Allergic rhinitis

Allergic rhinitis affects about 1/3 of the US population. Morbidity from this disease leads to decreased productivity, lost work/school days, and increasing costs of medical care and treatment. It is an important entity for the practicing otolaryngologist because many of these patients have failed medical management. In order to treat these patients, allergy testing may need to be performed in order to start vaccine immunotherapy.

Inflammation of the membrane lining the nose secondary to hypersensitivity to aeroallergens, characterized by rhinorrhea, sneezing, pruritis, congestion, post nasal drip and associated conjunctival, otologic or pharyngeal inflammation. These symptoms can be episodic, seasonal or perennial. Severity ranges from mild, to seriously debilitating with excess days of missed school or work. Risk factors include family history of atopy, serum IgE > 100 IU/ml before age six, higher socioeconomic class, exposure to aeroallergens, presence of positive allergy skin prick test.

Prick/scratch testing (SPT) is a superficial skin reaction that does not penetrate dermis. It is highly specific, sensitive, convenient and safe. A test is positive if there is a wheal and flare reaction which is greater than or equal to the histamine control.

Intradermal testing (IT) a dilute antigen extract is injected into the dermis, and a superficial wheal forms. After ten minutes, the wheal is measured again to see if there was any progression. If the diameter of the wheal has increased by 2mm or greater, then a positive response has occurred. This causes relatively minimal patient discomfort.

Immunotherapy is a viable option for patients not benefiting from traditional medical management (eg. nasal steroid spray, antihistamine, etc.) that works by altering one’s immunologic response. Adjuvant therapies may be useful to maximize effect of immunotherapy.

Source:
Medical Management of Allergic Rhinitis UTMB Dr. Quinn's online textbook of Otolaryngology [Apr 30, 2009]

Bell's palsy

Bell’s palsy is the most common diagnosis given to patients with acute facial palsy. Despite substantial effort to study its disease process, the management of Bell’s palsy remains controversial.

Although Bell’s palsy is a diagnosis of exclusion, it is the most common diagnosis given for acute facial palsy (> 60%). It causes peripheral facial neuropathy that tends to be unilateral and has a rapid onset. Its incidence is about 30 per 100,000. There is an equal male to female ration and a 3.3 times greater incidence in pregnant females. The left and right sides of the face are equally involved, and less than 1% of cases are bilateral. The recurrence rate is about 10% and can be ipsilateral or bilateral. Patients with diabetes have 4 - 5 times more risk of developing the disease. A family history is positive in about 10% of patients with Bell's palsy.

In 1982, Peitersen et al. published an article on the natural history of Bell’s palsy based on more than a thousand Danish patients. He found that Bell’s palsy occurred in every decade of life, with a mean age of between 40 and 44 years. It was less common before the age of 15 and after the age of 60 years. The prognosis for Bell's palsy is generally good with 85 % of patients recovering completely within one month. The remaining 15% progress to complete degeneration and will not usually show signs of recovery for three to six months. The longer the time needed for recovery, the greater the probability of sequelae. Patients with incomplete paralysis will recover with no sequelae 95% of the time. Based on this study, poor outcome of Bell’s palsy is associated with advanced age, late return of muscular function or beginning of remission, complete palsy, abnormal taste, stapedial reflex, and lacrimation.

Treatment options of Bell’s palsy range from observation, medical treatment, surgical decompression, to facial rehabilitation. The efficacies of oral prednisone and anti-viral agents have been studied extensively, yet there is no consensus among experts on ideal regimen and dosage.

Eye care is of utmost importance in facial nerve paralysis due to the risk of exposure keratitis. Artificial tears and lacrilube ointment should be prescribed. Taping of the eye lids during sleep may be helpful as well as the use of a moisture chamber. Patients should avoid contact lens, fans and dust, and should have eye protection when outside in the wind. Gold weight implant to the upper eyelid should be considered in patients with long-standing facial paralysis.

Source:
Dr. Kevin Ho UTMB Grand Round presentation: "Bell's palsy - to treat or not to treat". Feb 2007

季節性流感

季節性流感的高峰期又到達，家有幼兒的父母自然要提高警惕，保持家居空氣流通，以免病毒積 聚，教導孩子從街上回來後，更要徹底清潔雙手，避免將病毒帶進屋內。更重要是培養孩子的個人衞生習慣，雙手不要經常觸碰口鼻， 家長患有感冒時也要戴上口罩，避免交叉感染。

除 了從生活起居建立預防流感的保護罩，最好也替幼兒安排接受流感疫苗注射，讓孩子體內產生抗體對付流感病毒。九歲以下未曾接受疫苗接受的兒童，於首次注射 時，需要在相隔四個星期後再注射第二劑疫苗，才能發揮保護效果。而即使過往曾經接受疫苗注射，今年仍然再需要接種，因為流感疫苗所產生的免疫力會隨着時間 逐漸下降，經過一年時間疫苗所能發揮的效用已經不足以作出保護，再加上流感病毒會出現抗原漂移（antigenic drift），令病毒的外表出現少許差變，令去年的疫苗失去效用，所以必須每年重新注射。

流 感疫苗安全性甚高，除了對雞蛋及疫苗中成分有過敏的人士以外，任何幼童在徵詢醫生意見後也可以注射，但如果安排注射疫苗當天孩子出現不適或發燒，建議待病 愈後才注射。值得一提的是，季節性流感疫苗對豬流感沒有提供保護作用，反之亦然，兩種疫苗不能互相取代。如果孩子需要同時接種其他疫苗，必須分別注射於不 同位置之上。

Source:

http://the-sun.on.cc/cnt/news/20100127/00410_032.html

Balloon sinuplasty

Millions of Americans suffer from sinusitis each year. Functional endoscopic sinus surgery (FESS) has transformed the field of Rhinology and how we treat sinus disease in the past few decades. The concept of balloon sinuplasty stemmed from the success of similar balloon devices employed in other specialties such as cardiology, urology, GI, and vascular surgery. The idea of mucosal preservation in balloon sinuplasty is appealing for its potential to minimize scarring and re- of dilated sinus stenosisostium. Whether balloon sinuplasty will be as popular as angioplasty remains to be seen, but there is no question this technology has gained significant momentum within our specialty in the past few years.

Balloon sinuplasty provides a new armamentarium for otolaryngologists to treat sinus disease. Based on a series of multi-center prospective trials known as the CLEAR trial, balloon sinuplasty can be safely performed and effectively treat sinus diseases with minimal complications. According to Dr. Raymond Weiss, “sinuplasty is a new technique in performing endoscopic sinus surgery—not a new procedure but rather a new tool that further reduces mucosal damage and advance us toward our ultimate goal of improving function with maximal mucosal preservation”.

It has been recently reported that balloon sinuplasty can be safely and successfully performed under local anesthesia in the BREATHE-1 trial. While it holds great promise for office-based sinus procedures, further study is needed to better define its role in the surgical management of chronic sinusitis especially with regard to patient selection and disease types best suited for this technology.

Source:
Dr. Kevin Ho UTMB Grand Round presentation, from Dr. Quinn's online textbook of Otolaryngology

兒童睡眠窒息症

一般而言，如果小朋友的體重指標（BMI）超過二十五便屬於過胖，若超過三十更被界定為癡肥。肥胖除了增加兒童患上高血脂、脂肪肝、心臟病及糖尿病的風險，原來對耳、鼻、喉健康也有影響。最常見的例子是睡眠窒息症，研究顯示百分之一至三兒童曾經患上此症，患者以二至五歲的兒童為主。患上睡眠窒息症的孩子因為呼吸道收窄，以致睡眠時出現十至 六十次短暫性、每次維時約一分鐘的窒息情況。一般兒童可能由於扁桃腺或增殖腺肥大而令呼吸道收窄，但肥胖兒童除了上呼吸道軟組織較肥大外，他們的胸部及腹 部的脂肪會阻礙胸部擴張的幅度，增加呼吸困難及患上睡眠窒息症的機會，而不少研究指出，沒適當處理睡眠窒息症，會影響孩子的成長、學習、行為及心肺功能 等。

小朋友患上睡眠窒息症，可能會出現下列的影響：

• 專注力下降，難以集中精神
• 長遠會影響智力發展
• 顯著的行為問題
• 尿床

小朋友的身體及腦部都比大人為脆弱，阻塞性睡眠窒息症對他們的影響更為巨大，因此更需要盡早接受正確的診斷及治療。醫生為患病的孩子進行詳細評估後，會按照病情給予適當的治療，包括：

• 先治療及控制已知的鼻病；
• 控制體重；
• 手術治療 (增殖腺, 扁桃腺切除術)。

Source
http://the-sun.on.cc/channels/news/20090316/20090316021640_0000.html

弱聽年輕化

「聽」是十分重要的感官功能，令我們「聽」到聲音的聽力系統，由多個部分組成，包括外耳、中耳、內耳、聽覺神經及腦部等，而它們任何一個部分出問題都會影響到聽覺，絕對是缺一也不可。 正常情況下，我們應該可以聽到20分貝以上的聲音，若差於這水平便可界定為聽力受損，亦即弱聽。 導致聽力受損的原因多不勝數，例如耳垢積聚、中耳炎、耳骨硬化、膽脂瘤及年老退化等，都會令聽力變差，而長期身處高噪音的環境亦可損害聽覺。

聽障問題出現年輕化趨勢, 不少年輕人鍾情以iPod、MP3機等「炸機」，不過音量過大當心聽覺提早數十年衰退。澳洲國家聲學實驗室調查發現，六分之一澳洲人面臨聽覺受損威脅，多 達六成十八至三十四歲青年受耳鳴困擾。有六成常用耳機聽音樂的青年表示，需別人大聲呼叫才能吸引其注意。耳鼻喉專科醫生林建業建議，「炸機」要適可而止， 音量只宜調校至最高音量的三至四成。

澳洲國家聲學實驗室指，二十四歲以下青年是繼長者後最高危的聽覺受損族群，估計每六人就有一人聽覺受損，但調查指，當地只有四分之一人知道音樂聲浪過大會損害聽覺，而受耳鳴困擾的國民當中，以十八至三十四歲年輕人的比例最高。

Source:
http://the-sun.on.cc/channels/news/20080828/20080828020453_0000.html

流鼻血

流 鼻 血 的 成 因 大 致 分 為 局 部 性 及 系 統 性 兩 種 。 常 見 的 小 兒 流 鼻 血 是 局 部 性 出 血 ， 多 屬 良 性 。 鼻 中 隔 的 黏 膜 下 層 形 成 網 狀 的 利 特 氏 血 管 叢 帶 （ Little's Area ） ， 是 最 常 見 的 鼻 出 血 部 位 。 小 兒 會 因 鼻 敏 感 或 清 除 鼻 垢 時 ， 不 慎 弄 破 黏 膜 而 流 血 。 若 流 血 次 數 不 頻 密 ， 每 次 約 十 五 分 鐘 已 止 血 ， 家 長 毋 須 過 分 擔 心 。 若 持 續 流 鼻 血 ， 可 向 耳 鼻 喉 專 科 醫 生 求 診 ， 醫 生 會 以 藥 物 醫 治 或 做 簡 單 的 局 部 手 術 如 電 燒 止 血 等 ， 使 薄 膜 變 得 堅 固 ， 減 少 流 鼻 血 的 情 況 。

耳 鼻 喉 科 醫 生 處 理 鼻 出 血 的 建 議 ︰

‧ 勿 驚 慌 ， 安 慰 孩 子 使 安 靜 下 來 。

‧ 讓 孩 子 坐 在 陰 涼 的 地 方 ， 保 持 直 坐 姿 態 ， 頭 微 向 前 傾 。

‧ 用 拇 指 及 食 指 的 第 二 指 節 按 孩 子 的 兩 側 鼻 翼 約 十 分 鐘 。 孩 童 的 鼻 出 血 點 多 位 於 鼻 腔 前 部 靠 近 中 間 的 位 置 ， 一 般 情 況 下 ， 施 壓 於 出 血 的 一 側 可 止 血 。

‧ 冰 敷 鼻 樑 使 血 管 收 縮 以 助 止 血 ， 可 用 冰 袋 或 冰 冷 毛 巾 。

‧ 指 壓 法 可 重 複 施 行 ， 若 出 血 持 續 大 量 、 暈 眩 或 在 三 十 分 鐘 內 未 能 完 全 止 血 ， 便 應 立 即 求 診 。

‧ 止 血 後 ， 應 暫 停 熱 飲 一 小 時 及 劇 烈 活 動 十 二 小 時 ， 以 免 血 管 膨 脹 ， 逼 破 剛 剛 復 修 的 出 血 點 。