis and pancreatitis are more common in patients taking steroids.

AskDrBloom.com

References:

Poetker DM and DD Reh. A comprehensive review of the adverse effects of systemic corticosteroids. Otolaryngol Clin N Am. 2010: 43:753-768.

Nash JJ etal. Medical malpractice and corticosteroid use. Otolaryngol Head Neck Surg. 2011; 144(1):10-15.


14/Dec/2018

Chronic rhinosinusitis is a recurring, persistent inflammation of the nasal and sinus mucosa lasting longer than 12 weeks that is known to cause significant physical symptoms and adversely impact quality of life and daily function. It is successfully treated medically in the majority of cases. However, in the United States 500,000 patients undergo endoscopic sinus surgery a year to treat it. A recent article from T. Smith etal enrolled 180 adult patients in a nonrandomized, multi-institional study comparing medical therapy to surgery for chronic rhinosinusitis patients who failed initial medical management. Prior to enrollment, all patients previously failed medical management defined as a minimum of 3 weeks of broad spectrum antibiotics and 3 weeks of topical steroid use. Clinical judgement and patient preference were used to determine if patients had continued medical therapy or underwent sinus surgery with patients electing for about half of each. Both groups experienced significant improvement over the next 6 months with 10% of the medical group electing to have surgery during this time period. The remaining 90% of medically treated patients seemed satisfied. However, patients who elected to undergo sinus surgery, had a significantly greater improvement in some quality of life measures, a reduction in antibiotic and systemic steroid use and fewer missed school/work days.

Reference: T Smith etal. Medical therapy vx surgery for chronic rhinosinusitis: a prospective multi-insitutional study. Inf Forum Allergy Rhinol. 2011; 1:235-241.


14/Dec/2018

A decrease in the sense of smell is common as we age. The Skovde study found it to be present in 19% of people over 20 years and the Epidemiology of Hearing Loss Study found it to be present in 25% of people over the age of 53 years. Both studies found an increase in loss of smell as we age with the condition more common in men than in women. Olfactory impairment has been associated with the development of cognitive impairment and neurodegenerative disease including Alzheimer’s disease and Parkinson’s disease. A link between brain health and the sense of smell has been suggested in several additional studies. Schubert sought to determine what the incidence of smell impairment is in older adults. They found that overall 12.5% of adults 53 years and older would develop it within a five year time frame. The risk factors for development include nasal polyps, a deviated septum, heavy alcohol use. They found that exercise and use of stations or oral steroids decrease the risk.

Reference: C. Schubert etal. Olfactory impairment in older adults: five -year incidence and risk factors. Laryngoscope. 2011; 121:873-878.


14/Dec/2018

Conjunctivitis is an inflammation of the conjunctiva of the eye. This is the membrane covering the white of the eyes and the inside of the eyelids. If something irritates this clear membrane, your eyes may itch, tear, hurt, and become red or swollen. In some people, conjunctivitis is due to an allergy. In these instances, the condition is called either allergic conjunctivitis or ocular allergy. It can occur alone, or it may be associated with nasal allergy symptoms. Unlike conditions such as pink eye, allergic conjunctivitis is not contagious. Ocular allergies are very common, and may even be more common than nasal allergies.

CAUSES AND TRIGGERS
If you have an allergy, your immune system identifies something as an invader or allergen. Your immune system overreacts by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction. This reaction usually causes irritative symptoms in the eyes, nose, lungs, throat, sinuses, and intestinal tract.

The most common allergen is pollen, which is seasonal. People with seasonal allergic conjunctivitis (eye) or rhinoconjuntivitis (nose and eye) will experience symptoms at certain times during the year – usually from early spring, into summer, and even into autumn (fall). Those with perennial allergic conjunctivitis are susceptible at any time of year. These irritations may be triggered by dust, perfumes, cosmetics, skin medicines, or smog and second-hand smoke.

SYMPTOMS
Most people suffering from allergic conjunctivitis have problems in both eyes, and symptoms may appear quickly, soon after the eyes have come into contact with the allergen. The most common symptom occurs when the eyes become red, and the clear skin of the eye becomes swollen. The hallmark of eye allergies is extreme itchiness and the desire to rub the eyes. Other symptoms include swollen and red eyelids, or even a burning sensation.

TREATMENT
There are many different treatment options, depending upon the severity of the symptoms.

As with any allergy, the first approach for successful management of seasonal or perennial forms of eye allergy should be avoidance of the allergens that trigger your eye symptoms. When avoidance is not possible, then drops or even oral medications may be helpful. Over-the-counter (OTC) eye drops and oral medications are commonly used for short-term relief of some eye allergy symptoms.

OTC medications: Akwa tears, genteal etc. (artificial tears), vasocon-A (antihistamine and vasoconstrictor) – also known as “Visine-A” with side effects of increase in blood pressure, chronic red eyes on discontinuation.

Artificial tears can be used to sooth the eyes, and dilute the irritating allergens on the eyes. For mild, short outbreaks of symptoms, a mild anti-histamine drop with a medicine to reduce red eye injection can be used for a few days at a time. However, they may not relieve all symptoms, and prolonged use of some “get-the-red out” OTC eye drops may actually cause more harm than good.

For chronic allergies, a medication that is called a “mast-cell stabilizer” can be used. your doctor may prescribe a short-term steroid eyedrop to control your symptoms quickly, while continuing the long-term use of a mast-cell stabilizer. Prescription eye drops can be used with oral allergy medications from your doctor to treat eye allergies, which can also be a benefit to reduce eye symptoms, along with reducing any nasal allergy symptoms.

Prescription medications: Livostin, Emadine (antihistamines), Alamast, Alomide, Alocril, Cromolyn sodium (mast-cell stabilizers), Patanol, Zaditor, Optivar (antihistamines and mast cell stabilizer), Acular, Voltaren (non-steroidal anti-inflammatory), Loteprednol, Fluromethalone, Pred Forte (steroid)

Many patients find that they get more relief of their symptoms if the eyedrops are kept cold in the refrigerator.

February 10, 2010 Modified from AAAAI website by David Bloom, MD and Matthew Rings, MD.


14/Dec/2018

The nasal septum is the wall dividing the nasal cavity into halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this natural partition is a firm but bendable structure made mostly of cartilage and is covered by mucosa that has a substantial supply of blood vessels. The ideal nasal septum is exactly midline, separating the left and right sides of the nose into passageways of equal size.

Estimates are that 80 percent of all nasal septums are off-center, a condition that is generally not noticed. A “deviated septum” occurs when the septum is severely shifted away from the midline. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose. The symptoms are usually worse on one side, and sometimes actually occur on the side opposite the bend. In some cases the crooked septum can interfere with the drainage of the sinuses, resulting in repeated sinus infections.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is not generally performed on minors, because the cartilaginous septum grows until around age 18. Septal deviations commonly occur due to nasal trauma.

A deviated septum may cause one or more of the following:

  • Blockage of one or both nostrils
  • Nasal congestion, sometimes one-sided
  • Frequent nosebleeds
  • Frequent sinus infections
  • At times, facial pain, headaches, postnasal drip
  • Noisy breathing during sleep (in infants and young children)

In some cases, a person with a mildly deviated septum has symptoms only when he or she also has a “cold” (an upper respiratory tract infection). In these individuals, the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the “cold” resolves, and the nasal inflammation subsides, symptoms of a deviated septum often resolve, too. A deviated septum may also contribute to recurrent and/or chronic sinusitis.

Your Otolaryngology Visit:
After discussing your symptoms, the otolaryngologist will inquire if you have ever incurred severe trauma to your nose and if you have had previous nasal surgery. Next, an examination of the general appearance of your nose will occur, including the position of your nasal septum. This will entail the use of a bright light and a nasal speculum (an instrument that gently spreads open your nostril) to inspect the inside surface of each nostril. Surgery may be the recommended treatment if the deviated septum is causing troublesome nosebleeds or recurrent sinus infections. Additional testing may be required in some circumstances.

Septoplasty:
Septoplasty is a surgical procedure performed entirely through the nostrils, accordingly, no bruising or external signs occur. The surgery might be combined with a rhinoplasty, in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery. The time required for the operation averages about one to one and a half hours, depending on the deviation. It can be done with a local or a general anesthetic, and is usually done on an outpatient basis. After the surgery, nasal splints and/or packing is inserted to prevent excessive postoperative bleeding. During the surgery, badly deviated portions of the septum may be removed entirely, or they may be readjusted and reinserted into the nose. It has a good chance of improving nasal airflow and may improve chronic or recurrent sinus infection symptoms and/or frequency.

Septoplasty complications: Potential complications of the surgery include bleeding, hematoma, infection, perforation, need for further surgery.

Turbinate reduction: The inferior turbinates are frequently reduced in size at the time of septoplasty to further improve airflow.

Postoperative care: The patient usually follows up in the Otolaryngology clinic 4-8 days after the surgery for splint removal and to check on early healing. Recommend 10 days recovery time.

September 23, 2012 modified by Dr. David Bloom, MD

March 5, 2009 from the American Academy of Otolaryngology Head & Neck Surgery Website


14/Dec/2018

Epistaxis or nose bleeding is an especially common chronic nasal problem in adolescents and young adults. It is most commonly caused by a dry anterior nasal septum that has mucosa and blood vessels that crack and then bleed. It also is frequently caused by nasal trauma (nose picking) and may be increased by underlying medical conditions including hypertension, bleeding disorders, medications that cause anticoagulation or platelet abnormalities.

What are epistaxis symptoms?
Symptoms can vary with the season and may be brought on by changes in the weather. Heating and air-conditioning use may also create symptoms because of decreasing the humidity in the air. Nose bleeds may present as bleeding from the front of the nose and/or down the back of the throat.

How is epistaxis prevented and treated?
The most common treatment recommendation is to prevent drying in the nose using good hydration practices, a humidifier next to the bed if needed, and regular use of nasal saline and a topical agent such as vaseline, bacitracin or bactroban to prevent drying. Avoidance of nasal trauma/picking should also be encouraged.

To treat an anterior nosebleed, pressure with both fingers should be applied to each side of the lower nose directly over the anterior septum. Pressure should be held for 10 – 15 minutes. If bleeding resumes after releasing pressure, then it should be held for 15 – 30 minutes (without checking to see if the bleeding stops). If the bleeding resumes after holding for 30 minutes or continues down the back of the throat while pressure is being held, then the patient should go to the nearest urgent care or emergency room. Afrin/oxymetazoline is a vasoconstrictor (shrinks blood vessels in the nose) that may help decrease or control a nose bleed. You know you are holding pressure in the correct manner if you can’t breath through your nose.

When should my child see a doctor?
If your nose bleeds continue in spite of local treatment or persist for more than thirty minutes, it is appropriate to contact a physician. If the symptoms become overly frequent, it is also reasonable to see your physician.

Emergency treatment is rarely necessary except for extreme nose bleeds that persist in spite of treatment.

What happens during a physician visit?
The doctor will first obtain an extensive history about the child, the home environment, possible exposures, progression of symptoms, and risk factors for bleeding disorders. The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If active bleeding is occurring, the area may be cauterized and/or a nasal pack or nasal balloon placed. Nasal packing is usually left in place for 4 – 6 days. If no bleeding has occurred, but a prominent vessels is evident, the doctor may decide to cauterize the area to prevent future nosebleeds.

September 22, 2012 by Dr. David Bloom, MD


14/Dec/2018

Sudden sensorineural hearing loss (SSNHL) is a condition in which sensorineural hearing loss occurs in less than 72 hours. It usually affects adults between the ages of 43 and 53 years of age with a sense of fullness in the ear with muffled hearing. Approximately 28% – 57% will present with transient vestibular or balance symptoms. Many patients will recover spontaneously, but treatment with high-dose steroids, either oral or intravenous, has been shown to improve overall outcome. Recently, the use of intratympanic steroids has been increasing and several recent articles have addressed this treatment. The proposed benefits of intratympanic steroids include increased drug concentration at the cochlea and reduced systemic steroid exposure and associated adverse effects.

A recent systematic review by Spear and Schwartz of 176 articles, 32 representing initial or salvage intratympanic steroid injections for hearing loss demonstrated a consistent benefit of intratympanic steroids with a magnitude of improvement of 13 dB. Therapy needs to be started within 10 – 30 days of onset of hearing loss. For minor initial losses, this improvement may be sufficient for full recovery. For more severe losses, this improvement may return the hearing to a serviceable level. Overall, these authors concluded that intratympanic steroids are comparable to oral steroids for initial therapy and of benefit as a salvage therapy for patients who do not respond to an initial course of oral steroids for SSNHL.

Rauch et al. in a prospective, randomized, noninferiority trial involving 250 patients with unilateral sensorineural hearing loss presenting within 14 days onset of 50 dB or higher pure tone average (PTA) hearing threshold from 2004 – 2009 at 16 academic community-based otology practices with at least 6 months follow-up found that initial treatment with intratympanic steroids was not inferior to oral prednisone therapy. Overall, 32% (11 of 34) patients in the placebo group and 61% (20 of 33) in the steroid-treated group had full recovery. In subgroup analysis they found that patients with the worse prognosis for hearing recovery (PTA at least 90 dB and/or dizziness) showed a trend for improved outcome with oral versus intratympanic steroids.

Method 24cialisitalia.com of intratympanic steroid injection:

The intratympanic steroid injection uses four 1-mL dose of 40mg/mL of methylprdnisolone or 10 mg/ml of dexamethasone (less painful) over 2 weeks with a dose given every 3 to 4 days through the tympanic membrane (ear drum) into the middle ear space where it can diffuse via the round window into the cochlea (organ of hearing). Anesthesia can be provided with phenol but many patients prefer no local because the injection is brief. Patients are positioned supine at the operating microscope with the affected ear slightly up and remain in this position for 30 minutes after the injection.

Risks of oral and intratympanic steroids:

Adverse effects from oral steroids include change in appetite, mood or sleep pattern, worsening of psychiatric illness, weight gain, gastritis, increased thirst, hypertension, hyperglycemia, cataract formation and avascular necrosis of the hip.

Adverse effects from intratympanic treatment are generally local effects and include, ear pain, transient caloric vertigo, tympanic membrane perforation and infection (acute otitis media). Intratympanic treatment is more costly at approximately $688 versus a 2-week course of oral prednisone costing approximately $10.

Overall, intratympanic steroids are safe and equally effective as oral steroids. I offer it to all patients but prefer to use it for patients who seek to avoid the potential complications of oral steroids, have contraindications for oral steroid use or as a salvage therapy for patients who do not respond to oral steroid therapy.

AskDrBloom references:

Spear SA, Schwartz SR. Intratympanic steroids for sudden sensorineural hearing loss: a systematic review. Otolaryngol Head Neck Surg. 2011;145(4):534-543.

Rauch SD, Halpin CF, Antonelli PJ et al. Oral vs intratympanic corticosteroids therapy for idiopathic sudden sensorineural hearing loss. JAMA. 2011;305(20):2071-2079.


14/Dec/2018

The increasing use of imaging studies has lead to an increased number of incidental findings. One of these is mucous retention cysts which are found in 3 – 35% of the general population. They are dome-shaped cysts of mucous found approximately 90% of the time in the maxillary sinus. They infrequently cause symptoms. Dr. Moon and his team looked at 133 healthy individuals who were found to have a mucous retention cyst on routine MRI with a subsequent MRI in the future. They found that only 8.3% of the cysts increased in size and only 3% developed sinusitis. At follow-up, only 4.5% of the patients complained of nasal symptoms including nasal obstruction, discharge and postnasal drip. They determined that the risk factors for increase in size and potential for subsequent symptoms are bilateral mucous retention cysts and cyst size greater than 2.0 cm. These patients may warrant follow up annually. A wait and see approach is reasonable for unilateral cysts smaller than 2.0 cm.

Reference: I. J. Moon etal. Mucous cysts in the paranasal sinuses: Long-term follow-up and clinical implications. Am J Rhinol Allergy. 2011; 25(2):98-102.


14/Dec/2018

Meniere’s Disease is a syndrome including fluctuating sensorineural hearing loss, episodic vertigo, ear fullness and tinnitus (ringing of the ears). It is caused by hydropic distention of the endolymphatic system (inner ear). It has a prevalence of 218 per 100,000 people in the United States. Meniere’s Disease is idiopathic. While it is not caused by allergies, in some patients an allergic reaction produced by a food and/or inhalant allergen may stimulate an inflammatory reaction resulting in the development of symptoms. It is known that the endolymphatic system is capable of processing antigen and mounting an allergic response. It is thought that the endolymphatic sac could be the target organ of the allergic reaction. The resulting inflammation could lead to the hydropic distention.

In a survey by Dr. Derebery, 41% of Meniere’s Disease patients have confirmed concurrent allergic disease. The general population averages for allergic disease is 14%. Dr. Derebery reported in 113 patients with Meniere’s Disease treated with allergy desensitization and diet (avoidance of foods that they are allergic to) had much improved symptoms of allergic disease and decreased frequency, severity and interference with daily activities in their Meniere’s Disease compared to a control group of 24 Meniere’s Disease allergic patients that were untreated.

Although no double blind placebo controlled studies exist, it is reasonable to test patients with Meniere’s Disease who have allergic symptoms or a history suggestive of allergies and to provide immunotherapy and food avoidance as indicated.

Reference: Derebery MJ and KI Berliner. Allergy and its relation to Meniere’s Disease. Otolaryngol Clin N Amer 2010;43:1047-1058. Derebery MJ. Allergic management of Me


14/Dec/2018

Sleep apnea (AP-ne-ah) is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.

Breathing pauses can last from a few seconds to minutes. They often occur 5 to30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.

Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep. You often move out of deep sleep and into light sleep when your breathing pauses or becomes shallow.

This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness.

Overview

Sleep apnea often goes undiagnosed. Doctors usually can’t detect the condition during routine office visits. Also, there are no blood tests for the condition.

Most people who have sleep apnea don’t know they have it because it only occurs during sleep. A family member and/or bed partner may first notice the signs of sleep apnea.

The most common type of sleep apnea is obstructive sleep apnea. This most often means that the airway has collapsed or is blocked during sleep. The blockage may cause shallow breathing or breathing pauses.

When you try to breathe, any air that squeezes past the blockage can cause loud snoring. Obstructive sleep apnea is more common in people who are overweight, but it can affect anyone. For example, small children may have enlarged tonsil tissues in their throats, which can lead to obstructive sleep apnea.

Central sleep apnea

Central sleep apnea is a less common type of sleep apnea. This disorder happens if the area of your brain that controls your breathing doesn’t send the correct signals to your breathing muscles. As a result, you’ll make no effort to breathe for brief periods.

Central sleep apnea can occur in anyone. However, it’s more common in people who have certain medical conditions or use certain medicines.

Central sleep apnea often occurs with obstructive sleep apnea, but it can occur alone. Snoring doesn’t typically happen with central sleep apnea.

This article mainly focuses on obstructive sleep apnea.

Outlook

Untreated sleep apnea can:

  • Increase the risk of high blood pressure, heart attack, stroke, obesity, and diabetes
  • Increase the risk of, or worsen, heart failure
  • Make arrhythmias (ah-RITH-me-ahs), or irregular heartbeats, more likely
  • Increase the chance of having work-related or driving accidents

Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes, mouthpieces, surgery, and/or breathing devices can successfully treat sleep apnea in many people.


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