ENT - Otorhinolaryngology (ORL)

Ear, Nose and Throat Surgery (ENT) is also known as Otorhinolaryngology, Head and Neck Surgery. This area of medicine is concerned with disorders of the ear, nose, throat, the head and the neck.

ENT Surgeons (or otorhinolaryngologists) are specialist doctors who deal with medical and surgical treatment of conditions of the ears, nose, throat and structures of the head and neck.

Consultants

Dr Colin Barber Paediatric ORL Surgeon
Dr Michel Neeff Paediatric ORL Surgeon, Clinical Director
Dr Graeme van der Meer Paediatric ORL Surgeon
Dr Ed Toll Paediatric ORL Surgeon
Dr Raymond Kim Paediatric ORL Surgeon
Dr Craig McCaffer Paediatric ORL Surgeon
Dr Tanja Jelicic Paediatric ORL Surgeon

Referral Expectations

If your child has an urgent problem requiring immediate surgical assessment you are referred acutely to the ORL Department where your child will initially be seen by the Registrar (a trainee specialist) who will decide whether he/she needs to be admitted to hospital. Investigations will be performed as required and the more senior members of the team involved where necessary.

If the problem is not urgent, the GP will write a letter to the ORL Department requesting an appointment in the outpatient clinic. Each month the Department receives more new referrals than can be seen in clinic. One of the consultant surgeons working in the Department reviews the referral letters to determine who should be seen first, based on the information provided by the GP. Very urgent cases are usually seen within a couple of weeks, but other cases may have to wait a much longer time. Routine cases are often returned to the GP with some management advice.

When you come to the ORL Outpatient Department you will be seen by a member of the ORL team who will ask questions about your child's illness and examine him/her to try to determine or confirm the diagnosis. This process may also require a number of tests (e.g. blood tests, x-rays, scans etc). Sometimes this can all be done during one clinic visit, but for some conditions this will take several follow-up appointments. Occasionally some tests are arranged even before you are seen at the hospital to try to speed up the process.

Once a diagnosis has been made, the medical staff will discuss treatment with you. In some instances this will mean surgery, while other cases can be managed with medication and advice. If surgery is advised your child will be put on the elective surgical waiting list. Again these waiting lists are ordered according to the urgency and severity of the condition. The steps involved in the surgical process and the likely outcome are usually discussed with you at this time.

Common Conditions / Procedures / Treatments

Hearing Tests

Audiometry is the electronic testing of hearing ability. Your child will sit in a special room wearing earphones and be asked to respond when he/she hears a noise through the earphones. These tests can measure their hearing levels as well as other aspects of hearing such as the ability to recognise speech against background noise. For younger children more specialised hearing tests are available.

Tympanometry uses sound and air pressure to check middle ear function. A small, soft probe is placed in the ear for a few seconds and a computer measures the ear's response to sounds and pressure emitted through the probe. This test is often carried out in young children to assess for glue ear.

Otitis Media

This is inflammation or infection of your middle ear (the space behind your eardrum) and is often associated with a build-up of fluid in your middle ear.

Acute Otitis Media

This is usually caused by a temporary malfunction of the Eustachian tube due to allergies, infections or trauma. The Eustachian tube connects the middle ear to the nose and allows air to enter the middle ear, thus making middle ear pressure the same as air pressure outside the head. Acute otitis media results in an infection in the middle ear causing pain, fever and a red, bulging eardrum (the thin, transparent membrane between the outer ear canal and the middle ear). This condition is usually seen in young children. The treatment may be antibiotics if it is suspected to be a bacterial, rather than viral, infection, or if there are repeated episodes, surgical insertion of grommets into the eardrums may be required. Grommets are tiny ventilation tubes that allow normal airflow into, and drainage out of, the middle ear until the Eustachian tube begins to work normally. The operation is done under general anaesthesia (the child is asleep) and takes 10-15 minutes. Most grommets fall out naturally after six to twelve months, by which time the Eustachian tubes are often working properly.

Otitis Media with Effusion (Glue Ear)

Like acute otitis media, glue ear is usually the result of a temporary malfunction of the Eustachian tube and may either follow an episode of acute otitis media or occur on its own. The condition is usually seen in children. Fluid is present in the middle ear and the ear is not usually painful, but the ear drum is not red and bulging and there is no fever. Glue ear may lead to hearing loss, which can result in speech delays, and balance problems. Treatment options include: a prolonged course of antibiotics; grommet insertion; or treatment with decongestants, antihistamines or steroids.

Chronic Otitis Media

If the Eustachian tube is blocked repeatedly over a period of several years, there may be changes to the tissues of the middle ear such as deformity of the ear drum and damage to the bones of the ear. These changes may result in hearing problems, balance problems, and persistent deep ear pain. If such long term damage has occurred, an operation called tympanomastoidectomy may be required. This involves making an incision (cut) behind or around the upper part of your ear, drilling through the mastoid bone and removing, and possibly repairing, damaged tissues.

Otosclerosis

When the growth of one of the tiny bones in your middle ear, the stapes, changes from hard to soft and spongy, it leads to the condition called otosclerosis. As this abnormal growth develops, the stapes becomes more rigid or fixed in position. The stapes needs to be able to vibrate to allow sound vibrations to pass through to the inner ear. When the stapes is not vibrating as well as it should, gradual hearing loss can occur. Otosclerosis may occur in one or both ears and may sometimes be associated with ringing/clicking/buzzing noises in your ear (tinnitus). The condition will be diagnosed by hearing tests and tympanometry. Otosclerosis most often develops during teenage and early adult years and it tends to run in families. The condition can become worse during pregnancy.

Treatment

There are several different approaches to treating otosclerosis, one of the most common being a surgical procedure called stapedectomy. This is a microsurgical procedure (microscopic lenses are used to help the surgeon see the tiny structures involved) usually performed through the ear canal. A small cut (incision) is made in the ear canal near the eardrum and the eardrum is lifted, exposing the middle ear and its bones. Part of the stapes bone is removed and an artificial prosthesis inserted to help transmit sound into the inner ear. The eardrum is then folded back into position. The surgery can either be performed under general anaesthetic (you sleep through it) or local anaesthetic (the area treated is numbed) plus sedation (you are given medication to make you feel sleepy). You will be advised not to fly, blow your nose or allow any water to get into your ear for about six weeks after the operation. Other treatments include use of a hearing aid or taking sodium fluoride which helps harden the bone and can improve hearing in many patients with otosclerosis.

Hearing Loss

Hearing loss can be divided into two types: conductive hearing loss (caused by some sort of mechanical problem in the external or middle ear) or sensorineural hearing loss (caused by disorders of the inner ear, hearing nerve or associated brain structures).

Conductive hearing loss is often reversible and can be due to:

blockage of the ear by e.g. wax, inflammation, infections or middle ear fluid
poor sound conduction because of e.g. holes or scarring in the eardrum or the bones of the middle ear (ossicles) becoming fixed and rigid.

Sensorineural hearing loss is generally not reversible and can be caused by:

genetic make-up (this could include congenital conditions i.e. those you are born with, or late-onset hearing loss)
head injury
tumours
infections
certain medications
exposure to loud noises
the aging process (a significant hearing loss is experienced by about one third of people aged over 70 years).

Some of the signs you might notice that indicate you have a hearing loss include:

having to turn up the volume on the TV or radio
finding it hard to hear someone you are talking with
finding it hard to hear in a group situation where there is background noise e.g. in a restaurant
having to ask people to repeat themselves
you find people's speech is unclear - they are mumbling

Hearing loss can be partial (you can still hear some things) or complete (you hear nothing) and may occur in one or both ears.

Treatment

Treatments for hearing loss range from the removal of wax in the ear canal to complex surgery, depending on the cause of the loss. One of the most common treatments for hearing loss is the use of a hearing aid. The type of aid you get depends on the cause of your hearing loss and how bad it is, as well as what your preferences are in terms of comfort, appearance and lifestyle.

If your hearing loss is severe to profound, you may be suitable for a surgical procedure known as a cochlear implant. In this procedure, a small cut (incision) is made behind your ear and a device is implanted that can bypass the damaged parts of your ear. The surgery usually takes 2-3 hours and is performed under general anaesthesia (you sleep through it). You may be able to go home the same day or have to spend one night in hospital.

Sinusitis

In the facial bones surrounding your nose, there are four pairs of hollow air spaces known as sinuses or sinus cavities. These sinuses all open into your nose, allowing air to move into and out of the sinus and mucous to drain into the nose and the back of your throat. If the passage between the nose and sinus becomes swollen and blocked, then air and mucous can become trapped in the sinus cavity causing inflammation of the sinus membranes or linings. This is known as sinusitis.

Sinusitis can be:

acute - usually a bacterial (or sometimes viral) infection in the sinuses that follows a cold, or an allergic reaction.
chronic - a long term condition that lasts for more than 3 weeks and may or may not be caused by an infection.

Sinusitis can be a recurrent condition which means it may occur every time you get a cold.

Symptoms of sinusitis include:

facial pain or pressure
nasal congestion (blocking)
nasal discharge
headaches
fever.

Treatment for bacterial sinusitis is antibiotics and for non-infective sinusitis may include steroid nasal sprays and nasal washes.

If this treatment is unsuccessful, surgery may be considered. This is usually performed endoscopically; a tiny camera attached to a tube (endoscope) is inserted into your nose. Very small instruments can be passed through the endoscope and used to remove abnormal or obstructive tissue thus restoring movement of air and mucous between the nose and the sinus.

Snoring

Snoring is the harsh rattling noise made by some people when they sleep. Snoring occurs when the flow of air through the back of the mouth and nose becomes partially blocked and structures such as the tongue, soft palate (the back part of the roof of the mouth) and uvula (the tag that hangs at the back of the mouth) strike each other and vibrate.

Causes of snoring include: nasal polyps; a bend in the nasal septum (the partition running down the middle of the nose), large tonsils or adenoids, obesity, smoking, excess alcohol.

Surgical treatment of snoring involves the removal of excess loose tissue in the throat or soft palate.

Obstructive Sleep Apnoea (OSA)

When snoring is interrupted by episodes of totally obstructed breathing, it is known as obstructive sleep apnoea. The obstruction is caused by the relaxation of muscles that support the soft tissues at the back of the throat such as the uvula, soft palate, tongue and tonsils. These tissues then collapse and momentarily block the airway.

Episodes may last 20 seconds or more and may occur hundreds of times per night. While you are not breathing, the levels of oxygen in your blood drop which causes your blood pressure to go up and adds strain to your cardiovascular system. In addition, you are likely to feel overly tired during the day and your work, driving and overall performance may be affected.

The usual treatment for OSA is to wear a nasal mask that delivers pressurised air to keep the airways open while you sleep. This treatment is known as Continuous Positive Airway Pressure (CPAP).

Rhinitis

Rhinitis is the inflammation of the lining of the nose (nasal mucosa). The most common symptoms are a blocked, runny and itchy nose.

Rhinitis can be:

allergic – either seasonal (hay fever) caused by pollen allergies or perennial caused by e.g. house dust mite, pets.
infectious – e.g. the common cold
non-allergic, non-infectious – caused by irritants such as smoke, fumes, food additives

In the case of allergic rhinitis, the specific allergen (the thing that you are allergic to) may be identified by skin prick tests. This involves placing a drop of the allergen on your skin and then scratching your skin through the drop. If you are allergic, your skin will become red and swollen at the site.

Treatment of allergic rhinitis involves avoiding the allergen if possible, but if not possible then corticosteroid nasal sprays and antihistamines are the usual medications prescribed.

Tonsillitis

Your tonsils are the oval-shaped lumps of tissue that lie on both sides of the back of the throat. Sometimes tonsils can become inflamed (red and swollen with white patches on them) as the result of a bacterial or viral infection; this is known as tonsillitis.

If you have tonsillitis, you will have a very sore throat and maybe swollen glands on the side of your neck, a fever, headache or changes to your voice. In some cases, pus can be seen on the tonsils.

Tonsillitis mostly occurs in young children and can be a recurrent condition (it keeps coming back).

If the tonsillitis is caused by bacteria, antibiotics will be prescribed. If the tonsillitis is caused by a virus, treatment will usually consist of medications to relieve symptoms such as a pain killer.

If tonsillitis occurs often over a period of two or more years, then surgical removal of the tonsils (tonsillectomy) may be considered.

Swallowing Disorders (Dysphagia)

If you find it difficult to pass food or liquid from your mouth to your stomach, you may have a swallowing disorder or dysphagia. Symptoms may include: a feeling that food is sticking in your throat, discomfort in your throat or chest, a sensation of a ‘lump’ in your throat, coughing or choking.

A disorder may occur in any part of the swallowing process such as the mouth, pharynx (tube at the back of the throat that connects your mouth with your oesophagus), oesophagus (food pipe that takes food to your stomach) or stomach.

Causes of dysphagia include: the common cold, gastro-oesophageal reflux, stroke or a tumour.

Diagnosis may be by examination of a mucous sample or by viewing the pharynx, oesophagus and stomach using a small, flexible tube with a tiny camera on the end that is inserted down the back of your throat.

Treatments for dysphagia depend on the causes, but may include:

medication – antacids, muscle relaxants or medicine to slow down stomach acid production
changes in diet and/or lifestyle
surgery e.g. stretching or releasing a tightened muscle

Hoarseness

Hoarseness can be described as abnormal voice changes that make your voice sound raspy and strained and higher or lower or louder or quieter than normal.

These changes are usually the result of disorders of the vocal cords which are the sound-producing parts of the voice box (larynx).

The most common cause of hoarseness is laryngitis (inflammation of the vocal cords) which is usually associated with a viral infection but can also be the result of irritation caused by overuse of your voice e.g. excessive singing, cheering, loud talking.

Other causes of hoarseness include:

nodules on the vocal cords – these may develop after using your voice too much or too loudly over a long period of time
smoking
gastro-oesophageal reflux disease (GERD) – stomach acid comes back up the oesophagus and irritates the vocal cords. This is a common cause of hoarseness in older people
allergies
polyps on the vocal cords
glandular problems
tumours.

Diagnostic tests may include viewing the vocal cords with a mirror at the back of your throat or by inserting a small flexible tube with a camera on the end (endoscope) through your mouth. Sometimes tests may be done to analyse the sounds of your voice.

Treatment depends on the cause of the hoarseness and may include resting your voice or changing how it is used, avoiding smoking, medication to slow stomach acid production and sometimes surgical removal of nodules or polyps.

This information has been provided by healthpoint.co.nz, helping people better understand and use New Zealand health services.