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Feeling Foggy? A look at how your inner ear can affect the brain and cognitive thinking.

Several years ago, I developed intermittent bouts of what I would later term brain fog in which I experienced nonlucid moments, similar to waking up after anesthesia.  The first and most memorable of    these occurred while I was driving on I-565 to work one morning.  While not exactly dizzy, I recall feeling so strange that I pulled the car over on the interstate and waited for the spell to pass. After a few minutes, the episode subsided and I went on with my busy day, forgetting about the strange incident.  Months later, similar spells began occurring more frequently, heightening my preexisting hypochondriac tendencies that I had developed from years of reading medical books and watching TV programs about the rarest medical conditions in the world.

The spells would come on suddenly, without warning, and felt like a cloud engulfing my consciousness.  I had a really hard time explaining the symptoms to my family practitioner at the time.  “You know that feeling… where you’re having a dream… and then you start to fall… but then you don’t fall… but the ground is moving… and your thoughts don’t come as crisply or clearly…”  Gosh, I sounded crazy even to myself. I further tried to explain that words sometimes did not come easily, decision making became more difficult, and my concentration span seemed shortened.  After some routine blood work, I was reassured that my symptoms were likely from fatigue with an added dash of anxiety.  But something felt wrong.  The foggy spells progressed and I began experiencing pressure in my head, although the entire myriad of symptoms remained very non-specific.

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Nasal Foreign Bodies

Nasal Foreign BodiesNasal foreign bodies are usually encountered in children. However, occasionally they may occur in adults with mental retardation or psychiatric illness. Foreign bodies may be inorganic material such as plastic or metal. Examples include small parts of toys or even beads. These are sometimes discovered incidentally. Organic foreign bodies include wood, sponge, and food. They tend to irritate the nasal mucosa more and lead to earlier symptoms. Peas, beans, and nuts are among the more common organic foreign bodies. Males are more likely to insert foreign objects into their nose. Nasal foreign bodies including toys, building set pieces, coins, nails, screws, and batteries. In females, they tend to be jewelry and buttons. The average patient age is usually about 3 years.

Bleeding is commonly reported in patients with nasal foreign bodies, although it is not significant in nature. The foreign body itself may cause irritation to the lining, mucosal damage, and sometimes extension into adjacent structures. It can lead to septal perforation and cartilage necrosis. Unilateral foul-smelling nasal drainage in a child is a foreign body unless proved otherwise. A persistent foreign body can lead to sinusitis due to obstruction of the drainage pathways. Button batteries are very destructive and need to be removed within hours if possible to prevent chemical burns, ulceration, and severe damage within the nasal cavities. They cause destruction via low voltage electrical current and severe necrosis if the alkaline contents leak out. Damage can occur within hours and require immediate removal to prevent tissue destruction and complication. Sometimes foreign bodies can be displaced posteriorly and obstruct the nasal airway as well as lead to tracheal aspiration which is a serious situation. Nasal foreign bodies can sometimes be removed in the office in a cooperative patient. If not, the procedure would need to be performed under general anesthesia. Read More→

Hoarseness

HoarsenessTwo bands of muscles constitute the vocal cords. They vibrate to create sound arising from the larynx. Hoarseness can arise from various etiologies. Excessive voice abuse such as talking too much, screaming, or repeated throat clearing can create irritant laryngitis with thickening along the edges of the true vocal cords (callouses of the vocal fold). These may occur on both sides of the vocal cords facing each other and leading to poor approximation of the free edges. The condition may progress to a nodule or polyp. Symptoms of vocal cord lesions include vocal fatigue, low-pitch gravely voice, breathy voice, inability to sing high notes, rough voice quality, frequent throat clearing, and voice breaks. Treatment usually constitutes speech therapy and video stroboscopy. Further options include removal of the nodule or polyp under general anesthesia if there is no significant improvement with medical treatment. Other causes of hoarseness include an upper respiratory tract infection with irritant laryngitis. Reflux can also irritate the larynx and contribute to hoarseness. Sometimes a tumor may develop over the vocal cords especially in smokers. Paralysis of the vocal cord can occur following and upper respiratory tract infection, surgery, trauma, or cancer within the neck or chest.

If hoarseness persists for more than 2 or 3 weeks, especially in smokers, it is critical to have the larynx checked by an ear, nose, and throat specialist, especially to rule out any serious anomaly. The otolaryngologist will examine the vocal cords and often use a scope or strobe light to assess the vocal fold vibration and movement. Treatment is based on the specific etiology causing voice disorder. Most of the conditions can be successfully treated if identified and diagnosed early. Read More→

Dizziness and Vertigo

DizzinessDizziness and vertigo are common symptoms reported during office visits. They can result from an inner ear peripheral vestibular disorder or a central vestibular disorder involving the brain. It is important to differentiate the between them so as to make an accurate diagnosis and recommend appropriate treatment. Dizziness is a sensation of feeling faint, unsteady, or being lightheaded. Vertigo is more specific and refers to a frank spinning rotational perception of movement.

Vestibular dysfunction can be caused by head injury, aging, viral inflammation, autoimmune disease, loose crystals within the inner ear, etc. Below is a short list with appropriate description: Read More→

Sudden Hearing Loss

Sudden Hearing LossThe incidence of sudden sensorineural hearing loss is 1 per 5000 every year. This refers to nerve damage versus an ear infection with middle ear fluid. It is likely to strike adults in their 40s and 50s, although we have seen it in much younger and older individuals. Audiogram will usually reveal a 30 dB loss in 3 continuous frequencies that is sensorineural in nature. It is usually unexplained, although sometimes related to a viral upper respiratory tract infection, vascular disease, ototoxic drugs, brain tumor, autoimmune disease, or Meniere’s disease.

Ear exam is normal with no middle ear fluid or infection apparent. Patients typically wake up with this one morning or notice it over the day when they are trying to use the phone.

Sometimes patients may notice a loud pop before the hearing diminishes. Patients with sudden hearing loss may also become dizzy with tinnitus (ringing/roaring/chirping sounds). If this were to occur, one would suspect underlying Meniere’s disease as well. Read More→

Dizziness and Benign Positional Vertigo

Benign positional vertigo refers to small displaced crystals of calcium carbonate which called otoconia, otoliths, or canaliths. These crystals are typically attached to the otolithic membrane within the utricle of the inner ear. Sometimes due to trauma or aging, the otoconia can separate from the utricle, and become displaced in the semicircular canal within the inner ear. With head movements, the detached otoconia can stimulate sensitive nerve endings. The brain receives fall signals, which in turn, causes a spinning sensation or dizziness. Symptoms typically occur less than a minute and are precipitated by specific head movements against gravity.

The ear exam is typically normal. Physical examination, however, will typically elicit nystagmus or jerking eye movement indicating the affected ear.

Treatment involves repositioning the otoconia so as to stop false signals of movement to the brain. Canal positioning procedure, also known as the Epley maneuver, will move the canaliths or otoconia from the semicircular canals back to the utricle. Hopefully, the otoconia will then re-adhere to the otolithic membrane, dissolve, or disintegrate and therefore relieve patient’s chronic debilitating symptoms. The Epley maneuver is performed by a trained professional. Following the procedure, appropriate precautions are provided so as to prevent the otoconia from returning back into the semicircular canal. The Epley maneuver has a success rate of 80%. The recurrence rate is relatively low and more likely in patients that have spontaneous onset of BPV rather than related to trauma.

Brandt-Daroff exercises are also recommended for patients with BPV. They are done multiple times while at home until 2 days after the bouts of positional vertigo have ended.

Meniere’s Disease

Meniere's DiseaseMeniere’s disease refers to a condition typically manifested by severe dizziness with vertigo, roaring or ringing tinnitus, fluctuating hearing loss, and a sense of ear pressure or fullness that is sometimes painful. Meniere’s can occur bilaterally in 25% of patients. It is more common in adults in their 40s and 50s. There are about 600,000 people in the United States that have a diagnosis of Meniere’s disease. About 50,000 cases new cases are diagnosed every year. Dizziness may occur suddenly following an aura of roaring tinnitus and muffled hearing. Sometimes the dizziness is severe enough that patients are unable to ambulate. On the other hand, patients may complain of moderate to severe ear pressure and fullness with a sensation of ear fluid that is not evident on physical exam suggesting normal middle anatomy. This would therefore suggest inner ear pathology.

Meniere’s disease is caused by excess fluid within the inner ear or the labyrinth. The membranous portion of the labyrinth contains endolymph which is responsible for sending balance Read More→

The Pregnant Tourist

peppers

It was a beautiful Saturday morning, and I was in the mood to do some gourmet cooking. Somehow, it makes me relax and feel like I am in the kitchen with my Mom who cooks delicious meals. Alas, she never taught me how to cook, always telling me to go study instead. After marriage, I had to make some quick adjustments, and started collecting cook books. Fortunately, my husband has been very supportive although he did once call my pancake a “Frisbee” – something I have never forgiven him for. Over time, I have amassed quite a few books, and they appear pretty stunning sitting on the shelves. But there was one recipe that caught my interest described as chicken rolls filled with crushed dates, lemon juice, and chili peppers. So here I was cutting and preparing, when I got called to the Emergency room for a nose bleed. Oh well, I thought, shouldn’t take too long before I return and continue my cooking project. I was so very wrong!!

I walked in to find a sweet young pregnant lady holding a big basin filled with blood. It continued to pour out of her nose without any intention of stopping. Read More→

The Abscess That Wasn’t

frosty

It was blistery cold outside, and the strong winds shattered against our windows. Yes it was winter, and fairly close to Christmas. The office was lit up with decorations in anticipation for the holiday season, and my staff worked like little elves trying to get everyone taken care off. We were almost there. I still needed to do my Christmas shopping and was hoping to get to the stores after work. A far as the BIG Christmas dinner was concerned, my kids insisted on a complete homemade meal rather than catering this year. We came to a pact – ‘Home-Made’ – YES! – but with LOTS of help in cooking and cleaning up after dinner. Now, all I had to do was to make the grocery list; hopefully my sweet husband would do the shopping.

Things were moving along smoothly in the office when my staff informed me of a call asking if I would see a patient with a peritonsillar (throat) abscess. I hesitated for a split second but then agreed knowing this person too would want to enjoy a good meal during the holidays. Read More→

The Wonderful Cakes

cake

“John” suffered from recurrent sinus infections for years. We discussed surgery on multiple occasions, and eventually decided to proceed. Surgery confirmed severe disease, and the sinuses were carefully and thoroughly cleaned. After months of regular follow up and more treatment, John joyously announced that he had regained his sense of smell. Imagine our delight when he started bringing absolutely the most delicious homemade cakes to the office. Their quality could have put a seasoned baker to shame.

Alas, what about our low calorie and cholesterol diet? FAT CHANCE – cakes like these don’t walk into your office every day. John and I have since become good friends and I wish him continued good health.

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