this always comes first
Read the disclaimer. Please.
– D.
Open thread
I’ve been a lazy sack here — sorry! I blame that hectic old job with three hours’ commute time per day, the move, the new job, etc. Now that life is settling down, we can get back to business here.
For starters: any questions? Post ‘em below and let’s see how fast I can answer them!
D.
The plugged ear, revisited
Q: I’ve some kind of blockage in my left ear. It is not painful and I feel little or no pressure there. The problem is, I can’t get a scheduled doctor’s appointment for another 3 months. I already have partial hearing loss. I believe it will return to normal once my ear canal is cleared out. I’ve been using the OTC drops for softening the wax. It doesn’t help, much. I’m worried about the time frame I have to look at. Is it probable that I might have complete hearing loss by the time my Dr. can squeeze me in? I’ve looked at every option people have given me, and I’ve tried what doesn’t scare the ***** out of me.
Contact point neuralgia
Headache is a tricky topic. Sinus infection can, of course, cause facial pain and headache, as well as a runny or congested nose; but migraine can cause nasal congestion, too.
Congestion and pain also accompany one another in a condition known as contact point neuralgia, sometimes also called Sluder neuralgia. Facial pain occurs when structures within the nose press against one another. Structures that ordinarily do not touch may be brought into contact when the tissues swell from allergies, a cold, or a sinus infection.
Here is how I approach a patient in whom I suspect contact point neuralgia. I ask the patient to come see me when he is in pain. (In some cases, I have to squeeze someone into the schedule, but it’s worth it.) I then examine the patient’s nose with a fiberoptic scope. I do this BEFORE spraying a decongestant or topical anesthetic into the nose. Since I’m examining an unanesthetized nose, needless to say I have to be careful. I’m looking for one or more areas in which two structures touch — most commonly, the septum and one of the turbinates*.
Next, I place a cotton ball moistened with a decongestant spray (like Afrin) and an anesthetic (lidocaine) against the contact area. If the patient notes rapid relief of his pain, AND if reexamination of the nose with the fiberoptic scope reveals that the “contact points” are no longer in contact, this is fairly convincing evidence that the patient’s pain is contact point pain.
Another good maneuver is to place a saline-moistened cotton against the contact area. This should be done before the lidocaine/afrin application, as a control to see if the patient receives benefit from just any intervention. Saline won’t decongest or numb the nose, so it shouldn’t have an effect on the patient’s pain. If saline helps, then the afrin/lidocaine results will be suspect.
Treatment of contact neuralgia can be medical or surgical. Medications which reduce swelling in the nose can bring these areas out of contact. If this doesn’t work, usually there are good surgical options for accomplishing the same thing on a more permanent basis. These operations are known as turbinatoplasty (to change the shape of the turbinates) and septoplasty (to change the shape of the septum) . . . great topics for another day.
D.
*The septum is the cartilaginous/bony partition between the two nasal cavities. The turbinates are shelves of bone, covered with mucosa, which jut out from the lateral walls of the nose. The turbinates warm, humidify and filter the air that we breathe.
Anterior epistaxis treatment: a YouTube video
This isn’t my video, and in fact I’m critical of the technique used. First, some background: this is an example of treatment of an anterior nosebleed with silver nitrate, an oxidizing agent. The doctor is inflicting a chemical burn on the offending vessel in order to make it stop bleeding. You won’t see any bleeding (not for a while, anyway) but you will see a pimple-like projection above the mucosa. I like to think of these as itty bitty models of Mount Vesuvius, ready to blow.
In my opinion, this doc is far too liberal with his application of silver nitrate. Towards the end of the video, you’ll note that the grayness (evidence of silver nitrate burn) is nearly circumferential. Sometimes this is unavoidable, but I try my best NOT to do this, because it can lead to troublesome scarring.
Many bleeding sites are capillaries which do not rise above the surface of the mucosa. In contrast, these little volcanoes are often more troublesome. In my experience, they laugh at silver nitrate. I prefer bipolar electrical cautery for such vessels. This is more painful than silver nitrate, but it also results in a far smaller area of injured tissue. Silver nitrate-treated noses sometimes stay irritated longer than bipolar-treated noses. More to the point, bipolar cautery is more successful for treating these larger vessels.
The first time I treat a patient with epistaxis, the usual question is, “Will this stop me from bleeding again?” I ask the patient to imagine a pyramid. Most patients will get better after one or two treatments — think of the size of the base of the pyramid. A few patients will have to return for several treatments (we’re a little higher up in the pyramid, and the volume is smaller), while some will need still more aggressive interventions. A very few (the apex of the pyramid) will need surgical or angiographic intervention.
Yes, probably not the clearest metaphor, but folks seem to understand. It helps me to convey that the goal is to begin with low-risk, mild interventions (like silver nitrate or bipolar cautery) and reserve more aggressive methods for folks whose problems are sufficiently severe or stubborn to warrant such.
I will admit an ulterior motive to my pyramid discussion: I know that some of these folks will be back again and again no matter what I do. It’s the nature of the problem. I want them to know from the start that there’s a chance they could be in the apex of the pyramid. Otherwise, come the third or fourth office visit, they might think I’m some yutz who doesn’t know his nostril from a hole in the ground 
D.
Posterior nosebleeds
Q: My father-in-law has been experiencing nose bleeds. My concern is that they are not anterior nosebleeds; they begin in the back of the nose, sometimes only flowing down the throat. After the last nose bleed he had, the following day he had dizziness and lightheadedness. The nose bleeds can come on with no warning, i.e., sitting down watching TV, or during physical activity, i.e., playing with a 4 yr old grandchild. I just need to know if these symptoms are something to really worry about? Thank you.
Nasal polyps, steroids, and surgery
Q: I have had nasal polyps for several years which usually don’t bother me except when I have a cold or hay fever. My ENT doctor recommended surgery which I declined because of the chance of recurrence. Recently however, my right eustachian tube feels blocked and I was given a prescription for prednisone plus a steroid nasal spray to treat the polyps. Would prednisone for two weeks plus the nasal spray be better than surgery to relieve the polyps, or is surgery still the best treatment? Also, what is the best treatment for the blocked eustachian tube? (more…)
That “plugged ear” sensation
Q: I have been attending the ENT hospital on a regular basis for 4 years. I was discharged in October as the problem was resolved. My ears once again became blocked and I was unable to get an ENT appointment until July. I have tried Hopi ear candles that did clear the ear slightly and it made all my sinuses appear to be clearer. My hearing however is now impaired. Should I not try anything else now until my appointment? I do not have an infection. Also, a couple of years ago my eardrum was perforated.
The floor is going up and down (oscillopsia)
Q: Five years ago, I was diagnosed with hypothyroidism. I get a TSH test done regularly in order to ensure I am taking the correct dosage of Synthroid.
However, every few months or so, dizziness will just come on suddenly. It is not a ’spinning around’ dizziness but more like I am standing still and the floor is going up and down (sort of a ‘vertical’ type of motion although I am perfectly still). Walking up or down stairs poses somewhat of a problem during this time. Most recently I felt this way at night. When I woke up the next morning, even before opening my eyes, I knew I was going to feel the dizziness which I did. I simply opened my eyes (my head still lying flat on the pillow) and I was dizzy. It will go away after about 10 minutes but then reappear during the day a few times. This will last for about 3 or 4 days and then will disappear completely for the next few months. I spoke to my G.P. about this who has only said, “There is nothing I can do. There is no blood test for this.” I had mentioned this to him a few times!
From what I can recall, I feel somewhat fatigued when these spells occur. And, perhaps I am eating more carbohydrates than usual, but I don’t really think that such would affect this. My eating habits do not change too radically from one day to the next….
I would love to know if there is a certain food group that I should be avoiding (i.e. carbos, more protein, etc.) or what in fact is really going on! This does concern me. I haven’t been happy with my doctor’s response to this.
Big tonsils and obstructive sleep apnea in a five-year-old
Q: My daughter is 5 years old and her tonsils are very large. She has a hard time breathing and snores a lot. I have been very concerned. I took her to an ENT specialist and he recommended to remove her tonsils. I have been very reluctant to have the surgery. Since I gathered lot of information from your site regarding tonsillectomy, I am thinking to remove her tonsils.
headache, occipital neuralgia
Q: My situation is, for about a month I have been experiencing a pain in the back of my head. I don’t consider it a headache because it comes and goes quickly, but it is sharp. I also occasionally experience a feeling of goose bumps in the area. I don’t usually notice the pain when I am busy, but when I am not doing anything, I feel it. It is in a specific spot, not a general area and the spot is sensitive to the touch. I spoke to my doctor about it and am getting an MRI in a couple of days. Of course I have myself convinced it is a brain tumor. My doctor said it may be neuritis. After hearing this I ran home to look it up on the internet. From what I have read it sounds like it could be occipital neuritis but I am not sure. My question is, will an MRI be able to tell if it is neuritis, and is this kind of pain common to brain tumor. I don’t have any other symptoms other than the spot being sensitive and occasional goose bumps. Thank you for any help you can give me.
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