Cough is one of the most prevalent complaints in our ENT clinic; however, a cough is not considered chronic until it has persisted for over 8 weeks. It is believed that chronic cough is a secondary nerve condition that could be related to nerve damage caused by inflammation, infection, or allergy1. In ENT, when we see a chronic cough, it is usually related to acid reflux or sinus/allergy drainage. Pulmonologists also see a lot of chronic cough for other lung and bronchial related issues such as asthma and allergic bronchitis. Your ENT may refer you to a Pulmonologist to rule out one of these conditions or vice versa depending on your other symptoms.
Chronic cough relating to acid reflux disease or GERD.
While some patients will complain of heartburn, chest or back pain, and/or a sour taste in the mouth, many of our ENT patients deny any of these symptoms other than a chronic cough. Most often, the cough does not occur on its own but with other associated symptoms such as a feeling of something in the throat, throat pain, throat clearing, hoarseness, and difficulty swallowing2. In such cases where these symptoms present, your ENT will usually perform a laryngoscopy to rule out any other laryngeal disorders as cause for these symptoms such as vocal cord nodules or throat cancer. Chronic cough that could be related to GERD is often treated with a Proton Pump Inhibitor (PPI) such as omeprazole/Prilosec or any of the many others. Low level symptoms may be treated with a histamine blocking medication such as ranitidine/Zantac instead. While this treatment is designed to control any potential reflux, studies have shown that with chronic cough, the problem of reflux could be a simple case of which came first, the chicken or the egg. Cough can cause excess abdominal pressure causing reflux, and the irritation from reflux can cause cough. So, while the medication is treating the reflux, it may not actually be helping the cough, and that is when your ENT may start to examine other causes such as allergy and sinus drainage1.
Chronic cough relating to allergy and sinus drainage.
Post nasal drip (drainage in the throat) and throat clearing usually go hand in hand, and when these symptoms are associated with nasal discharge or nasal congestion, we usually blame cough associated with this feeling with allergies or sinus problems. Your ENT will likely try a combination of medications that could include an antihistamine pill or spray, a nasal steroid spray, an anticholinergic spray, steroid pills, and/or antibiotics1. If the problem persists despite medication, a sinus CT may be ordered to see if chronic sinusitis is the source. If negative, however, other reasons for the cough may be pursued.
Idiopathic or neurogenic cough, or cough of an unknown cause.
When pulmonary sources and ENT sources of cough have been ruled out (usually by failure to respond to treatment), we will label the diagnosis as neurogenic cough or idiopathic cough. For this reason, neurogenic cough is often labeled as a diagnosis of exclusion2. It is believed by researchers that in the patient’s past there was an assault on the nerves (such as virus, allergy, reflux, etc) causing inflammatory changes in the sensory nerves that produce cough. It is also believed that the act of coughing itself can be producing these changes leading only to further cough1.
Treating neurogenic or idiopathic cough.
This topic of research has been popping up recently in the ENT journals, and with very few studies to confirm and create a widely accepted care plan. The only information to share on this matter is that findings are showing that short term relief can be found in using speech therapy along with a nerve medication such as Neurontin combined with antidepressant amitriptyline. The problem is that adverse side effects are very common and further studies are still needed to draw conclusions on what agents work best, how medications should be dosed, duration of therapy, and long-term outcomes of such treatment3. It is for this reason, that your ENT is not likely to suggest this form of treatment for the foreseeable future.
Perhaps the greatest ray of hope in all of this is that for most patients that come to our ENT clinic, we can get most of patients feeling better by medically treating their acid reflux, allergies, sinusitis or all of the above. We also offer a full-service Allergy Clinic at ENT Consultants, LLC to help those whose cough is allergy related and CareStream In-Office CT Scanning and The Minimally Invasive Sinus Center for cough due to chronic sinus problems. So if you have a cough that has lasted 8 weeks or more, Appointment Request so that we can evaluate you and hopefully get you feeling better!
1 Chung KF. Approach to chronic cough: the neuropathic basis for cough hypersensitivity syndrome. J Thorac Dis. 2014 Oct; 6 (Suppl 7): S699-S707. [PubMed]
2 Altman KW, Noordzij JP, Rosen CA, Cohen S, Sulica L. Neurogenic cough. Laryngoscope. 2015;125:1675-1681.
3 Giliberto JP, Cohen SM, Misono S. Are neuromodulating medications effective for treatment of chronic neurogenic cough? Laryngoscope. 2017;127:1007-1008.
1. Wash Your Hands.
Washing your hands is the simplest and most effective way to stop the spread of germs. Washing your hands often and properly can keep you and your loved ones healthy. For more information on when and how you should wash your hands: https://www.cdc.gov/features/handwashing/index.html
2. Get a Flu Shot
Every flu season is different, and influenza infection can affect people differently, but millions of people get the flu every year, hundreds of thousands of people are hospitalized and thousands or tens of thousands of people die from flu-related causes every year. Even healthy people can get very sick from the flu and spread it to others. The flu shot can dramatically reduce the spread of the virus. For more information on types of vaccines, how they work, and who should and should not be vaccinated: https://www.cdc.gov/flu/protect/keyfacts.htm
3. Drink Plenty of Water
Drinking water helps to keep the mucus membranes in your nose and throat lubricated by keeping the mucus secreted thin and healthy. Good hydration is also good for your voice box and can help prevent sore throats and laryngitis.
4. Nasal Saline Spray and Saline Nasal Irrigations
As ENT specialists, we recommend saline nasal irrigations to anyone with sinus problems or allergies because, as Dr. Medaris always says, “Dilution is the solution to pollution!” Saline is key to good nasal hygiene and keeps the nasal mucosa functioning at its best. Nasal saline throughout the day is also a good idea during the cold, dry winter months, as this is the first line defense against nosebleeds.
5. Stay Home if you are Sick
This may seem like common sense in the fight against the spread of germs, but visit any shopping center or grocery store during the holidays and you will inevitably see drones of sick people. Sick people that are spreading germs and infecting others. Conversely, if you are sick and go out where there are other sick people, you could risk getting worse.
6. Keep an Extra Clean Home
Even though winter is not known for being an allergy season, there are still plenty of allergens that live in your home – especially during the winter months. By keeping your home extra clean during the cold months, you can limit you and your family’s exposure to allergens, which in turn to allergies and have been known to turn into infections when not well treated. For cleaning tips to help reduce allergens: https://www.omahasinus.com/in-door-allergies.html
7. Avoid Overeating
Overeating can cause heartburn or acid reflux. When a person overeats it not only causes the stomach to make for acid for digestion, but it also distends the stomach making the valve between the stomach and esophagus ineffective. Even if a person doesn’t feel heartburn, they could be having silent reflux symptoms of dry cough, sore throat, hoarse voice, or lump in the throat or throat drainage symptoms. When the issue starts to effect the throat, the condition becomes a bit harder to manage and treat.
8. Get Some Exercise Most Days of the Week
Even 15 minutes of exercise everyday has shown health benefits. Regular exercise reduces risks of chronic diseases, helps maintain muscle and bone health, and helps with depression and mental health. Daily exercise also helps to promote a healthy immune system, which can help with all the cold and flu germs going around during the holidays.
9. Don’t Smoke or Quit Smoking if you Do
As ENT specialists, we harp on this more than any other bad habit, and for good reason. Smoking is the leading cause of non-HPV related head and neck cancers. Oftentimes, the stress of the holidays to increase smoking, which in turn increases the risk of cancer. We challenge people to use this time of togetherness, giving and family to quit smoking.
10. Get Into the Giving Spirit
Being Santa’s helper has multiple health benefits including: lower blood pressure, lower stress levels, lower risk of depression, increased self-esteem, and generally a longer, happier life. So, while you are trying to stay healthy during the cold and flu season, we invite you to get into the holiday spirit, as this is one of the easiest steps you can take during the season of giving to promote good health.
What your Ear Specialist would like you to know about ear wax and ear wax removal.
Ear wax is one of the most common ear problems and reasons for ear fullness that primary care doctors (Family Doctors and Internists) and ENT doctors see, and removing ear wax is the most common procedure done on ears in the United States. Because this is such a common issue, patients often wonder how they can remove ear wax at home. All too often, patients turn to ear candling, and we are here to discuss this option and why there are so many reasons you should consider another option instead.
What is Ear Candling?
Ear candling is a procedure done to remove ear wax. Performed by beauticians, naturopaths, and often by patients at home, this procedure involves placing a hollow candle in the ear canal, lighting the wick, and allowing the candle to burn3. When the procedure is finished, patients are encouraged to open the fabric candle and view the contents, which practitioners of this ear wax removal method believe to be ear wax, debris and bacteria. Alternative medicine practitioners have also been known to use ear candling to treat sinus infections, ear infections, headaches, tinnitus (ringing in the ears), vertigo (dizziness) and strengthen the brain!
Do Ear Candles Work?
In a word, no! But how do you know? There is so much stuff in the candle when I am done? People who use ear candling will tell you two things about how these devices work: 1. That there is a chimney effect and that the burning candle creates a vacuum that draws ear wax, debris and bacteria out of the ear canal, or 2. That the ear wax heats up the wax melting it and allowing it to drain out over the following few days.
So here is the science behind the no…
Study 1: This study tested the “chimney” theory of ear candling by creating an artificial ear canal and measured the pressure in the ear canal during the procedure. The experiment showed that no negative pressure was created during ear candling! This study also found instead of removing ear wax and debris, the ear candle actually deposited a powdery substance! When this substance was analyzed using gas chromatography and mass spectrometry, the powdery substance was found to contain chemicals found in candle wax but not ear wax1.
Study 2: This study tested the “melting” theory of ear candling. In much the same way as the first study. An artificial ear was created and candled. During the procedure, air temperature was measured 10mm from the base of the candle while it was burning. The highest temperature that was reached during the experiment was 22oC or 71.6oF – well below core body temperature and certainly not warm enough to “melt” ear wax2!
But the stuff in the ear candle, it must come from somewhere?! Where does the stuff in the ear candle come from?
Answer, the candle itself! Another study performed and published in the same journal article as previously mentioned Study 1 discusses a small clinical trial where ear candling was performed patients without ear wax and patients with ear wax. An otoendoscope was used to photograph these patients before and after the ear candling procedure. In patients with ear wax prior to ear candling, there was no change in the appearance of their ear wax after the procedure. In patients with clean and healthy ear canals prior to ear candling, there was candle wax deposited into the previously clean canal1!
Is Ear Candling Safe?
No! In fact, the American Academy of Otolaryngology Head and Neck Surgery strongly advises against ear candling for this reason3. But what can happen? Remember the journal article that showed that wax was deposited into the canal rather than removed? Well, that same article cites a survey done by members of the American Academy of Otolaryngology Head and Neck Surgery that showed that of 40 patients who admitted to having used ear candling, 21 had to be treated for injuries sustained from the procedure. These injuries included burns to the ear canal, occlusion of the ear canal, hearing loss, ear canal infections, and ear drum perforation (hole in the ear drum)1. The picture shown to your left shows ear candling wax that has burnt through the ear drum and lodged into the deep meatus of the ear.
Does the Cost Justify the Risks of Ear Candling?
While the cost of purchasing your own ear candling system and doing it yourself is pretty inexpensive, the cost to repair the damage as seen in the picture above can be pretty costly. I did a little research on ear candling cost online and found the following prices:
However, when I asked one of our providers about what would be involved to repair the damage seen in the picture above as well as our billing manager, the answer I received was:
Assuming the patient did not have insurance…
The cost of a new patient evaluation + a couple grand in surgeon fees to remove the wax and repair the damaged ear drum + thousands of dollars in hospital and anesthesia costs + expensive ear drops to treat the ear + multiple follow up visits + hearing test (possibly more than one) = assuredly medical bankruptcy
Assuming the patient has insurance – you would likely owe a large portion of your deductible and co-insurance to multiple entities.
So, given the monetary risk plus risk of potential pain and suffering you may endure from injury, is it worth it to even try this method of ear wax removal that has been shown to be ineffective?
What are Some Other Methods of Removing Ear Wax?
· Ear Wax Drops.
This method of removing ear wax can be done safely by patients at home, in so far as the patient knows that their ear drums are intact (no perforations or ear tubes) and that they do not have an infection brewing in their ear canals. Some of these drops may cause irritation to the ear canals especially if over or incorrectly used. We recommend that you consult with your doctor before trying these to make sure that you will not make the problem worse or that you do not have a condition that would limit you from using these products.
· Ear Wax Flush
This should never be done by patients on their own. Many primary care providers use this method to clean ears in their offices, and are many times are successful. However, as ENT specialists, we see the instances where primary care providers (more often than not primary care nurses) have over-aggressively attempted to flush ear wax and have either failed or made the problem worse by causing trauma to the ear canal or ear drum.
Not advised. Imagine loading a black powder rifle where you tamp down the gun powder into the gun. This is essentially what happens when you put a Q-tip into the ear canal. They have also been known to cause cuts in the canal and dry out the ear canals.
How do Ear Specialists Remove Ear Wax and How Much Does Ear Wax Removal Cost?
ENT specialists at Ear, Nose & Throat Consultants remove ear wax under direct visualization of the ear canal using an ear microscope and specialized tools to make sure that they are not traumatizing the fragile structures of the ear. It usually takes only a few minutes of time and can be done as often as needed to promote healthy ears.
But what about cost? Really quite affordable! For cash pay patients cost is about $120+ (depending on any other issues and if one-sided or both sides) and even less for those with insurance! We also offer payment plan options.
Many times, after your ears have been cleaned by one of our providers and found to be healthy otherwise (no issues with infection or ear drum perforations), they will recommend that patients use mineral oil or baby oil or ½ rubbing alcohol ½ white vinegar to help with cerumen control.
So, if you have issues with ear wax and are looking for a safe and affordable way to get your ears cleaned, Contact Us today for a quick and easy visit! We offer the safest option and peace of mind, which is priceless!
1 Seely DR, Quigley SM, Langman AW. Ear candles – efficacy and safety. Laryngoscope 1996; 106(10) : 1226-9.
2 CBC Marketplace: health. Health Canada’s statement on ear candling. Ottawa, ON: Health Canada; 2000. Available from www.cbc.ca/consumers/market/files/health/earcandle/statement.html. Accessed 2017 Oct 26.
3 Entnet.org: patient health. Earwax and care. Alexandria, VA: American Academy of Otolaryngology Head and Neck Surgery; 2017. Available from www.entnet.org/content/earwax-and-care. Accessed 2017 Oct 26.
Fall in the Omaha and Bellevue area means that the trees will turn beautiful shades of yellow, orange, and red. It signifies Husker football, cooler days and nights, and that annual trip to Vala’s Pumpkin Patch or the Bellevue Berry Farm. But the fall is a pretty miserable time for many Nebraskans and Iowans because of hay fever or fall allergies.
Symptoms of allergies…
Often mistaken as a semi-annual cold or sinus infection, allergies most commonly happen in the spring and fall and have many of the same symptoms of a cold or sinus infection such as congestion, runny nose, facial pressure or pain, post nasal drip, and cough. The problem comes when people do not adequately treat their allergies causing the swelling in the nose to get out of control and the drainage to back up. Trapped mucus is a breeding ground for bacteria, and that is when we see allergies turn into a sinus infection.
How do I know when my allergies have turned into a sinus infection?
We tell our patients that if you have over 5-7 days of yellow or green, thick nasal drainage despite using a saline nasal rinse (such as the Neilmed Sinus Rinse Kit or NetiPot), you now have a sinus infection. Prior to the 5-7 days, we cannot know if your issue is just stagnant allergy secretions or a viral infection like a cold or flu. It is at this point that we recommend that you either see your primary care physician or your ENT specialist for an antibiotic. If you have this sort of infected drainage for over 3 months or have had to be on antibiotics for sinus infections 3-4 times or more, then you likely have developed chronic sinusitis and should see an ENT doctor to see if there is infection that is trapped and needs drained surgically. Many times, chronic sinusitis starts out as allergies that have gotten out of control, and your ENT will likely discuss a necessary daily regimen to try to manage this underlying condition to help prevent future infections and even surgery.
How do I treat my allergies so that I don’t get a sinus infection?
If you are looking for things to do at home that have been clinically proven, then you are in luck! Most of our good prescription allergy treatments have gone over the counter and are available for the general public. We recommend combining an oral antihistamine with a nasal steroid while also rinsing your nose daily with a saline rinse for best coverage. Many people are turned off by the idea of a nasal rinse, but as Dr. Medaris always says, “Dilution is the solution to pollution!” So giving it a good college try is worth the benefits! If you do not like the idea of daily medication, it is worth mentioning that local honey and essential oils (also technically “medicines”) are not well studied, and there is no sound scientific evidence of the effectiveness of these treatments. We also do not recommend nasal or oral decongestants such as Sudafed, pseudoephedrine, oxymetazoline (Afrin), neosynephrine, or Vicks inhalers, as these drugs have side effects that can affect blood pressure, heart beat/rate, and also can cause rebound or worsening nasal congestion.
Oral Antihistamines & Nasal Steroid Sprays Available Over the Counter That We Recommend: (store brands and generics are just as effective)
***ALL OF THESE MEDICATIONS COME IN DOSING FOR CHILDREN AS WELL AS ADULTS!
***FLONASE AND FLONASE SENSIMIST COME IN DOSING FOR CHILDREN AS WELL AS ADULTS!
When the allergy treatment fails…
If you are treating your allergies, or your children’s allergies, and still get a sinus infection, you need to be seen and evaluated, as there are other prescription medications that can be tried. We also offer allergy testing and allergy treatment to help desensitize you to the things that are causing you to be sick in the first place. Or if the problem is severe enough, surgery may be an option; however, we can never really cut out allergies or infection.
The bottom line here, is that you do not have to suffer! We are the Omaha and Bellevue area’s one-stop sinus and allergy shop, and we are here to help you get your life back so that you can cheer on your favorite football team, take that trip with your kids through the corn maze, enjoy a night by the campfire with friends, or do whatever fall activities you have been missing out due sinus and allergy. Call us today for your evaluation 402-778-5250 or request an appointment online!
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