Common ENT Problem – Hoarseness

If you think about what a wonderful device the human voices, it is simply amazing! From the beginning of our lives when we come into this world screaming to the last words we say we are always using it. Some fortunate people have even created art with their voice. But what exactly happens when we are having difficulty with her voice? Today we’re going to take a look at the voice, and hoarseness.


I know of a few other organs in the body with his much odd nomenclature as the human voice box. Take for instance the anatomical term is – the larynx. This is more commonly known as the voice box. It is the area that plays a crucial role in our speech, and breathing. It also helps to separate the air that we breathe, from the food that we eat. The voice portion, larynx, is separated into an upper portion (supraglottis) a middle portion (glottis) and a lower portion (subglottis).  The actual voice is created from the middle portion. Within the larynx specialized muscles come together in a, “V” shape and vibrate together. This rhythmic movement created during inhalation and exhalation is what creates our voice. The characteristic narrowing and opening of this aperture in combination with muscular tension produces different pitches of the sounds that we hear. Some of you ever wondered why you go hoarse?

Hoarseness can come from a whole host of different reasons. For instance, if you’ve had an upper respiratory tract infection such as a sinus infection or cold the type of mucus that your sinuses generate changes. With this change comes a difference in the mucus is ability to lubricate the voice box. This will cause your voice to crack, go hoarse, and sometimes your voice will completely go away. Because mucus plays such an important role to the voice box I like to think of it as the oil that lubricates the engine of our voice. Certainly other factors can affect the voice as well through the same mechanism. Allergies, are another example that changes the mucus for the worse and can alter the voice.

Vocal abuse is another way in which we can create hoarseness. Who among us has not been to a concert and yelled overly loud only to find out the next morning that you could not speak at all. This type of mechanism is really more like muscular overload, and secondary swelling. The vocal cords, which are very tiny, have been stressed over their limit and if you could see them with a microscope you would see that there is significant swelling and inflammation of the vocal cords and because of that the very fine contact points that allow you to generate your unique pitch have been damaged. Hopefully, for most individuals, it is only a temporary problem and will heal over time. Unfortunately, some individuals repeatedly do this type of damage to the vocal cords causing more permanent changes. Changes such as singers nodules, or vocal cord polyps, can occur over time and permanently change the lighting of the voice box.

The final group of individuals who have are the ones that are very concerning. These are individuals who, in many cases, have smoked and created chronic irritation of their voice box. Of course, most people are familiar with the deepening pitch of the voice box, as a person accumulates years of smoking. Unfortunately, the deepening pitch is not the only thing that changes with the voice box. The repeated damage caused by smoke can cause cancerous changes to the voice box. These changes very frequently alter the frequency of the voice, or sometimes remove it altogether. This is very concerning and needs to be looked at by a specialist. This is a condition that can be treated in many cases, if caught early enough.

So, when you find yourself alone today go ahead and sing out, and enjoy your voice. It is a most amazing instrument of our being. Think about your voice, and all that it does for you. Perhaps you are the most gifted singer (I know I am not) but your voice is still, your voice.

Stay Healthy!



Ear problems in Adults

Most people are familiar with ear infections in children. That nagging high fever, fussiness, and trouble sleeping that cause children and their parents misery.  But adults get ear problems too!  Very frequently people will come in to see me with either muffled hearing, pain in the ear, or a failure of the ear to clear with pressure, and be surprised that they are having ear issues as an adult. Ear problems are not limited to babies and school-age children. They can be a significant source of problems for many adults as well.

First thing to be aware of is the anatomy of the inner ear and how the ear works. The outer ear, and the canal itself funnel sound to the eardrum in order to provide the maximum amount of sound energy to the eardrum. At the level of the eardrum sound energy is converted to mechanical energy by striking the drum itself and causing the bones (Hammer, Anvil, and Stirrup) to vibrate. At the end of the Stirrup the mechanical energy is transferred to a fluid medium inside the cochlea. Once inside the cochlea, like a wave in a swimming pool, the wave proceeds through the cochlea bouncing off the walls stimulating the nerve of the inner ear. This creates a small electrical change which is transmitted from the cochlea through the nerve of hearing to the brain and we are able to perceive sound!!!

Ear infections can cause damage in multiple different areas of the hearing mechanism allowing us to have continued and repeated infections, as well as decreased hearing. For instance, the following areas can be damaged if you have had infections to them:

  • Eardrum
  • Middle ear cavity
  • Eustachian tube opening
  • Mastoid cavity
  • Ossicles (bones of hearing)

Most commonly in our area of northern Nevada we have issues with individuals who have problems in the middle ear, and eustachian tube. This can be created from prior ear infections as a child, or it can be created with allergy issues that cause swelling and inflammation. You must remember that the clearances inside the middle ear cavity are extremely small. For most patients the opening of the eustachian tube if a hundredth of a millimeter and is normal. The tolerances are so exceedingly small that it is not uncommon for a person with a normal ear to have transient difficulty. When you combine this with the large amount of altitude change in northern Nevada it is easy to understand how elevation changes, as well as allergies will only serve to cause the system to malfunction.

Quite frequently patients are surprised that they are having ear issues. But as I try to explain to them the pollens and other allergens combined with the drastic altitude changes causing ensuing barometric pressure changes are a unique attribute of our high desert lifestyle.

Generally, treatment strategies are directed at trying to reduce the inflammation and swelling and provide better airflow through the middle ear cavity and mastoid system. This can be accomplished by using antihistamines such as Allegra, Claritin, and Zyrtec. And it can be augmented by using nasal sprays such as Flonase, and Nasacort. All of these medications work in conjunction to reduce swelling, and alleviate the blockage of flow that is encountered. If you are having difficulties like this please mention it to your primary care provider and they will be able to help you.

Stay Healthy


Nose and sinus issues….

Over the last several weeks we’ve been having issues with air quality because of the large amount of smoke going into the Truckee Meadows area. Because of this, many patients are calling in with issues regarding head congestion and sinus congestion. I thought that I would talk a little bit today about the issues surrounding this problem that seems to affect many people in northern Nevada.

The way I like to think about nose and sinus problems, is that it boils down to a problem with space. There needs to be enough space for air to flow through your nose so you can breathe, and there needs to be enough space so that air can get in and out of the sinuses. When one or both of these are not met, we start having problems.

The anatomy of the nose and sinus is relatively simple. There is a passage from the front of her nose to the back separated by a wall (septum) that we breathe through. Inside the nasal passage, there are multiple small openings leading to different families of sinuses. We have sinuses in the forhead (frontal), between the eyes (ethmoid), in the cheeks (maxillary), and at the base of the skull (sphenoid).

Generally speaking, there are a few things that can decrease the space. You can have swelling inside the lining of the nose that can decrease airflow through it (allergies, or inflammation secondary to infection, or polyps). You can also have anatomical blockages that slow airflow through the nose decreasing space (deviated septum).  Because the blockage inside the nasal cavity can get large enough it can impact the sinuses. Once that occurs you begin to have symptoms not only from the nose, but the sinuses as well.

In most instances patients will experience something such as an allergy to pollen’s, dust, or animal dander and that will cause a generalize swelling inside the nasal cavity. In most patients they can take antihistamines over-the-counter, or even some nasal sprays (Flonase) that have been made over the counter to help reduce the swelling, or inflammation in order to breathe better. This is why certain medications that include Sudafed, a very potent vasoconstrictor are helpful for many patients. That particular class of drug will cause the tissue lining to shrink in provide more passage of airflow through the nose. Unfortunately, that same classification of drug can cause problems for people who have high blood pressure.

Still some patients try the over-the-counter remedies with the antihistamines, decongestants, and nasal sprays but they do not find any relief. In those patients we need to begin an investigation to figure out exactly why the nose is either not breathing correctly or the sinuses are not draining correctly. What we are seeking to find out is what is occupying the space. So the first thing that we will do as a nose doctor, is to ask you about your symptoms, examine the inside of the nasal cavity, and potentially take some images of the anatomy so that we can have a roadmap of where the problem may be.

If you are having problems with your nose and sinuses and do not feel as though it is getting better with your over-the-counter medications, you need to mention this to your primary care provider, or seek help from an ENT physician. Although it does not sound medically serious, it significantly impacts your quality of life if you are unable to use your nose!


Stay Healthy!


Ear wax issues…..

Not infrequently patients complain of hearing loss which can either be gradual or sudden in nature. Occasionally, this hearing loss can be created by ear wax. The technical name for this is a cerumen impaction, and almost everybody has some issues with it throughout their lifetime. What many people do not know is that the ear is a self-cleaning organ. The ear itself creates oils and waxes which line the ear canal helping to keep bacteria in check in creating a perfect ecosystem within the ear canal itself. Sometimes however this ecosystem can be upset and things can start to go awry. This is predominantly an issue when we start putting things in our ear to clean it.   So for those of you who are wondering how to keep your ears clean read on…

Many options are available to clean ear wax out of the canal. The conservative approach is to avoid using cotton-tipped applicators such as Q-tips for routine cleaning. The normal ear canal skin will flake off in such a way that the ear canal skin and wax is pushed gently to the outside of the ear. Using such devices as a Q-tip you actually impact the debris and interfere with the, “conveyor belt like activity” of the ear causing an impaction.

Some people find it beneficial to use an earwax softening drop that allows you to keep the ear canal skin more supple, thereby lubricating the canal. There are multiple different versions of over-the-counter, commercially available products that you can try. The general division of these is between water-based and oil-based. The water-based ones such as peroxide ear drops tend to have a nice loud fizzy sound. Although they are very popular, and there is nothing wrong with them, I do not think that they do as good a job as the oil-based ones. The oil-based drops (such as olive oil) do a better job of saturating into the ear canal and penetrating the skin to help lubricate the canal and allow the ear to clean itself. This has an additional benefit of preventing itching, which so frequently occurs with earwax issues.

Still sometimes people are unable to get their ears clean and so they must seek attention and that is when they are first introduced to ear canal irrigation, and mechanical wax removal under direct visualization. Ear canal irrigation is generally done at an urgent care or your physician’s office with a warm water irrigation that is directed into the ear canal to mechanically wash out the ear wax. You have to be very careful with this because the tympanic membrane is very thin (actually thinner than a piece of paper) and it can be damaged if it is not done in a gentle way. Additionally, some patients have ear surgery issues that prevent them from having this done.

Mechanical wax removal is typically done with an operating microscope in the office of an ENT physician while the patient is awake. This is done because the microscope allows you to be able to have appropriate depth perception and to use micro instruments in order to remove the waxy material. Suction can also be used, just like a vacuum cleaner to remove the material and get it out of the ear.

When patients come and see me because they’re having recurrent earwax issues, I always recommend that once we get the ear canal cleaned that they should go on a regimen of utilizing something such as olive oil, or Sweet oil if they prefer, once or twice a week. By purchasing a small eyedropper and placing 4 to 6 drops of olive oil in your ear canal once or twice a week you can maintain a healthy environment for your ear. This additional lubrication, will allow the ear to be able to gently move the earwax out of the canal, and has a bonus effect of decreasing the amount of itching that occurs. Seldom do we need more than the simple solution to keep the ear clean and healthy!


Stay Healthy!