Intranasal Treatment for Clogged Ears

A common cause of clogged ears with inability to pop them easily is due to eustachian tube dysfunction. There are a number of ways to address this annoying problem, but one of the first steps to try is intranasal medications whether in nasal spray form or nasal drop form.

The whole idea behind intranasal treatment is the fact that the ears are connected to the back of the nose via a tunnel called the eustachian tube. Watch video explanation.

Normally, when the ears are popped (also known as valsalva), the individual is opening up the eustachian tube to allow pressure and/or fluid in the ears to drain/escape out into the back of the nose. That's why when you blow your nose, you often hear a popping noise in the ears. Read more about how/why this happens here.

Patients suffering from eustachian tube dysfunction are unable to get the tunnel to open up. In this scenario, the pressure or fluid remains trapped in the ear. It's a plumbing problem in its essence.

Given the problem is the eustachian tube, intranasal medications are used to try and open up the tunnel and make it easier for the individual to pop the ears open.

Trick is... how to get the intranasal medications to where the eustachian tube is located in the very back of the nose.

There are a few ways to accomplish this... some which work better than others.

Method 1:
Use a nasal spray medication and aim the bottle to the back of the neck while keeping the head down (looking at the floor). The spray bottle MUST be perpendicular to the face. Why? Take a look at the diagram below:

If you aim the bottle towards the eye or top of the head, the medication is hitting areas of the nose where the sinus cavities are... not where the eustachian tube is located.

You have to look down and point the nasal spray bottle up towards the ceiling because all nasal spray medications use a straw that requires vertical orientation (same reason why when you drink Pepsi from a cup, the cup is upright).

Anatomically, the nasal spray "shoots" the medication straight up to where the eustachian tube is located.

Method 2:
Use an eye dropper and place a drop of the medication into the nose and have it "drain" to where the eustachian tube is located. Practically, this means filling a prescription of the nasal spray medication, opening up the bottle, and pouring the contents into an eye dropper.

This method requires positioning the head such that gravity will ensure proper movement of the medication to where the eustachian tube is located.

There are two ways to achieve this. This first way is the "Head-Tipped-Back Position".

In this position, the nasal drop will "fall" down to where the eustachian tube is located:

Mygind's Position is the alternative position which accomplishes the same thing, but the person is laying down looking up. For some people, this position is more comfortable than bending the head back.

Studies have shown that Method 2 (nasal drops) works better than Method 1 (nasal spray). However based on my personal experience in my patient population, Method 2 is not as well tolerated as Method 1. People often feel like drowning or suffocating when performing this maneuver (mini water-boarding so to speak). Also, it seems to be more irritating to the mucosal lining of the nose and throat.

And as we all know, if it is not comfortable or user-friendly, patients will not do it.

As such, I usually recommend Method 1 (nasal spray) which works "good enough". For patients who are ambitious and are willing, go with Method 2 (nasal drop).

Reference:
Techniques of Intranasal Steroid Use. Otolaryngol Head Neck Surg 130(1):5-24.
Intranasal delivery of drugs to eustachian tube orifice. The Journal of Laryngology & Otology (2011), 125: 934-939

Images taken from Techniques of Intranasal Steroid Use and Wikipedia.

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Tonsillectomy Airway Fire

ABC News reported in 2008 about a California family suing doctors as well as Conmed, an electro-surgical instrument company, for an airway fire that occurred on April 18, 2003 on an 8 years old child during a routine tonsillectomy surgery.

Apparently, an electrocautery device was being used to remove the tonsils when the endotracheal tube caught fire resulting in burns to the child's mouth and airway (no death). It is suspected that the electrocautery device during the surgery either burned a hole into the endotracheal tube where it encountered oxygen resulting in the fire or there was a leak around the endotracheal tube which caught fire. The jury found the surgeon to be negligent, but returned a defense verdict for the device manufacturer Conmed. The other defendants settled.

Use of electrocautery is still popular among ENT surgeons removing tonsils, but has been abandoned by an increasing number of surgeons (including our practice) over the past few years due to risk of airway fire as well as concern for unnecessary thermal injury to surrounding normal peritonsillar tissues. Electrocautery produces temperatures between 400 to 600 degrees Centigrade which both cuts and stops bleeding simultaneously. However, as can be seen in this unfortunate case, it can also burn through an endotracheal tube and cause an airway fire.

Airway fire is another reason why laser tonsillectomy is rarely performed as the risk is the same if not greater than electrocauterization.

Our office uses coblation technology to remove tonsils. Coblation uses a radiofrequency plasma field to cut and stop bleeding simultaneously at near room temperatures thereby avoiding risk of airway fire as well as thermal injury to surrounding oral tissues.

Of note, there are about 500 cases of operating room fires related to use of electrosurgical instruments every year of which 20-30 causes serious injuries.

Read the ABC News report here.

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Study Suggests (Incorrectly?) Steroid Nasal Spray Use Does Not Help with Eustachian Tube Dysfunction

In the May 2011 edition of Archives of Otolaryngology-Head & Neck Surgery, a study was published on a randomized, placebo-controlled, double-blind prospective clinical trial (the best kind of research) to determine whether Nasacort AQ steroid nasal spray can resolve eustachian tube dysfunction as well as ear symptoms related to this disorder. Eustachian tube dysfunction at its mildest would cause symptoms of ear clogging much akin to the way the ears fill up when flying or driving up the mountain. At its worst, can lead to fluid buildup in the ear as well as chronic ear infections.

In the study population of 91 patients, they found that use of a steroid nasal spray did NOT help...

HOWEVER, after reading the paper, there is a major flaw to how the study was conducted which would significantly affect study outcomes. Mainly, how the nasal spray is used would strongly affect whether it will help or not.

According to the paper, patients were instructed to simply administer "2 metered sprays in each nostril once daily (55 µg per spray)..."

Nothing else.

Unfortunately, this type of administration is bound to fail, mainly because using a nasal spray in this manner is inadequate when addressing eustachian tube dysfunction.

First of all, the eustachian tube openings are at 90 degrees to the face, so the steroid nasal spray bottle needs to be directed towards the back of the head and not towards the eye. This needs to be specifically mentioned/demonstrated as it is not intuitive for most patients (and even doctors). The first picture is INCORRECT! The second picture is correct use. Read more here why directionality is important.

Second, a valsalva maneuver (blow air out the nose while keeping the nares pinched) must be performed after nasal spray administration in order to force the nasal spray medicine up into the eustachian tubes in order for the medication to affect the region of concern. Without a valsalva, the nasal spray medicine sits in the nasal cavity which would help with sinus problems, but not the ears which is the area of complaint. Valsalva needs to be done regularly throughout the day during treatment.

Why is this maneuver important? It's like pouring draino (steroid nasal spray) into a clogged toilet, but than not using a plunger (valsalva maneuver).

In any case, there are other studies that have found steroid nasal sprays to be helpful for eustachian tube dysfunction as listed under references.

Read more about eustachian tube dysfunction here.

References:
Management of Eustachian Tube Dysfunction With Nasal Steroid Spray. Arch Otolaryngol Head Neck Surg. 2011;137(5):449-455. doi:10.1001/archoto.2011.56

The role of topical nasal steroids in the treatment of children with otitis media with effusion and/or adenoid hypertrophy. Int J Pediatr Otorhinolaryngol. 2006;70(4):639-645.

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2006 Jul 19;3:CD001935.

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U.S. Rep. Gabrielle Gifford Gets a Tracheostomy After 7 Days of Intubation

U.S. Rep. Gabrielle Gifford who is recovering from a gunshot wound to the head 7 days earlier had her breathing tube removed and a tracheostomy tube placed on January 15, 2011.

Many people will wonder why a tracheostomy tube was placed when she's been intubated for only 7 days and even though she has been able to breath on her own since Tuesday. Along with the trach tube, a stomach feeding tube was also placed.

A tracheostomy tube is a small tube placed through an opening in the neck allowing for airway protection, improved ease of breathing, and improved pulmonary care.

It is unusual to keep a patient intubated for greater than 7 days due to risk of tracheal stenosis due to mucosal ulcerations that occur with prolonged intubation. Such ulcerations not only occur in the airway and throat, but also the mouth and lip regions. The exact timing to trach is still controversial however.

However, a tracheostomy tube does appear to speed overall recovery and decrease the number of days of hospitalization.

Though many family members (and patients) may be appalled by the cosmetic appearance of a trach tube, everyone needs to remember a trach tube is TEMPORARY and can be removed without much fuss once the patient regains strength.

Read more about trach here.

Read the Reuters article here.

Watch a video of a trach.



Reference:
Tracheostomy: why, when, and how? Respir Care. 2010 Aug;55(8):1056-68.

Early versus late tracheostomy in patients with acute severe brain injury. J Bras Pneumol. 2010 Feb;36(1):84-91.

Early tracheostomy in intensive care unit: a retrospective study of 506 cases of video-guided Ciaglia Blue Rhino tracheostomies. J Trauma. 2010 Feb;68(2):367-72.

The impact of time to tracheostomy on mechanical ventilation duration, length of stay, and mortality in intensive care unit patients. J Crit Care. 2009 Sep;24(3):435-40. Epub 2009 Jan 17.

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