INFORMATION

Background

Saline (saltwater) nasal rinses are an excellent and safe treatment for your nose and sinuses. The nose collects dust and pollens when you breathe in. For people with a tendency to allergic rhinitis (hay fever) or sinusitis, this dust and pollen may cause the lining of the nose to swell resulting in a blocked nose and/or sinuses. The nose then tries to clear the dust and pollen by producing excess mucus to ‘flush out’ the dust and pollen, causing mucus to run out the front of the nose or drip down the back of the throat.

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There is good scientific evidence that saline rinses improve rhinitis and sinusitis symptoms with improved quality of life for patients. They are a safe and ‘natural’ treatment and have the same action on the nose as going for a swim in the sea.

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How to use saline rinses

You should rinse your nose at least once daily. You may need to rinse multiple times a day if your symptoms are worse, you are in a dusty environment or you have recently had surgery on your nose/sinuses. Given that it is a natural and safe treatment, you cannot ‘overdose’ by rinsing too often. 


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1. With your head downward over a sink (or in the shower), turn your head to one side

2. Squeeze the saline rinse gently into the top nostril

3. Breathe normally through your mouth

4. The solution should come out through your other nostril

5. Repeat the process on the other side
    

There are excellent short instructional videos on YouTube, search for ‘NeilMed Sinus Rinse Video’.

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Where to get salt sachets and DIY recipe

• The sachets contain salt and baking soda and so you do not need a prescription to get refills. Sachets can be purchased over-the-counter from pharmacies or on-line (often cheaper).

• You make your own rinse solution by dissolving 1 ⁄ 2 teaspoon of non-iodised salt and 1 ⁄ 4 teaspoon of baking soda in 250ml of warm water

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Practical tips

• If you are also using a nasal spray, use the saline rinse first to avoid washing the spray out of your nose


• If you cannot tolerate full rinses try using a saline spray instead (not as effective, but better than nothing)


• Manufacturers recommend you replace the bottle or pot every three months


• Try adjusting your head position to prevent the rinse going into your ears or down the

  back of your throat


• Using rinse volumes over 200ml is more effective.

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Ear Wax

Why do we have ear wax?

Ear wax is a healthy normal substance that keeps our ear canals healthy. It is part of our immune system and allows our ears to clean themselves. Wax repels water, has anti-bacterial properties and stops dirt, dust and other debris getting farther into the ear.

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Our ears have a self-cleaning mechanism that slowly expels wax from the ear. The skin in the ear canal very slowly migrates outwards, carrying the wax and any trapped debris with it.

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What will happen if I do not clean my ear canals?

In almost every case, the ear’s self-cleaning mechanism will clear wax from your ear canals at a slow but steady rate, preventing excessive wax build-up, but keeping your ears healthy.

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How should I clear out ear wax?

Usually the best treatment to prevent excessive wax is to simply leave your ears alone and allow them to self-clean. It is especially important to avoid using cotton buds or other implements in your ears (see below).

Some people do need wax cleared out for various reasons, including some hearing aid users and people who have had radiotherapy or ear surgery.

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If wax is causing a problem, there are several ways to remove it: 


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• Wax dissolving drops - you can buy these over the counter at most pharmacies. Olive oil

  is another alternative, though it is less effective.


• Ear syringing - this can often be done at your GP clinic


• Ear suctioning - this is performed with specialised equipment, including a microscope, by ENT Surgeons and Ear Nurse Specialists. It is the safest way to clean ears, but the most expensive and can be a little uncomfortable.

  What is wrong with using cotton buds?

• Cotton buds are a frequent cause of excessive wax and ear problems. They remove only a small amount of wax from the ears, pushing most of the wax deeper into the ear canal where the ear’s self-cleaning mechanism cannot clear it out. Worse still are the hundreds of tiny scratches cotton buds cause, which lead to irritation and entry points for bacteria to cause painful infections (otitis externa). 


• Irritation from cotton bud use is a very common cause of chronically itchy and uncomfortable ears. Other implements such as bobby pins and paper clips can be just as harmful. The discomfort and irritation will not stop if there is ongoing cotton bud use.
  
   

How Best to Use Ear Drops

Background

• If possible get someone to put the drops in the ear canal for you


• Lie down with the affected ear up

• Once the drops are in place, stay in this position for 3-5 minutes. Use a timer to help measure the time. It is important to allow adequate time for the drops to penetrate into the ear canal.

• A gentle to-and-fro movement of the ear will sometimes help in getting the drops to their intended destination. An alternate method is to press with an in/out movement on the small piece of cartilage (tragus) in front of the ear.

• You may then get up and resume your normal activities. Wipe off any excess drops.

• Keeping the ear dry is generally a good idea while using eardrops

• Try not to clean the ear yourself as the ear is very tender and you could possibly damage the ear canal or even eardrum

• If the drops do not easily run into the ear canal you may need to have the ear canal cleaned by your clinician or have a wick placed in the ear canal to help in getting the drops into the ear canal

• If you do have a wick placed, it may fall out on its own. This is a good sign as it means the inflammation is clearing and the infection subsiding.

• Do not remove the wick yourself unless instructed to do so
  
   

Grommets: Post-Operative Care

Background

• Grommets, also known as ventilation tubes, drain fluid from behind the eardrum to relieve hearing loss and/or pain


• Most grommets stay in for 6 to 18months, allowing many children to outgrow their ear problems


• Grommets usually fall out on their own. They are very small and you usually do not notice them when they fall out.

  What to expect after surgery

• Your child may resume normal activities, including school/daycare, the day after surgery


• There may be some blood-tinged drainage from the ear after surgery. Drainage is normal

  for the first 48 hours after surgery.


• Your child may have a mild ear ache for a few hours after surgery
   

Medications after surgery

• Some children require a course of ear drops for a few days after grommets are placed. If drops are needed for your child, you will be given a prescription before you leave the hospital.


Once grommets are inserted they cause minimal pain. Paracetamol or ibuprofen are usually the only pain relief required.
 

Water precautions

Most children with grommets do not need to take special precautions when bathing or swimming. Wearing ear plugs has little effect on preventing problems and data show a child would have to wear them on average for almost three years to prevent one episode of mucky discharge from the ears.
 

Most guidelines recommend against the routine use of water precautions as there is little benefit and this is outweighed by the associated cost, inconvenience and anxiety.
 

Some children with grommets find that water stings their ears when they swim. If this occurs it will not damage your child’s ears, but it may be more comfortable for them to wear ear plugs when swimming.
 

Ear infections

Your child may still get ear infections with grommets, however they are unlikely to have ear pain with these infections.
 

Visible drainage from the ear canal

• If an infection occurs you usually notice drainage or a bad smell from the ear canal. The drainage may be clear, cloudy, or even bloody. If your child gets an ear infection with visible drainage from the ear canal:

• Do not worry - the drainage indicates the grommet is working


• The best treatment is usually antibiotic drops alone. You may be prescribed ‘eye drops’ to

• use in the ear, as these are less likely to sting.


• Oral antibiotics are unnecessary for most ear infections with grommets, unless your child

• is very ill or has another reason to be on an antibiotic


• When there is drainage from the ear, avoid getting water in the ear canal when bathing or

• hair washing - cotton wool coated in vaseline works well
   

No drainage from the ear canal

• If your child gets an ear infection without visible drainage:

• Your doctor or nurse will check if the grommet is still working by looking to see if it is in place and not blocked. If the grommet is working, the infection will usually resolve without the need for antibiotics.


• If the grommet is blocked, the ear infection is treated as if the grommet was not there. The blocked grommet does not do any harm, but neither does it do any good.


• Ibuprofen and/or paracetamol may be necessary for any ear pain
   

References

Water precautions for prevention of infection in children with ventilation tubes (grommets). Cochrane Database of Systematic Reviews 2016 [DOI: 10.1002/14651858.CD010375.pub2.]
 

Laryngopharyngeal Reflux

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Background

Laryngopharyngeal reflux (LPR) is when acid and digestive enzymes from the stomach flow back up the oesophagus (food pipe) into the back of your throat. LPR is often accompanied by symptoms of gastroesophageal reflux such as heart burn or ‘indigestion’. However, you can have LPR symptoms without having heartburn.
 

LPR is generally not a dangerous condition, but it can contribute to bothersome problems including:

• Cough
• Frequent throat clearing
• Sensation of a lump in the throat
• Hoarse voice
• Burning or acid taste in the throat
• Sensation of mucus/fluid in your throat.
 

There are numerous causes of LPR and so treatment is also varied. Treatments can be categorised as changes in lifestyle, medication-based or (rarely) surgery.
 

Lifestyle modification
Weight loss

If you are overweight, weight loss is usually the most effective treatment for your LPR. Weight loss will only come from a combination of improving your diet and increasing your physical activity.
 

Avoid foods/drinks that cause LPR 

Foods and drinks that cause LPR include:

• Alcohol
• Fizzy drinks including beer
• Chocolate
• Peppermints
• Spicy foods
• Acidic foods (eg tomatoes and lemons/oranges/limes).

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Meal times

Large meals shortly before going to bed will make LPR worse. Try to have an early dinner.
 

Raise the head of your bed

Place blocks or books under the bed legs at the head of your bed to raise the bed head by 10-15cm. By doing this, gravity will help stop flow of stomach acid and digestive enzymes up your food pipe into your throat.

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Olfactory (Smell) Training Therapy

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Background

There are many causes of loss of smell, the most common being viral infections, sinus disease, and age-related changes. Olfactory training (OT) is a relatively new treatment for disorders of smell and there have now been several meta-analyses showing OT is safe, cost- effective and can help you recover your sense of smell.

OT involves sniffing four potent scents twice a day for several months to retrain the brain and smell receptors in your nose, in much the same way that exercise trains your muscles, heart and lungs. Just like physical exercise, it takes a sustained effort and it is not a quick fix. OT works on the basis of neuroplasticity, which is the brains ability to compensate for a change in sensory input.
 

Is olfactory retraining appropriate for me?

It is important the underlying cause of your loss of smell is first diagnosed by a doctor. Although OT can be very helpful, it may be more effective to treat the underlying cause.
 

How to use olfactory retraining

Purchase four different fragrances (eg lemon, rose, eucalyptus and clove) essential oils from a chemist or supermarket. Some people prefer to use other strong odours, such as cooking herbs, cinnamon, chocolate, coffee etc. The actual scents used are not critical, as long as they have a strong odour you use four different ones.
 

Open a bottle and take repetitive short sniffs, rather than one long sniff, for 20 seconds. Repeat this for all four fragrances twice a day.
 

Results may be improved if you ‘visualise’ the smell as you as you sniff it. For instance, picture in your mind a eucalyptus tress as you smell eucalyptus oil. This helps neural pathways to regenerate between the smell receptors in the nose and the smell centres in the brain. 

 

As your sense of smell recovers, you may notice previously pleasant smells become awful, known as parosmia. This is a sign that your sense of smell is recovering and you should persist with OT.

How long will it take for my smell to recover?

In general, the longer you use OT, the greater your improvements will be. The minimum duration you should use OT is 3 months. There is no maximum time to use it for, and many patients continue to use it for years.

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What are my chances of recovering my sense of smell?

The sooner you start OT the better the results. Conversely, the longer it has been since you lost you sense of smell, the less likely you are to have a significant improvement in your symptoms. The prognosis of smell recovery also depends on the cause of your loss of smell. In general, approximately two thirds of patients experience improvement. OT has been shown to help about 30% of patients with loss of smell.
 

Are there any medications or operations that will help?

If there is an underlying condition causing your loss of smell, such as sinusitis, there may be surgery or medication that is helpful. However, for most causes of loss of smell there are no effective medications or supplements.
 

Practical Tips

• If the fragrance bottle has a very small opening, it may be better to tip a drop onto paper tissue to smell


• If you cannot smell the scents do not give up, OT can still work


There are several useful videos on YouTube, search for ‘AbScent NoseWell Smell Training’.




Interesting articles

www.nytimes.com/2021/03/26/well/live/covid-anosmia-smell-training.html


www.theatlantic.com/health/archive/2021/03/covid-19-smell-recovery-its-own-strange-

experience/618357/


www.bbc.com/news/health-56865129

Tonsillectomy & Adenoidectomy: 
 Post-Operative Instructions

General advice

• Do not plan any trips where you are more than 60mins from emergency medical help for at least two weeks after tonsillectomy - major bleeding is uncommon but can occur without any warning during these two weeks


• Take pain relief regularly, even if you are not too sore. It is best to ‘stay ahead’ of the pain rather than wait until it is very bad. Most patients are prescribed several different pain medications that work well in combination with each other.


• Eat and drink normally - there are no food types you need to avoid. We now know that two weeks of soft food is unnecessary and the sooner you return to a normal diet the better.


• Take frequent small sips of water throughout the day to minimise the chances of dehydration, which worsens the pain


• Avoid exercise and heavy lifting for 3 weeks after the surgery


• You can brush your teeth normally
   

Bleeding after a tonsillectomy

You should either call an ambulance (dial 111) or go promptly to the nearest emergency department if you:

• Spit out more than one tablespoon of blood for adults


• Spit out more than one teaspoon of blood for children


• Child vomits blood (children may swallow blood, which then makes them vomit it up)
   

Approximately 1 in 30 patients will have bleeding after a tonsillectomy. This can occur any time up to three weeks after the surgery, but most often occurs around days 5 to 8. Most bleeding settles on its own, but a small number of bleeds become very serious and potentially life-threatening. For this reason, bleeding after a tonsillectomy should never be taken lightly.
 

What to expect after tonsillectomy

The following symptoms are all normal after a tonsillectomy and will resolve without any specific treatment:

• It will take at least 2 weeks to recover from you operation


• The back of your throat will look white and ‘mucky’ - this is not an infection and does not

  need any antibiotics •

• Your ears may hurt - this occurs because the pain signals from the throat and ears are carried by the same nerve to the brain. Take pain relief as needed.


• You will gradually feel better over about 5 days. Between days 5 and 7, patients often feel worse for 24-48hrs, before continuing on with a steady recovery.


• Ongoing snoring and/or apnoeas (breath holding episodes) may occur for a few weeks after the operation until all the swelling has settled


• There may be some small streaks of blood in your saliva


• Your breath will smell for about two weeks


• Uvula swelling - the uvula is the ‘dangly thing’ at the back of your mouth and it is often swollen after a tonsillectomy. The swelling should settle on its own.