The most common types of ear infection are middle and outer ear infections. The middle ear infection (otitis media) occurs when fluid accumulates behind the eardrum (tympanic membrane). Outer ear infections (external otitis) involve the skin of the ear canal and are usually caused by bacteria or fungus. Inner ear infections are less common and may be caused by viruses that affect the nerves and other structures controlling hearing and balance.
Children under 10 years old have poor function in the ventilation / drainage pathway (the Eustachian tube) that connects the middle ear to the back of the nose. This more horizontal position reduces drainage of fluid and flow of air to the middle ear.
Very young children have immature immune systems, so exposure to other sick children in daycare and school settings makes them more likely to get upper respiratory infections. These upper respiratory infections, such as colds, result in swelling in the Eustachian tube, which can make it less able to function to protect the middle ear.
Allergies are quite common in children, but they may not actually have significant effect on a child’s risk of ear infection.
Bottle-feeding, milk products, and pacifier use are assumed to cause ear problems, but there is not much scientific evidence to support this theory.
When enlarged, adenoids, the pad of tissue in the back of the nose, can block the Eustachian tube. Younger children generally have larger adenoids, which can also be a contributing factor to ear infections.
Earwax is a natural body secretion that protects the ear canal from infection. Over cleaning the ear canal, whether with a Q-tip, washcloth or instrumentation, can cause infection, pack the wax more deeply inward or even puncture the eardrum. But some people do need to have their ears cleaned more often than others. At your next visit, please ask Dr. Agresti for personal recommendations.
This condition is called a serous effusion and it can occur following treatment for an ear infection. Generally, when the Eustachian tube improves, the fluid is reabsorbed by the body. However, in some cases, fluid may stay present for months. Medical treatments, such as antihistamines, decongestants and nasal sprays may improve drainage from the nose and Eustachian tube. However, sometimes it still becomes necessary to have a physician insert ear tubes. These tubes can help resolve conductive hearing loss immediately in children and adults. This treatment path is especially important for children who have speech delays, learning problems or developmental delays.
Some children with repeat ear infections or persistent fluid may be offered ear tube surgery, called a myringotomy. During this procedure, we make a small incision in the eardrum, suction out the fluid and insert the spool-shaped tube. Surgery is typically recommended after many ear infections occur in a one-year period, if fluid has been present with hearing loss for several months or if there has been damage to the eardrum. Though the tubes cannot fix the underlying problems of immature Eustachian tube function or poor ventilation, they can help support your child through this growth phase. Approximately 10% of children will need tubes placed more than once. Eventually, growth and development should provide a permanent solution to this problem.
Photo: TM with myringotomy incision & TM w/ Tube (need photo)
In children, tubes are placed under general anesthesia. The entire procedure takes less than ten minutes and does not require a hospital stay. In adults, tubes can be placed in the office with a topical anesthesia applied to the eardrum.
In some patients, we recommend removal of the adenoids at the same time as myringotomy and tubes. Adenoid tissue is located at the back of the nose and the top of the throat and can physically block the Eustachian tube. In addition, adenoid enlargement can provide an ideal environment for bacteria growth, which can, in turn, cause inflammation of the Eustachian tube or travel into the tube. When a child has a blockage of the nose caused by adenoids that results in snoring, mouth breathing or recurrent respiratory infections, and when ear tubes have already been tried, an adenoidectomy may be recommended. Adenoidectomy adds a small amount of time and risk to the procedure, so it should only be undertaken if there is a strong indication.
Living in South Florida, children are likely to be exposed to water from the ocean and swimming pools. That is why we recommend using a silastic earplug (such as Mack’s Earplugs) or a custom swim plug, which we can create for you in our office. For children participating in swimming lessons, we recommend swim headbands, as well. We also recommend that both children and adults with ear tubes be checked every 3 to 4 months after surgery to ensure there aren’t any problems with the tube and to perform intermittent hearing tests.
When it comes to air travel, having ear tubes in place is not a concern. Your ear will equalize pressure between cabin and the middle ear space immediately, unless the tube is clogged. If you are concerned, please schedule a check-up, and we can ensure the tube is open.
NOSE AND SINUS
The type of sinusitis you have determines the length of time the symptoms last:
Acute sinusitis: 10-14 days
Subacute sinusitis: 4-8 weeks
Chronic sinusitis: 8 weeks or more
Recurrent sinusitis: several attacks occur within the same year
Sinusitis is most commonly treated with antibiotics. The length of treatment and the type of antibiotic used is based on the severity of the symptoms and the length of time they have been present. Sometimes it is necessary to obtain a sinus culture to determine what type of bacteria is there so we know which antibiotic to use.
Steroid therapy may be recommended if the tissues of the nose and sinuses are very swollen, as steroids act as a strong anti-inflammatory. This medication can be prescribed in the form of a nasal spray, pills or nebulized.
For many people, a safe and effective treatment for sinusitis is sinus irrigation in the form of a squeeze bottle or neti pot. Saline (balanced salt water) keeps the nasal sinus cavities moist and clean, which prevents the trapping of secretions inside the sinus openings. In certain cases, Dr. Agresti prescribes single or combined medications tailored to a patient’s individual needs. If you live in a cold, dry climate, a room humidifier may also be helpful.
Most sinusitis patients are successfully treated with medical therapy, but for those whose symptoms cannot be controlled, we generally recommend surgery. Prior to surgery, we will order a CT sinus scan to evaluate if there is structural narrowing of the sinus drainage pathways and/or if there are polyps or cysts in the sinuses. Dr. Agresti uses CAT scan computer guidance technology in the operating room, which assists in locating details in the sinus anatomy during surgery. She also uses Ballonplasty technology, which can be used to help widen narrow, boney sinus openings. Surgery is performed under anesthesia and usually takes 1½-2 hours, depending on how many sinuses are involved. Endoscopy allows instruments to be placed through the nostrils so there are no incisions on the nose or face. Recovery takes 4-5 days, although more vigorous exercise is not recommended for at least 10-14 days.
One of the most common causes of difficulty breathing through the nose is a deviated nasal septum. The nasal septum is a midline structure made up of cartilage (front) and bone (top and back) that divides the nose into right and left passages. It can be seen by looking into the nostril. If it is deviated (crooked) from birth or from trauma, it can block airflow into the nose. This obstruction may contribute to difficulty breathing through the nose, snoring and obstructive sleep apnea.
A deviated nasal septum that causes difficulty breathing at rest, during exercise or sleep can be straightened with a surgery called septoplasty. This procedure involves removal of the deflecting cartilage and bone and can be performed under sedation or general anesthesia in an outpatient setting. Typically, this surgery takes 45 minutes and has a two to three day recovery period. Septum repair is commonly combined with a reduction in the nasal tissues called turbinates that can swell abnormally and worsen the airway obstruction. Septoplasty is sometimes combined with a rhinoplasty to correct external nasal deformities that will improve the outward appearance of the nose and face.
Normal swallow function can be divided into four different stages. The first stage is the oral preparation stage during which chewing breaks down food in the mouth to create the lump of food and liquid ready for swallowing. The second stage is the oral stage during which the tongue pushes the food to the back of the mouth beginning the cascade of involuntary events that follow. The third stage is called the pharyngeal stage, which allows food to travel down to the lower throat (hypopharynx), the epiglottis to deflect food away from the trachea, and food to enter the esophagus. In the fourth stage, the esophageal stage, the food travels by muscular contractions down the esophagus into the stomach.
Difficulty swallowing or dysphagia is an alarming symptom and may be indicative of a problem in the throat or neck. If you have symptoms such as: weight loss, discomfort in the chest or back during swallowing, food getting stuck in the throat or chest region, a lump in the throat feeling, drooling, ear pain, coughing or choking on food or liquid, or a change in voice quality, you should call Dr. Agresti’s office immediately to schedule an evaluation. This problem can result in malnutrition and dehydration and needs to be addressed as soon as possible.
GERD (gastroesophageal reflux) is a chronic gastrointestinal disease that results from liquid and food contents in the stomach backwashing up into the esophagus irritating the lining of the esophagus. From time to time, many people experience reflux, heartburn, and a sour taste in the throat. When it occurs two or more times a week, an evaluation is recommended. The condition is typically treated with diet and lifestyle changes, such as reducing the acidity of your diet, cutting consumption of alcohol and chocolate, eating smaller meals, and not indulging in late night eating. Medications such as antacids and proton pump inhibitors can be successful at controlling symptoms. If, however, you use these medications on a long-term basis, physician supervision is suggested. Dr. Agresti recommends that even people taking medications for reflux should be screened for Barrett’s Esophagus because they still have increased odds of developing B.E., dysplasia, and esophageal cancer.
Larynpharyngeal reflux (LPR) occurs when the aerosolized and liquid acid from the stomach backwashes to the larynx and throat, which are extremely sensitive to acid and cause irritation to these tissues. Many people with LPR never experience heartburn. We call this condition silent reflux or atypical reflux. Symptoms include: dry cough, throat clearing, excess mucous in the throat, the feeling of having a lump in the throat, trouble swallowing, intermittent hoarseness or loss of voice, and post nasal drip (PND). Many patients are told their throat symptoms are due to PND, but this is rarely the cause, unless there is an active nasal/sinus infection.
First, Dr. Agresti will take a through history and perform a physical exam of the head and neck, including a flexible fiberoptic scope of the nose, throat, larynx, and upper esophagus. If symptoms and concerns are more serious, the doctor will recommend an ambulatory 24-hr pH monitoring procedure which can be done in-office. This test involves placement of a tiny tube in the nose and throat to measure the amount of acid that backwashes to the throat. The tube is connected to a small pocket-size computer that records activity for 24 hrs. Once completed, she will interpret the results and develop a treatment plan.
If you are having a swallow problem, Dr. Agresti will take a thorough history and conduct a physical exam, including passing a flexible fiber optic through your nose, so she can examine the larynx and lower throat region. Dr. Agresti can perform a Transnasalesophogoscopy(TNE) in her office with no bowel prep, and it will take just minutes to complete. It is a valuable test because it allows a direct examination of the esophagus and stomach, and allows Dr. Agresti to perform brush biopsies to check for precancerous esophagus cells called Barrett’s Esophagus. This test is very safe and cost effective.
Barium swallow tests are performed mainly at hospitals and are designed to detect structural and functional abnormalities. Potential findings include: tumors of the head, neck, and esophagus, GERD, ulcers, hernias, diverticula, strictures, polyps, esophageal varices, muscle disorders or spasms, and achalasia. Sometimes Dr. Agresti may suggest a Speech/Language Pathologist perform a FESS (Functional Endoscopic Evaluation of Swallow), during which a flexible scope passes through the nose so that the swallow function can be viewed while a patient is actually eating. These exams help locate which of the four stages of swallowing are involved in the problem so that we can develop strategies to correct or cope with the problem.