tinnitus

Tinnitus is abnormal perception of sound in the ears. Tinnitus is taken from the Latin word tinnier meaning ring. About 10% of world population complains of this symptom. This can be of long or short duration, subjective or objection type, or continuous/ intermittent/ pulsatile in character.
To evaluate a proper history of onset of the complain is taken, thorough examination of the patient has to be done, audiological and radiological investigation is advised, blood examination to rule out any infections.
Treatment is to first treat the cause if a etiology is found. If no cause can be elicited then reassurance is given that it is not a life threating disease and a proper diet modification, avoidance of smoking/ caffeine products and measures to cope with the problem like listening to light music is advised.

Tinnitus

Tinnitus is abnormal perception of sound in the ears. Tinnitus is taken from the Latin word tinnier meaning ring. About 10% of world population complains of this symptom. This can be of long or short duration, subjective or objection type, or continuous/ intermittent/ pulsatile in character.
To evaluate a proper history of onset of the complain is taken, thorough examination of the patient has to be done, audiological and radiological investigation is advised, blood examination to rule out any infections.
Treatment is to first treat the cause if a etiology is found. If no cause can be elicited then reassurance is given that it is not a life threating disease and a proper diet modification, avoidance of smoking/ caffeine products and measures to cope with the problem like listening to light music is advised.

Upper Respiratory Tract Infection

Serous Otitis Media (SOM)

Its a condition where in there is collection of fluid in middle ear (tympanic cavity) either due to impairment in drainage of normal secretion of fluid in middle ear or due to excess secretion. Presents with symptoms(complains) of impaired hearing, tinnitus(abnormal sounds in ear), earache. This condition can be treated by conservative method by giving decongestants either oral or locally acting nasal drops, to treat the infections by giving antibiotics to decrease the secretions. If this fails then surgical drainage by myringotomy in the poster inferior quadrant of tympanic membrane to be done. Beer can principle is used to help in better drainage where another incision is made in poster superior quadrant so that air enters middle ear through this hole and helps in faster and better drainage. Grommet can be inserted for long term treatment.

Pathological Effects of Adenoids

Pathological effects of adenoids:
It may be implicated in upper respiratory tract infections due to partial or complete obstruction or as a result of sepsis.Others are rhinosinusitis, rhinitis, otitis media and otitis media with effusion.Adenoiditis is a distinct infective entity.
Otitis media with effusion:
Adenoidectomy in otitis media with effusion is traditionally been ascribed to anatomical obstruction of eustachian tube while this is contributory but cannot account for if adenoid is small in size. Acute or chronic adenoid infection particularly by Haemophilus Influenzae results in squamous cell metaplasia, reticular epithelium extension, fibrosis of interfollicular connective tissue and reduced mucociliary clearance in children with otitis media with effusion compared to those without otitis media with effusion. These changes increase bacterial adherence leading to biofilm infection resulting in middle ear effusion.Biofilm infection may be defined as a structured community of bacterial cells enclosed in a self produced polymeric matrix and adherent to an inert or living surface.
Recurrent acute otitis media:
The trials of the management of recurrent acute otitis media has shown that adenoidectomy not effective in reducing episodes in children below 2 years.It is likely that partial maturational selective IgA deficiency is a causative factor in these otitis prone children. Low dose prophylactic antibiotic treatment is preferred to adenoidectomy in this group to prevent recurrent acute otitis media and its sequelae till maturation of immune system occurs naturally.
Upper airway obstruction and obstructive sleep apnoea:
The prevalence of severe sleep disturbance in children due to upper airway obstruction is estimated at approximately 1%, with peak between 3 to 6 years of age and equal sex incidence.Airway obstruction due to adenoid hypertrophy produce depressed arterial paO2 and paCO2 levels which to normal after adenoidectomy. The respiratory improvement following adenoidectomy also results in a significant increase in serum insulin like growth factor -1 accounting in part for the clinically observed growth spurt following surgery.Studies have shown that adenoidectomy for upper airway obstruction, the radiographic estimate of the adenoid size correlated highly with the improvement in polysomnographic scores following surgery.
Rhinosinusitis:
Chronic sinusitis undergoing adenoidectomy or Adenotonsillectomy improvement was reported in the majority following surgery. Very few required FESS.
Olfaction:
Olfactory sensitivity is reduced in relation to adenoid size and this improves post surgery. This may in part account for the poor appetite reported in children with adenoid hypertrophy.Neoplasia:Unsuspected neoplasia of the adenoid in childhood is rare. Atypical lymphadenopathy and persistent and asymmetric enlargement of the tonsils and adenoid in the absence of infection are suspicious and should prompt early imaging and biopsy.
Etiology:
Common in childrenPhysiologicalUpper respiratory tract infectionsLow socio-economic statusEnvironments like crowding, pollutionCommon cultured bacteria is H.Influenza, group A Beta haemolytic streptococci, staphylococcous aureus, Moraxella catarrhalis, Streptococcus pneumoniae.
Clinical features:
Nasal: Nasal obstructionDischargePostnasal dischargeSleep apnoeaHyponasal speechEpistaxis rarelyAural symptoms:Recurrent otalgia, deafness, ear discharge due to acute otitis media/ secretory otitis media/ chronic suppurative otitis media.
Throat symptoms:Recurrent pharyngitis/ tonsillitis/ mouth breathingGeneral features:Mental dullness, nocturnal enuresis, night terrors
Adenoid facies:Long standing mouth breathing/ nasal block lead to following-Pinched nose/ mouth breathing/ saliva dribbling/ flat nasal arch/ malar hypoplasia/ elongated face/ dull idiotic appearance/ loss of nasolabial fold/ short protruding upper lip/ crowding of teeth/ high arched palate/ deafness-inattentive child.
General features:
Recurrent lower respiratory tract infection, frequent diarrhea, low nutritional status, pigeon chest, protuberant abdomen, enuresis
Treatment:
Control infection with proper antibioticsAntihistamines/ decongestantsSteroid spray to be triedImprove nutritional statusBreathing exercisesAdenoidectomyMyringotomy
References:
1) Zhang AF et al , Department of Otorhinolaryngology and Head Neck, Dalian Municipal Central Hospital, Dilian, China
2) Berlucchi M et al, Department of Paediatric Otorhinolaryngology, Piazzo Spedali Civili, Brescia, Italy
3) Michael Gleeson, Ray Clarke et al, Scott-Brown Otorhinolaryngology and Head Neck Surgery, 7th edition, vol 1
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Enlarged Adenoids

Adenoids

Adenoids which is also called as pharyngeal tonsils or nasopharyngeal tonsils are a mass of lymphoid tissue situated at the very back of the nose, in the roof of the nasopharynx, where the nose blends into the mouth.

Santorini described it as Lushka’s tonsil. Wilhelm Meyer coined the term adenoid. In early childhood this is the first site of immunological contact for inhaled antigens though historically it is the site of focus of infection and more recently cause for persistence of otitis media with effusion.

Adenoids appear 4-6 weeks of gestation at the junction of roof and posterior wall of nasopharynx. Extends to fossa of rossenmuller and to eustachian tube orifice as Gerlich’s tonsil. By five years of age adenoid could be identified. Growth continues rapidly during infancy and plateaus between 2 and 14 years of age. Regression of adenoid occurs rapidly after 15 years of age in most children, but it is largest at 7 years of age. However clinical symptoms are more common in a younger age group due to the relative small volume of nasopharynx and increased frequency of upper respiratory tract infections.