Treating ear, nose and throat infections

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In Nigeria today, ear, nose and throat-related conditions constitute a major burden of infections. Yet the majority of the citizens are ignorant of ENT treatment options, leading to shortage of health personnel as the field is not considered lucrative. In fact, a recent survey conducted by Professor Babagana Ahmad, medical director of the National Ear Care Centre, Kaduna, revealed that in a population of about 170 million, Nigeria has only 200 ENT specialists.
However, the pattern of these diseases may vary from community to community or hospital to hospital, based on the availability of specialist personnel or facilities for the management of such diseases, which are either congenital or acquired in origin.
According to an ENT audit put together by Dr A. J. Fasunla, Department of Otorhinolaryngology, University College Hospital, Ibadan, the acquired diseases include infections, inflammatory diseases, neurologic diseases, vascular diseases, trauma, benign and malignant tumours etc.
ENT diseases are serious public health problems with universal distribution affecting all age groups. The knowledge of the ear, nose, throat, head and neck diseases is very important because of the type of morbidities which they cause due to impairment of the inherent physiologic functions that usually take place in the head and neck region. These include problems of hearing, breathing, swallowing, phonation, speech, olfaction, taste, protection of the lower respiratory tract and clearance of secretions.
Aesthetic problem of the face and psychological problem may occur in neoplasm and neurologic diseases of the head and neck region.Below are some examples of ENT disorders:

Tonsillitis
When the tonsils become inflamed for long periods of time, they may have to be surgically removed. This procedure is called a “tonsillectomy.” Though tonsillitis used to be treated with tonsillectomy frequently, it is no longer the practice and is now only done in specific instances. When inflammation is severe enough, it can interfere with swallowing and breathing.
Tonsil removal is indicated in cases of extreme obstruction of the airways or swallowing. Often tonsils are enlarged, swollen and painful during tonsillitis. Less absolute indications for tonsillectomy include: recurrent acute throat infections, chronic tonsillitis that does not improve with antibiotics, obstruction leading to bad breath or changes in voice. There are many causes of tonsillitis.

Ear infection
Ear infections are one of the most prevalent ENT disorders. They occur when germs become trapped inside the inner ear. The Eustachian tube, a tiny tube that originates in the ear and drains in to the back of the throat, usually keeps unwanted germs out. If this tube is too small or becomes clogged by fluid and mucus, bacteria or other microbes may be able to enter the ear and cause an infection. Signs and symptoms of an ear infection include:
* recent history of an upper respiratory infection
* pain and pressure
* fever
* loss of balance
* difficulty hearing
* nausea and vomiting
* fluid discharge from the ear (this indicates perforation of the tympanic membrane)

Ear infections are more common in children. If your child has an ear infection, it may be difficult to detect. Here are some things you may notice about your child:
* pulling or tugging on the ears
* increased fussiness, especially at bedtime
* fails to startle at loud noises or does not consistently respond to name
* eating or drinking abnormally

Strep throat
Strep is an abbreviation for a family of bacteria called “streptococci.” Strep throat occurs when the throat and surrounding structures become infected with this germ. While strep throat is a common infection, many other infections have the same symptoms. You must have an actual strep test at your doctor’s office to be certain that your symptoms are associated with a streptococcal infection versus a different bacterial or viral infection. Symptoms are usually abrupt in onset, including:
* red, sore throat
* difficulty swallowing
* enlarged tonsils
* enlarged lymph nodes
* white patches on the tonsils or in the back of the throat
* fever
* body aches
* fatigue
* skin rash (rare)

Notably absent in strep throat are a runny nose and cough. You may also suspect strep throat if you have been exposed to someone with a strep infection in the last two weeks. Children between the ages of 5 and 15 are most at risk. You are also more likely to get a strep infection during the winter months.

Sinusitis
Sinusitis occurs when a germ finds its way in to the hollow recesses of the skull that surrounds your eyes and nose. The infection can then become trapped there, causing inflammation, pressure and pain. Acute sinusitis is often secondary to a common cold, so you are more likely to get sinusitis during the winter months.
Chronic sinusitis is sometimes an inflammatory disorder caused by untreated allergies or conditions, such as bronchial asthma. Sinusitis can last from weeks to years, if left untreated. Symptoms of sinusitis are:
* headache
* cough
* nasal discharge of various colours and consistency
* congestion
* toothache
* fever
* fatigue

Sleep apnoea
Apnoea is a medical term, meaning to stop breathing. Sleep apnoea is a disorder causing one to stop breathing for brief periods of time while sleeping. Sleep apnoea is a common disorder and can cause severe health problems, if left untreated. If you suspect that you have sleep apnoea, see a doctor. Symptoms include:
* waking up frequently in the middle of the night
* feeling unrefreshed upon awakening
* daytime drowsiness
* mood swings
* depression
* waking up with a dry, sore throat
* morning headaches

In addition to these symptoms, many individuals with sleep apnoea have often been told by a spouse or other family member that they snore, gasp or choke while sleeping. Family members may have observed an episode in which you stopped breathing while asleep. You are more likely to have sleep apnoea if you are overweight, have enlarged tonsils, take sedatives at bedtime or have inherited a shorter airway than the general population. People who are obese and have uncontrolled hypertension are more likely to have obstructive sleep apnoea.
The majority of people will experience one or more of these disorders in their lifetime. While visiting with your physician, discussion of your symptoms may help your doctor to come up with a diagnosis of an ENT disorder.

Diagnosis of ENT disorders
Many tests are used to diagnose ENT disorders. Regardless of your particular ailment, there is specific information you should always have ready for your physician to help him diagnose your problem. Here are some of the questions your doctor may ask:

* What are your symptoms and when did they start?
* Have you been taking any medications (over-the-counter, including vitamin and herbal supplements or prescription)? If so, your doctor will want to know the dosage.
* Are you allergic to any medications? If so, what are they and what kind of reaction did you have?
* Do you have a previous history of ENT disorders?
* Do you have a family history of ENT disorders?
* Do you have any other medical conditions?
* Have you been running a fever?

Here are additional questions if the patient is a small child:
* Has the child had nausea and vomiting? If so, has the child continued to have wet diapers?
* Has the child been abnormally fussy or lethargic?
* Has the child had balance problems?
* Has the child’s eating and drinking habits changed?
* Has the child shown signs of decreased hearing, such as not responding to their name immediately or not startling at loud noises?

Diagnosis of ear infections
If you have signs and symptoms of an ear infection, your doctor will use an otoscope to visualise the outer ear and eardrum. If an infection is present, the ear may appear red and swollen. There may also be a fluid discharge. Unlike other infections, the exact bacterium that is responsible cannot always be determined. As such, doctors choose antibiotics that will cover the most likely organisms when they suspect a bacterial source. This is because it can be difficult to obtain a sample from the ear for a culture. Antibiotics will not cure a viral infection, and it can take as long as three weeks for your body to fight off the virus.

Diagnosis of swimmer’s ear
With swimmer’s ear, the outer ear and ear canal may be red. Upon examination, the doctor may notice pus in the ear canal, and the skin may be scaly or shedding. The doctor may be able to obtain a fluid sample for culture.

Diagnosis of sinus infections
If a sinus infection is suspected, an endoscope may be used to go up the nose and visualise the opening in to the sinus cavity and take a direct sinus culture. Nasal swabs are not useful due to false positive results that do not reflect the sinus pathogen. By endoscope, the doctor will be looking for inflammation and/or discharge. Four view x-rays or a CT scan may be indicated, if other tests are inconclusive.

Diagnosis of strep throat
Strep throat causes enlarged reddened tonsils that sometimes have white patches on them; however, many viral infections can cause this as well. If strep throat is suspected, a throat culture will be taken and sent to the lab. This test is quick and easy to perform with only mild discomfort as it may cause a gagging sensation. A cotton swab is brushed against the back of the throat then sent to the lab to test for streptococcal bacteria, the cause of strep throat. The standard test can take one to two days; however, a rapid strep test can also be performed, which only takes a few minutes.
If the rapid strep test is positive, antibiotics will be started. If the rapid strep test is negative, you will be sent home and the standard culture will still be performed. About 20 per cent of negative rapid strep tests will become positive after a day or two in the laboratory. Sometimes your doctor may make the diagnosis based on classic symptoms and signs to treat you presumptively even without a swab.

Diagnosis of sleep apnoea
Sleep apnoea is a disorder causing one to stop breathing for brief periods of time while sleeping. In your first visit, the doctor will begin by obtaining a comprehensive medical history. Before ordering a sleep study, he or she will likely ask some of these questions:
* Have you ever been told that you snore?
* Have you ever been told that you have stopped breathing while asleep?
* Do you awake refreshed in the morning or do you suffer from daytime drowsiness?
* Do you suffer from mood swings or depression?
* Do you wake up frequently in the middle of the night?

The doctor will look inside your mouth for evidence of enlarged tonsils, uvula(a bell-like piece of tissue that hangs down from the roof of the mouth toward the back of the throat) or other structures that may be blocking the airway. The uvula contains some glands and affects vocal resonance. If the doctor suspects sleep apnoea, they may order a sleep study. Sleep studies are usually conducted at a sleep centre. After you fall asleep, a monitor, which measures the oxygen concentration in your blood, will be placed on your finger. Normal oxygen saturation during sleep in otherwise healthy men and women is 95 per cent to 100 per cent. If you stop breathing while asleep, this number will drop.
Another sleep study used to diagnose sleep apnoea is called a “polysomnogram.” It measures not only the amount of oxygen in your blood, but brain activity, eye movement and muscle activity, as well as your breathing and heart rate.
Based on your present symptoms, your doctor may choose to use a combination of these tests to diagnose your specific disorder. He will then use this information to create an effective treatment plan.

ENT treatment
ENT treatment can be handled by either a general practitioner or an otolaryngologist (ENT). Though general practitioners treat a number of ENT disorders, your family doctor may not feel comfortable treating you and may refer you to an ENT specialist. Seeking out a specialist on your own may also be helpful, if you are unhappy with the care you have received, need a second opinion or want more information than your general practitioner can provide.

How can I find an ENT specialist?
If you have been referred to an ENT specialist by your family doctor, he or she probably already has a specific doctor in mind. If not, you can use the to find a list of ENT specialists in your area.

What ENT treatments are available?
The best ENT treatment will vary according to what type of problems or symptoms you are having. In the early stages of a disorder, surgical procedures may not be warranted, as in tonsillitis, for example. Early treatments will also depend on whether or not the disorder is related to an infection. If an infection is suspected, tests may be performed to determine whether the cause is bacterial or viral. Viral infections will not respond to antibiotics.
If surgical procedures are indicated, the doctor or nurse will give you instructions to follow before the surgery, including when you need to stop eating solid foods, when to stop drinking clear liquids and whether or not you will need to start or stop any medications before the surgery.

Are there other specialists I need to see for my ENT treatment?
In some cases, an ENT specialist may diagnose your problem, but ultimately send you to another specialist for treatment. For example, many ENT doctors will diagnose cancer of the head and neck. They may surgically remove tumours and then send you to an oncologist for radiation or chemotherapy. Likewise, some children with chronic ear infections may have delayed speech development. In these cases, the ENT specialist and a speech pathologist may work together, as a team, to treat the child. Your ENT doctor can assist you in seeking out other medical specialists.
Of course, prevention is the best treatment for any disease, but if you find yourself battling an ENT disorder, remember that information is powerful. Make sure you find a physician who lets you become involved in the treatment of your own disorder. You are your best advocate.

Report compiled by Adebayo Folorunsho-Francis with additional from American College of Allergy, Asthma and Immunology; National Heart, Lung and Blood Institute and National Institute on Deafness and Other Communication Disorders