The section of the body from the ears to the nose and throat is relatively small, but many things can go wrong, either congenitally or during one’s lifetime.
The specialists responsible for treating them are known to the public as earnose- and-throat doctors, but they refer to themselves as otolaryngologists.
Fortunately, ENT specialists have a growing number of technologies in their armamentarium, from the most sophisticated cochlear implants to give the gift of hearing to both children and adults, to tiny endoscopes that gobble up inflamed tissue and polyps in the nose.
The latest developments in otolaryngology were presented to the general public earlier this month at Jerusalem’s Shaare Zedek Medical Center, which held the sixth in its Shishi Bari (Healthy Friday) lecture series.
There were so many who came to hear that many folding chairs had to be added all along the sides of the 300-seat Hedi Steinberg Auditorium.
Otolaryngologists diagnose and manage diseases of the ears, nose, sinuses, larynx (voice box), mouth, and throat, as well as parts of the neck and face. The hospital’s ear, nose and throat and head-neck surgery department, chaired by Prof. Jean-Yves Sichel, was established as a small unit in 1989 by Prof. David Cohen; since then, it has grown significantly. The ENT department, which includes the seventh floor inpatient facility and a fourth-floor clinic, has since treated 21,357 patients and performed 2,000 operations.
The aging of the population, as well as new options to help children – who comprise half of the department’s patients – has greatly increased the number of patients, the French-born Sichel said. Hearing loss affects about 10 percent of older people, who are tested and usually sent for hearing aids. But only about 20% of those who need them actually go for testing and purchase them (with health fund subsidies), usually because they are too embarrassed to wear them.
Cochlear implants are provided to suitable adults (who cannot hear well with hearing aids) as part of the basket of health services.
ENT specialists also treat balance disorders, tinnitus (chronic buzzing in the ears, usually caused by noise), ear infections and cranial nerve disorders, while those who are specialists in pediatric hearing problems perform cochlear implant surgery on babies and young children. The younger they are, the easier it is for them to learn how to decipher sounds and words and the better their ability to learn how to speak.
As for noses, chronic sinusitis (infection of the sinuses) and rhinitis (runny nose) are a very common complaint that keeps ENTs busy, as do allergies, nasal obstructions because of a deviated septum separating the nostrils, benign polyps and a poor sense of smell.
There are also diseases of the throat, voice box and the esophagus, including voice and swallowing disorders. Smoking, overuse of the voice and other factors can cause malignant growths in the throat, and ENT surgeons are also qualified to operate on thyroid and salivary gland cancers and perform reconstructive and cosmetic plastic surgery on patients.
Sichel showed slides of a woman with a huge goiter (enlarged thyroid gland) in her neck. “This causes serious functional problems, pressing on other organs. Of course, it is also embarrassing to patients. A needle biopsy is usually conducted to remove cells to see whether they are malignant. As people get older, their risk of thyroid cancer grows, and for some reason, women are at higher risk than men.”
The entire gland, or half, can be removed or reduced by giving radioactive iodine (but some patients don’t like the idea of being exposed to such radiation). The surgical scar is usually very faint six months after the operation. As the thyroid secretes enzymes that maintain metabolism, surgery reduces or eliminates the amount of enzymes, so they have to be replaced on a regular basis.
SHAARE ZEDEK audiology institute coordinator Riki Salem said that her hospital has the largest institute for hearing problems in newborns in the country – as every baby is objectively screened for hearing problems soon after birth, and the Jerusalem hospital delivers 22,000 babies year, the most in the country and in the world.
“The famed Helen Keller, who was born both deaf and blind, once said, ‘Blindness separates people from things, while deafness separates people from people.’” How do you know if you have a hearing problem? asked the Australian-born Salem.
“If you have problems hearing others on the telephone; if you have to exert yourself to follow a conversation; if you complain the TV is too loud; if you say What?’ a lot; if people don’t seem to speak clearly; if you have trouble making out the voices of women and children; or if you often get angry because you don’t understand what others are saying.”
Older children cooperate with the audiologist by playing games and answering questions. Adults tested for their hearing sit in sealed rooms and wear earphones to react to sounds produced by an audiometer.
The results of hearing low to high tones (10 to 120 decibels) are shown on a graph called an audiogram that delineates the type, degree and configuration of hearing loss, including the frequency, pitch and intensity of the sound heard.
Hearing aids are usually the best solution for a variety of hearing problems for every age, said Salem. “There are regular-sized and mini-sized models inside the ear canal, behind the ear – many kinds that can differentiate between noise and speech,” she added. Cochlear implants, which bring sound directly to the auditory nerve, bypassing defective bones in the middle ear, can be helpful in cases when hearing loss is due to chronic problems such as liquid in the ears.
Salem added that many auxiliary devices to listen to TV and radio, FM systems for children in classrooms and special phones can be used to improve one’s quality of life.
PROF. RONEN Perez, head of the otology unit, said that if there is a little hole in the eardrum, hearing is not very much affected, but if larger, it can be repaired with a “patch.” The three tiniest bones in the body – the malleus, incus and stapes – translate sound waves into pulses in the middle ear that are transmitted to the internal ear; then the spiral-shaped cochlea translates sound into nerve impulses to be sent to the brain.
If these bones are unable to vibrate due to disease, surgery can “unstick” them by performing a stapidectomy to restore hearing.
All surgery inside the ear is extremely delicate, requires very sterile conditions and is performed with microscopic lenses affixed to the surgeon’s glasses, he said. “When we know we are doing such surgery, we avoid drinking coffee in the morning so our hands won’t shake even slightly.”
The youngest patient needing cochlear implant surgery was only three months old (the youngest in Israel and one of the youngest in the world) and couldn’t wait for an operation before his first birthday because he had meningitis), while the oldest was 84.
Another interesting case was a child who came to the hospital with two cochlear implants from another hospital, but still was deaf. Perez found that the implant wire had been threaded into the wrong place. They inserted a new one properly and the patient now hears well.
SNORING affects between 25% and 40% of Israelis – and makes their sleeping partners miserable, said Dr. David (Pierre) Atal. Just snoring is harmless, except to the person who hears the noise, but if it comes with sleep apnea – in which breathing stops for a few seconds many times per night, it can raise the risk for heart attacks and strokes and lead to tiredness (and a higher occurrence of road and work accidents) during the day. People snore because of a narrowing in the upper respiratory system; in some, it is congenital, but in others is develops, especially in the overweight or obese.
Sleep apnea is diagnosed in sleep labs or – increasingly – with sensors worn at home during sleep. “We sometimes put patients under anesthesia while they sleep and use an endoscope; this is the most accurate way to fine out where the narrowing occurs. Treatment,” stressed Attal, “is not easy. There is no magic cure. We often recommend that patients lose weight. We can also cauterize with radio waves the soft palate in the mouth so it stops vibrating and causing noise. It is not painful, but the success rate for treating snoring is only 75%.”
Using a continuous positive airway pressure (CPAP) machine with a mask worn over the face during sleep forces air into the upper respiratory system and can eliminate snoring. “We were one of the first centers to implant a stimulator in the chest that leads to the neck where it stimulates a nerve, thus strengthening muscles in the chest, which can reduce or stop snoring. We think this is really the hope for the future in dealing with snoring.”
THE NOSE and sinuses are lined with a delicate membrane that releases mucus and protein that protect the tissues, which are rich in blood vessels, said Dr. Uri Peleg.
Cigarette smoke, different temperatures and drugs affect this mechanism and can cause chronic rhinitis, which is defined as such if the superfluous mucus is produced continuously for three months or more.
In a fifth to a quarter of cases, patients suffer from allergic sinusitis, in which mucus results in infections; in the US alone, treating this costs $3.4 billion a year. Dust mites’ excretion, animal fur and grass can cause year-round problems, while certain plants and trees such as olives make the problem seasonal, noted Peleg, adding chemicals, nose drops and various drugs such as contraceptives, hypertension drugs and psychiatric medications as additional causes. Patients complain of a very wet runny nose, itching, tearing and tiredness.
In many cases, the actual cause is unknown.
Polyps – benign growths in the nose that often release pus – can make breathing difficult.
Treatment includes spraying saline solution to wash out the nose, various antibiotic sprays, antihistamines, steroids – or functional endoscopic sinus surgery (FESS) to remove the polyps. The result is great relief, but unfortunately, benign polyps tend to recur.
Sichel concluded that people with ENT problems should seek help and not be bashful, as treatments are usually very effective. All (Hebrew-language) Shishi Bari lectures, aimed at edifying the public, can be viewed on the hospital’s website at www.szmc.org.il