Cricoid Pressure May Minimize Symptoms of Reflux (LPR)

Specifically throat symptoms attributable to reflux such as globus, throat-clearing, phlegmy throat, chronic cough, etc. However, cricoid pressure may not be realistic nor practical even if it does help.

In one of the more unusual studies I have seen, researchers deliberately infused 60 cc of hydrochloric acid into the esophagus of 14 patients who suffered from LPR as well as 12 healthy controls. 9 patients exhibited confirmed LPR (laryngopharyngeal reflux) events, but none in the control group. With moderate sustained cricoid pressure (20-30 mmHg), only one patient had a confirmed LPR event.

Theoretically, why would cricoid pressure work?

The cricoid cartilage is located immediately below the voice box. It is a circular cartilage that is right at the level where the throat connects to the esophagus. By putting pressure on the cricoid cartilage, the top part of the esophagus is manually compressed shut which theoretically would prevent reflux from regurgitating up into the throat.

It is based on this theory that anesthesiologists often perform cricoid pressure to prevent aspiration during intubation for surgery, especially if a patient is suspected of drinking/eating something prior to surgery.

The problem with cricoid pressure is that in order for this to work, it needs to happen continuously which may make it unrealistic and impractical for patients who suffer from LPR. Continuously means 24/7/365. Not just when symptoms are present (because it's too late than).

Reference:
Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24735.

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Acupuncture Alleviates Pain After Tonsillectomy in Children

The study showed that acupuncture significantly decreased pain after tonsillectomy in children (2-17 years of age) with reported pain levels before acupuncture of 5.52 (SD=2.28) out of 10 which fell to 1.92 (SD=2.43) after acupuncture.

This retrospective research was conducted in 31 patients who underwent a tonsillectomy within a 3 month period of time by Dr. James Ochi, one of only a handful of dual board-certified ENT and medical acupuncture in the United States. No study patients received any narcotics for pain control beyond tylenol, ibuprofen, and a single dose of intra-operative dexamethasone. The tonsillectomy itself was performed using electrocautery set at 24W.

The acupuncture points used for pain control are shown below and was performed bilaterally:

Image taken from the Research Paper

All patients received acupuncture at LI4 (between thumb and index finger). Additional points were found effective in relieving tonsillectomy pain and provided on an as needed basis at (in decreasing frequency) CV23, GV24.5 and GV20. Acupuncture points LI20, LI11, and LI10 were utilized in only a few patients.

LI4 point is hypothesized to work so well because:

"Stimulation at LI4 increases activity in the somatosensory cortex and a region of the brainstem known as the periaqueductal gray area, as revealed by functional magnetic resonance imaging, that are involved in processing pain signals." [link]

Although promising, in order to be fully convinced of the effectiveness of acupuncture for post-tonsillectomy pain, further research that is prospective, randomized, and controlled is required.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.


Reference:
Acupuncture instead of codeine for tonsillectomy pain in children. International Journal of Pediatric Otorhinolaryngology Volume 77, Issue 12 , Pages 2058-2062, December 2013

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Sinus Headache [video]

I could describe it... but I think it's better if you just watch the video...

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Negative Ear Pressure Causing Inability to Pop a Clogged Ear

Have you ever closed the lid on an air-tight container containing a left-over hot meal and stuck it in the refrigerator? And than when you try to open the lid the next day once that hot meal cools down, it is REALLY hard to open the lid because of the accumulated negative pressure? In essence, the negative pressure has "locked" the lid down.

Well, something similar can also potentially happen inside the ear with eustachian tube dysfunction, especially with negative pressure (rather than positive pressure).

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva (watch video below). Once medical treatment has failed, ear tube placement has been the step of last resort.

The question some patients have is WHY does it become so hard to get an ear to pop open with eustachian tube dysfunction...

It may be that the mucosal lining of the eustachian tube has swelled to the point that there is no opening present.

There may also be a physical obstruction blocking the eustachian tube due to large adenoids, nasal polyps, or some other nasal mass.

However, a lesser known phenomenon is due to the negative pressure itself creating a suction effect on the lining of the eustachian tube analagous to the stuck container lid mentioned in the first paragraph. The middle ear negative pressure itself may be literally "sucking" the lining of the eustachian tube closed. If the negative pressure is great enough, it may be very hard to get it open.

When this happens, the eustachian tube becomes "locked".

One can "mimic" this effect even in a healthy individual (not that anybody would want to try). When a swimmer dives deep into the water, some ear pain will start to develop due to the negative pressure building up in the middle ear. If the swimmer does not ear pop and continues to go deeper into the water, at around 3.9 feet, it may start to get very difficult to get the ear to pop open even with effort. At around 5 feet of water depth, it will become impossible to pop the ear open. Normally, swimmers and SCUBA divers continuously ear pop when diving at depth to prevent any ear discomfort.

As such, in situations where negative ear pressure is present and medications fail to resolve the ear clogging, a hole can be surgically made in the eardrum WITHOUT tube placement which will often resolve the symptoms fairly quickly. The hole "releases" the negative pressure to allow the eustachian tube to function normally. The analogy would be that once you release the negative pressure within an air-tight container, it becomes very easy to remove the lid thereafter.

The eardrum hole typically heals closed in a few weeks and the clogged ear sensation will often not come back. If it does, the myringotomy (surgically creating a eardrum hole) can be repeated and if necessary, a tube can be placed to prevent the body from healing the hole closed anytime soon.



Some things that have helped some people to pop their ears:

 

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"Mother's Kiss" to Remove Nasal Foreign Bodies

In 1965, a general practitioner Vladimir Ctibor described the "Mother's Kiss" technique of removing nasal foreign bodies in a child.

Essentially, a trusted adult (like a mother) places her mouth over the child's mouth as if to perform mouth-to-mouth resuscitation. While pinching off the unaffected nostril, the adult than blows gently into the child's mouth until resistance is felt caused by the child closing the glottis. At that moment, the adult gives a sharp explosive exhalation to deliver a strong puff of air that passes up into the nose and out the unblocked nostril. If successful, this air puff will also blow the foreign body out the nose as well.

If the adult blow's air when the child's glottis is open, air will just go into the lungs rather than up the nose.

Prior to the procedure, the child is informed that the mom will give the child a "big kiss," hence the name of this procedure.

Now... does this technique actually work?

According to one meta-analysis, it works about 59.9% of the time.

The way I consider it... it can't hurt to try before using instruments to manually remove the nasal foreign body. A "mother's kiss" is certainly a more comfortable and familiar approach for a child versus the alternative.

However, one warning point... the child should be calmly breathing during this procedure. If the child becomes hysterical during the procedure, the child might strongly inhale through the unblocked nostril and potentially suck the foreign body (if small enough) down into the lungs making an unlucky situation into a medical emergency.

Another point for those uninformed... do NOT use this procedure on ear foreign bodies. It will NOT work. The ear canal is a closed container with no inlet or outlet for any air pressure produced by a "Mother's Kiss." In fact, trying to perform this procedure on the ear may cause a ruptured eardrum and even permanent hearing loss.


Reference:
Removal of Foreign Bodies from the Nose. NEJM 1985; 312:725.

Efficacy and safety of of the "Mother's Kiss" technique: A systematic review of case reports and case series. CMAJ 2012. DOI:10.1503/cmaj.111864 (full length pdf)

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Ear Pain Causes Based on Acupuncture Principles

When a patient complains of ear pain or pressure, I wonder if an acupuncturist sees a problem with the whole body rather than a problem just around the ear itself...

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Yoga Pose to Treat Ear Pain or Pressure

So here's something I learned about yoga...

There is a yoga pose called Karnapidasana which can supposedly cure ear pain and pressure gradually over time. The term derives from "Karna" meaning ear and "Pida" which means pain, discomfort, or pressure.

So... who knows? Give it a try... if you can physically do it safely.

DISCLAIMER: Not recommended for those who are not flexible. Also, not something I personally recommend to treat ear pain and pressure.

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How Can Nasal Obstruction CAUSE Clogged Ears?

It is not uncommon that patients who suffer from a clogged nose also develop clogged ears.

Why??? There are 2 major and 1 minor reasons.

First a little anatomy lesson.

In the back of the nose, there is an opening that leads into a tunnel (eustachian tube) that goes up into the ear. When the ears get clogged, a person can get the pressure out by "popping the ears." This can be accomplished by yawn, swallow, or trying to blow out the nose that is pinched shut. When the ear pops, what happens is that the tunnel opens up allowing pressure to come out the ear. Watch video:



Mucosal Swelling

Now when the patient's nose gets obstructed, it may mean the nasal lining has become swollen making it difficult to breath. It also means the tunnel that goes up into the ear may be swollen shut as well. As such, it may become difficult if not impossible to pop the ears. This is known as eustachian tube dysfunction.

Negative Pressure Inside the Nose

However, there is a more active process that may lead to ear clogging beyond just mucosal swelling of the eustachian tube.

When the nose is obstructed, every time the patient tries to breath in thru the nose, negative pressure is built up in the back of the nose where the eustachian tube opening is located. As such, this negative pressure inside the nose can get transmitted up into the ear resulting in negative pressure to slowly build up in the ear as well which can ultimately cause a clogged ear sensation. This is just like sucking on a straw to draw fluid out of a cup, though in this case, the straw is analogous to the eustachian tube, the fluid is air, cup is the ear, and the mouth is the nose.

Bernoulli's Principle

In fluid dynamics, Bernoulli's principle states that for an inviscid flow, an increase in the speed of the fluid occurs simultaneously with a decrease in pressure.

To use an example, if you are driving a car with the window down, the fast-moving air outside the car creates a negative pressure inside the car causing things to not just blow around, but does cause some suction effect to things within the car (paper inside the car potentially getting "sucked" to the outside).

When the nose becomes clogged, airflow increases in the back of the nose (think garden hose where you have the same amount of water flow, but by changing the nozzle diameter, flow can be increased by making diameter smaller or decreased by making diameter larger). Due to Bernoulli's principle, negative pressure builds up inside the ear due to this increased nasal airflow.

This negative pressure can be transmitted into the ear causing it to become clogged.

So there you have it... 3 reasons why a clogged nose can lead to clogged ears!

That also means that often, if you just treat the clogged nose... the clogged ears will get better as well!

Reference:
Upper airway obstructions and chronic otitis media: A clinical study. American Journal of Otolaryngology - Head and Neck Medicine and Surgery. Volume 35, Issue 3 , Pages 329-331, May 2014

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Barometric Sinus Headache

MSNBC published a story on April 26, 2012 regarding headaches that come and go with pressure changes such as when flying in an airplane.

The neurological researchers call it "airplane headache" and the story makes it sound like a newly discovered headache, but in actuality, it is something that has been known for a very long time.

Human sinus cavities are air-filled cavities. When outside pressure changes relative to the air pressure within the sinus cavity, air pressure literally increases or decreases within the sinus cavity which a patient may perceive as pain/pressure over the face. This barometric sinus pressure would occur ONLY if the sinuses are clogged shut. If they are open, no problems would occur.

This phenomenon is analogous to a balloon (sinus cavity) that increases in size with decreasing pressure (going up a mountain or ascending in a plane) or decreases in size with increasing pressure (going down a mountain or descending in a plane).

As such, just like the MSNBC story suggests, the principal way to prevent such barometric sinus headache is to take a medication that prevents sinuses from clogging shut. One of the most effective medication is afrin nasal decongestant nasal sprayto be used 30-60 minutes before ascent and descent.

If this issue is a persistent chronic problem, surgical procedures such as balloon sinuplasty can be performed to make the sinus openings larger to decrease the chance of closure from mucosal edema.

Akin to barometric sinus pressure, the ears undergo a similar process which is why people "pop" the ears with pressure changes.

The ear equivalent of a barometric sinus headache is eustachian tube dysfunction.

Source:
Is flying giving you an 'airplane headache'? MSNBC 4/26/12

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Video of Eustachian Tube Popping Open with Valsalva

Ever wonder what the eustachian tube looks like when the ear pops open with valsalva maneuver? Valsalva is accomplished by trying to blow air out a nose that is pinched closed. The eustachian tube is a tunnel that goes from the back of the nose to the ear.

Well, here you go! Video provided courtesy of Dr. Vijay Anand.

Watch this video to see where this eustachian tube is exactly located.

Read more about ear popping and when one is NOT able to pop the ears, a condition called eustachian tube dysfunction!

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Video on Ear Clogging and What Happens When They Pop Open (or Don't)

A new video has been created describing anatomically how a person pops the ear open when it feels clogged or under pressure. Also explained is what happens anatomically when the clogged ear is very difficult if not impossible to pop open; a condition called eustachian tube dysfunction.

Check the video out here!

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Stabbing Headache Around Eye or Cheek

Do you suffer from a stabbing headache in the areas denoted in red? Do these headaches seemingly come out of nowhere one day? Perhaps started after a viral upper respiratory infection?

You may be suffering from a condition known as contact point headache. This type of headache is also known as:

• Sluder's neuralgia
• Anterior ethmoid neuralgia
• Sphenopalatine ganglion neuralgia
• Pterygopalatine ganglion neuralgia

This type of headache has often been confused with cluster headache, migraine without aura, sinusitis, or other undefinable pathology especially since CT scans and MRI scans that are obtained often do not reveal any tumor or presence of infection.

Click here for more information.

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