A common source of the infection is increased moisture trapped in the ear canal, from baths, showers, swimming, or moist environments. When water is trapped in the ear canal, bacteria that normally inhabit the skin and ear canal multiply, causing infection of the ear canal. Swimmers ear needs to be treated to reduce pain and eliminate any effect it may have on your hearing, as well as to prevent the spread of infection.
Other factors that may contribute to swimmers ear include:
- Contact with excessive bacteria that may be present in hot tubs or polluted water
- Excessive cleaning of the ear canal with cotton swabs or anything else
- Contact with certain chemicals such as hair spray or hair dye (Avoid this by placing cotton balls in your ears when using these products.)
- Damage to the skin of the ear canal following water irrigation to remove wax
- A cut in the skin of the ear canal
- Other skin conditions affecting the ear canal, such as eczema or seborrhea
HOW IS SWIMMERS EAR TREATED?
Treatment for the early stages of swimmers ear includes careful cleaning of the ear canal and use of eardrops that inhibit bacterial or fungal growth and reduce inflammation. Mildly acidic solutions containing boric or acetic acid are effective for early infections.
HOW SHOULD EAR DROPS BE APPLIED?
- Drops are more easily administered if done by someone other than the patient.
- The patient should lie down with the affected ear facing upwards.
- Drops should be placed in the ear until the ear is full.
- After drops are administered, the patient should remain lying down for a few minutes so the drops can be absorbed.
TIPS FOR PREVENTION
- A dry ear is unlikely to become infected, so it is important to keep the ears free of moisture during swimming or bathing.
- Use ear plugs when swimming
- Use a dry towel or hair dryer to dry your ears
- Have your ears cleaned periodically by an otolaryngologist if you have itchy, flaky or scaly ears, or extensive earwax
- Dont use cotton swabs to remove ear wax. They may pack ear wax and dirt deeper into the ear canal, remove the layer of earwax that protects your ear, and irritate the thin skin of the ear canal. This creates an ideal environment for infection.
Article credit: entnet.org
As we're nearing the end of the summer season, many have wondered about what to do for swimmer's ear.
Most people (kids included) can swim safely, regardless of the type of water, and the ears are going to be fine. In other words, with normal anatomy and natural ear wax, swimming should not create a problem.
However, some people seem to get "swimmer's ear". Now, the term is colloquial for "acute otitis externa", which is an infection of the outer ear. This part of the body naturally has several bacteria and fungi in it. What happens is that the balance can become upset by introducing water into the ear.
The easiest way to restore the balance without much expense is to use a balance of isopropyl alcohol and distilled white vinegar in a 50-50 mix, adding drops into the ear canal with a syringe. The exact percentage of isopropyl, the exact vinegar, and the syringe versus dropper are debatable, but in general this can alleviate most infections before they become severe.
This is not direct medical advice: if you or your loved one have an allergy to vinegar or alcohol, have had ear surgery, have Bell's palsy, have a hole in the ear drum, or any other medical conditions then you should come in for an appointment right away.
Also, this is not to be thought of as something to do for every day maintenance. Again, the ears naturally take care of themselves, and wax has antibiotic and antifungal properties built in.
This blog post idea started with a question of "How about swimmer's ear and how to avoid? My kids get it the same time every summer. And what about trying to make your teen wear ear plugs, impossible!"
It's true: I was looking through some e-prescribing history, and there are some patients who get a script on or around the same day every year!
It seems there are two possible scenarios: to use ear plugs as a method of controlling the water from getting in, or treating with the aforementioned concoction after exposure, especially during that "same time every summer".
I like these plugs:
And I am not a huge fan of the silcone self-forming ones, since they seem to irritate, can get caught deep, and for kids who have "ear tubes", I have seen them pull the ear tubes out while removing the silicone!
Some people like the ear bands, like these
The pain of swimmer ear can be intense, for certain. One may use the pain medicine that you know will help your child or youself , meaning over the counter medicines.
Now, about how to make a teenager wear plugs?
Take away his or her allowance? I kid: if they get infections, remind them of the pain of getting them if they don't use the plugs.
As most of you know, never use cotton tipped applicators in the ears (e.g. "Q-tips"). Also, if the "ear hole" (the external auditory canal) is too swollen to get any medicine in, they should be brought in for an ear wick and they look like this when inserted
When it come to treating with medical ear drops, there are a few good options. Sometimes, people are allergic to the ear drops they are prescribed, so if that happens, please come in for an appointment as well. A common thing we see a lot, is that there is a chuild who had swimmer's ear, went to an urgent care center in East Jubip, Anystate and was given an ear drop. The ear gets worse. This is a red flag, of course! That patient needs to be examined, so come in for an appointment.
"Surfer's ear" is a condition that is not painful and usually presents in adulthood. The theory is that chronic cold water exposure in youth stimulates the ear canal to make little bony growths in the canal. In these, it only presents a problem by either catching wax up on the bumps, or by blocking the soundwaves from getting to the ear drum and deeper.
Diabetics with swimmer's ear need to be VERY cautious. Diabetics and some others are people most likely to be at risk for "malignant otitis externa". The term malignant is usually reserved to mean cancer, and in this case it is not used to denote cancer, but rather a very severe and life-threatening problem where the infection spreads deep into the skull base and creates serious morbidity and rarely, mortality.
SINUS RINSE: How, why, and who
Many people enjoy using the sinus rinse. And many people ask about the "correct way". There might be more than one correct way, but we recommend......
This one in particular. The reason, is because it is easier to use!
Is named "the Neti Pot", but the reason why I don't recommend it in particular is that it is simply more challenging.
Now, the biggest turn-offs have to do with the following:
A) Putting anything in your nose (grandma said not to!)
B) The burning sensation for novices (this usually goes away)
C) The [false] idea that the fluid MUST go from one side to the other
D) The possible gagging sensation.
Indeed, it is true that one should NOT put anything in their nose without consulting a physician first. Maybe nasal saline spray is an exception to that "rule".
But, many find that sinus rinse can help them breathe better, and those who work in dusty, moldy, or otherwise hostile environments find that "nasal douche" cleans out the nose best.
However, there is an important caveat: a well designed study has shown that those who use the rinse every day or multiple times per day experienced a 62% DECREASE in sinus infections when they stopped doing this.
In other words, the sinus rinse can cause sinus infections! We believe that the reason why is due to either:
A) Changes in the cilia (little hair) function
B) Sterility of the solution or bottle
C) Expulsion of [needed] mucous "blanket" in the nose
D) other unknown factors
So, WHEN SHOULD YOU DO THE SINUS RINSE?
We believe that the rinse can be done for a cold, or after heavy dust exposure, and definitely after Nasal Surgery
Use Distilled water (option is tap water then cooled to lukewarm..test it first!0
Fill bottle to dotted line (250 mL)
Add at least one if not two packets of premade salt/soda combo
Homemade option is kosher or packing salt, NEVER table salt with balanced portion baking soda)
I like to put it in microwave for 10 seconds....but that's because I think the nose "prefers" lukewarm or body temperature liquid. Again, CHECK the temperature on your wrist like a baby bottle
Now, here's where it gets interesting....I tell people to rinse in the shower! Go for a deep 80-90 degree bow like so...
This is for three reasons....and depends on leg strength:
A) Effluent (what comes out) can exit via one, the other, or both nostrils
B) Effluent is very unlikely to make you gag and go into the throat, since your torso is horizontal
C) Effluent won't wind up on your bath counter or floor!
So, if that is not possible, then try to do it as deep as you can while being safe from fall, but the downside is that it might get into the back of the nose and down into the throat.
In the end, high volume - low pressure (HVLP) rinsing is what we recommend. The opposite (low volume - high pressure (LVHP) is discouraged. Here is one study as to that topic: http://www.ncbi.nlm.nih.gov/pubmed/23714166
NASAL SURGERY NOTES
We consider nasal surgery mostly for those who have both symptoms and signs of problems in the nose.
Other than "balloon sinuplasty", the surgery we perform is done under general anesthesia at Columbia Memorial Hospital in the city of Hudson, New York.
- Before Surgery
Before surgery, there will be a consultation and sometimes two, with discussions about the plan and the anatomical considerations. Many require nasal imaging (ie "CAT scans") and as a courtesy to you, hudsonENT staff will obtain prior-authorization from insurance. If needed, you can tour the hospital.
Medicines prescribed will be used only after surgery (unless discussed), but can be picked up the evening before surgery. Not everyone needs medicine, and the exact regimen is tailored by me for you.
Do not take blood thinners for ten to fourteen days (10-14) before your surgery date.
These pages are helpful to determine what a blood thinner is.....
- The Day of Surgery
You will register at the hospital ground floor, then come up to the third floor. Ambulatory nursing will ask you questions about your health, robe you and obtain IV access (ie "put an IV in").
You will see me, the anesthesiologist, and other staff. Your family member or friend can be with you all the way to the "preop holding area". Thereafter, you'll be escorted into the operating room (OR).
In the OR, myself, the anesthesiologist, the surgical technician and the circulating nurse will be there during the entire procedure. The first step will be to situate you comfortably; then give medicine through the IV; then through the breathing tube. WHile that happens, I will be working through your nostril to correct the issue for which you are there. Be it straightening the septum or opening the sinuses, it is done through the nostrils.
SInce the surgery is done through the nostrils, scars, "black eyes", and changes in the shape of the nose are not intended. In fact, these would be very rare unless I have discussed this with you before-hand.
The exact steps in surgery are beyond this blog, and can be discussed with me should there be interest.
After you wake up [from anesthesia], you will be in the "PACU" (post-anesthesia care unit, aka recovery room) for an hour or so. There will be a bandage on the nose. You might have some ice chips here. When the anesthesia personnel and nurses find you to be ready, you'll leave the PACU for the ambulatory bed you started at earlier in the morning, have some food and drink, then be allowed to go home if you and the ambulatory nurses feel ready.
Nasal saline spray will be required starting in PACU, given each 15 minutes, and continued until discharge. At home, use the nasal saline as often as you can, maybe not more than once per 30 minutes but not less than once every two hours.
- After Surgery: first week, before first "post-op" visit
At home, you can eat and drink whatever you would like. You may bathe. In the shower, resist the urge to bow the nose!
-You should not blow your nose at all until you see me again
-You should not take blood thinners
-You should not lift anything more than ten pounds (10#), including children, TV sets, trays of baked ziti and such.
You can take acetaminophen (Tylenol) for pain, or the stronger medicine I have prescribed. If you are constipated, do not force yourself, but take 100 mg of colace (stool softener). Bearing down (aka Valsalva maneuver) leads to markedly increased nasal pressure, and could create a nasal hemorrage.
The top two front teeth and/or roof of the mouth might be numb or tingling. This is normal and should resolve over time.
Expect nasal bleeding.
It should be light, but present. If you have none, that is alright, but since I do not use nasal packing, you should expect a small trickle. You will notice more when you go up to change the channel, grab a snack, or go to the bathroom. If you have a serious, profuse, dark red nasal bleeding please call the office right away, call 911, or proceed directly to the nearest emergency room.
For those inclined to take "alternative medicine", Arnica montana is acceptable in it's sublingual form before and after surgery.
You should not leave the general Hudson Valley area without discussing with the office [before surgery] until further notice, but typically for the first two weeks after surgery.
The nasal saline spray should be continued. No other things shall be placed into the nose without our consent. In other words, do NOT do sinus rinse, nasal medicine spray, pepper spray, or use a finger in the nose.
The nose will be more clogged after surgery than it was before. This is normal, expected, and temporary. You might want to sleep on a recliner (e.g. LazyBoy), or use pillows. A humidifier in the room on the night stand next to your head could help keep moisture.
- First Postop: Day 8 (POD 8) or 11 (POD 11)
When you come to Hudson to have your first postop, the nose will be sprayed with the decongestant you had before and you will have something called "nasal endoscopy with debridement".
This is critical for many reasons:
1. The debris, mucus and clots are removed
2. The status of the surgery is seen
3. Any early problems with healing can be addressed and usually corrected right then and there
4. You will have relief of breathing
5. Usually, you will be relieved of peri-operative restrictions.
Sometimes, implants (but not packing) are placed in the nose. These, sutures and such may be removed at this visit. It will be gentle, through your nostrils, and effective. You can drive yourself to and from this appointment.
Missing this appointment can yield bad results. This appointment and it's timing are ESSENTIAL.
This next phase (after POD 8) is when the nasal saline bottle spray can be changed to as needed, and the sinus rinse will begin. We would like you to start the rinse that night (Friday night), then continue it twice a day.
The rinse is best done with your torso horizontal to the ground, which usualluy needs a shower so that your other floors don't get soiled. We will give you the rinse bottle, and you will get distilled water and packets. Use it twice daily for the first two weeks after this visit, then once daily during weeks 3 and 4.
We usually tell patients, "you might see any color of the rainbow come out with the rinse", and then some.....including black or brown mucus. THis is normal. If this discoloration comes out without rinse, with fever, with pain, or something else not discussed, please notify the office right away, Sinus infections can happen after sinus surgery, especially in the first month or two as the nose is healing.
You also might see portions of clear lattice (if implant used), little blue things that look like the number one (1), and or sutures. These can be expected, but again, if they are not seen that is acceptable as well. Whatever surgical new-age equipment was used (eg implants, sutures, surgical fasteners), they are absorbable and "well-tolerated".
If nasal medicine is needed (e.g. fluticasone), it will be recommended at this time and should be sprayed in the nose about 15 monutes after the rinse, either morning or not but not usually both.
- Second Postoperative Visit
About a month after the first visit, and 5 weeks or so after the surgery, you willm be seen again. Often, this visit is a check with the nasal endoscope (which interestingly is labeled surgery by your insurance but is not really surgery) and sometimes a debridement takes place here too. As above, this means removing clots or debris.
After this, sinus rinses are recommended on an as-needed basis.
After this visit, and depending on how you are doing, Dr Kortbus will see you one, three or six months therafter. If any concerns arise in that period, please don't hesitate to call.
When done in experienced hands, nasal surgery is meant to increase the quality of life. Breathing typically is improved after some healing period. Nasal surgery is not a cure for the common cold or for allergies, but nasal surgery should decrease the quantity and quality of nasal and sinus problems.
(c.f. Int Forum Allergy Rhinol. 2014 Oct;4(10):823-7. doi: 10.1002/alr.21366. Epub 2014 Sep 11.)
The Care of the Tonsillectomy Patient
This post is one of the reasons why I decided to even start writing blogs: this exact information can be very helpful when trying to recover from tonsillectomy. For the most part, I (Dr. Kortbus) will write it to "you", the person who just had tonsillectomy. Of course, if this blog is being read by a parent or caregiver for their loved one, "you" is the patient being cared for!
- Before Surgery
Taking blood thinners is discouraged for ten days prior to (before) surgery. Also, they should not be used for 14 days after surgery unless cleared with hudsonENT.
Here are two good lists of "things that thin the blood"
Please remember, herbs and supplements and such can thin the blood JUST like "medicine" can! This is why it can be critical for you to let medical providers know what you take (both medicine and other "things you put in your mouth").
Also, before surgery, be prepared and be sure to have acetaminophen (unless allergic), a working thermometer (ear preferred over mouth for site of temperature taking), and plenty of icy foods available. Cool water, sorbet, "Italian ices", cool refrigerated beverages are all recommended. If you only want a milk shake, then go ahead and have it. It would be better to have something and stay hydrated than to avoid the milk shake due to fear of phlegm.
You might have heard about promising children ice cream after tonsillectomy: the interesting part was that the children sometimes would rather not swallow and avoid the ice cream than have their treat. This sheds some light on how sore the throat can be after surgery. In addition, my nursing colleagues might suggest refraining from milk based products for several reasons (phlegm, cough, stomach irritation, and the like). But again, it would be better to have something and stay hydrated than to avoid the iced cream due to concern about phlegm.
In general, starting two weeks before surgery, think about everything you are putting into your mouth. Sometimes, we don't really think about what certain foods and drinks can do to the body.
- The Day of surgery
You will come to the hospital some time before, have a series of intake questions and vital signs while discussing this with the hospital "ambulatory" nurse, and "have an IV" started. Children under 8 years old or so might not have this before surgery. You will see the surgeon and anesthesiologist as well, who will answer and address concerns. After reading this blog, you might not have any!
After tonsillectomy, expect pain. Unfortunately, it does not matter who performs the tonsillectomy or how it is done, pain after tonsillectomy is a fact. Now, articles are written comparing one method to another, but suffice it to say, pain will be present after tonsillectomy. It is a rare person indeed who has absolutely no pain at all after tonsillectomy.
For adults, I usually prescribe a strong narcotic. The other over the counter option is acetaminophen (aka Tylenol), but not NSAIDS (eg Motrin, ibuprofen, Advil, Midol, etc) nor acetylsalicylic acid (aka Aspirin) since these thin the blood. Again, motrin, ibuprofen, and aspirin should NOT BE USED. Some ENT surgeons find NSAIDs acceptable, but I believe it is not. Please do not use them.
If the narcotic is not effective, give it time. Do not take more narcotic, as it can dangerously lower the breathing rate and depth. If either of these medicines (tylenol, narcotic) do not work, you are strongly encouraged to go to the nearest emergency room to "have an IV", at which time further medicine and hydration can be used.
For children, there is a serious risk of giving narcotics, so these are NO LONGER PRESCRIBED for tonsillectomy. The United States Food and Drug Administration (FDA) has warned about the use of codeine (in particular) after tonsillectomy:
On the bright side, it is extremely rare to have pain after the healing period, which is about three (3) weeks time. In other words, this time of pain comes to an end.
Interestingly, a number of patients do very well for the first five days or so, then "out of the blue" have intense pain on post-operative day (POD) 5...which in your case will be Tuesday. This is considered normal as well, and does not typically signify that something is going wrong. This has to do with the way the inflammatory cycle in the body works. If it is accompanied by fever or pus, then please call the office.
The first thing to do to avoid bleeding is to follow the instructions of this blog, and most importantly to avoid blood-thinning products.
The next is to watch what you eat. People chuckle, but I always say "no pizza, no bagels, no chips"! And sometimes I am asked why.....because, of those patients I have cared for who have had bleeding, these are the things that were being eaten when the bleeding started. The issue could be the larger bolus of food taken with these foods, the sharp edges of the processed carbohydrates, or the chemical "acidity". At any rate, not partaking of these three "classes" of foods has served well: the rate of bleeding after tonsillectomy if these three are avoided approaches ZERO.
That means, if you don't eat pizza (even if you only eat the cheese!), any bagel part, or "chips", you will probably not experience this serious and sometimes life-threatening complication of surgery. By the way, chips mean pretty much the bagged or boxed stuff in the middle of the market (eg potato chips, cheesy poofs, tortillas, nachos, etc).
In the first few days, stick with cool or lukewarm (ie room temperature) food and drink. I would not recommend hot beverages, hot soup, or food that is still hot from cooking.
- Nausea and vomiting
Nausea and vomiting from anesthesia (which is general, meaning intubation) can be seen, and is usually "self-limited". This means that it goes away on it's own over time. That time is usually a day and rarely two days. If it lasts longer, call the hospital anesthesia department for recommendations.
The act of removing the tonsils (tonsillectomy) tends to briefly increase the temperature. Oftentimes, this is not usually due to infection but rather due to temporary immune sytem effects. Temperature below / less than 101.7 degrees Fahrenheit is usually NOT AN INFECTION. There have been concerns about the patient that "usually has a temperature of 96, so 100 is a fever". Again, that is usually a result of the act of having tonsils removed, and not usually infection. When in doubt, it is best to call the pediatrician or urgent care, or the office for details.
This "hyperpyrexia" can be treated with acceptable acetaminophen (Tylenol). However, if the temperature does not go down after giving this medicine, or if it comes back only a short time later, then definitely seek out medical attention.
Infection after tonsillectomy is rare. Antibiotics used to be prescribed, but they did not change this unlikely scenario [of post-operative infection] and are not currently encrouraged on any routine basis.
The tonsil bed (where the tonsils used to be) always looks yellow to white, maybe with black spots, and a "chunkiness". This is usually NOT THRUSH or fungus. This is "fibrinous exudate", the normal healing process for musous membrane healing. Thrush and fungus are nearly never seen after tonsillectomy. See the images below:
There are lists of potential complications that have been written about [ever in the history of mankind]. Other than pain and bleeding, these are exceedingly rare. They include dental trauma (ie chipped tooth), numb tongue, and such.
- Post-operative doctor visit
You are encouraged to see other medical providers for routine care. Children especially can get colds and such frequently, and these are best managed by the pediatrician and not the ENT surgeon. Of course, you are encouraged to call the office any time but the mangement of viruses and common ailments is best made by those who are more familiar with "what is passing through" the community. That would be the primary care, emergent care, urgent care, or pediatric care providers!
Due to most insurance regulations, the surgeon requires a visit after ninety (90) days of healing. Please do follow-up after that time, so we can check on how the mucous membrane is healing, and to see if there are any other concerns.
Thanks for reading! Please stay tuned, let me know what topics you'd like via email (firstname.lastname@example.org) or the comments section below, and give me feed back!
Thanks for your time and Thanks for letting me help you today!
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