Table of Contents

I	Ears
	Earwax Itchy Ears Decreased Hearing Tinnitus
II	Nose
	Aging Rhinitis Bloody Nose Allergic Rhinitis
III	Throat
	Sore Throat Cough

Earwax

Ear wax or cerumen is produced in small subcutaneous glands in the outer one third of the external ear canal. The skin of the ear canal grows on the ear drum and migrates laterally out the ear canal, carrying the wax outward. With aging, the wax is thicker and the skin moves slower; wax is drier and accumulates.

The recommended home remedy is a prescription ear drop called Domeboro Otic. The ear drop moistens the wax and stimulates ear canal skin migration, thereby decreasing ear wax accumulation. Two drops are placed in each ear twice a week, usually after bathing - Tuesday and Saturday are fine. If a lot of wax has accumulated, this should first be removed by your physician.

Domeboro Otic should not be used for middle ear infections or in people with a perforation or hole in their ear drum. Domeboro is an aluminum acetate solution. You can make your own with acetic acid (vinegar) by mixing 1 part water, 1 part white table vinegar (approximately 5% acetic acid) and 1 part rubbing alcohol (70% isopropyl alcohol). This works equally well, but smells like vinegar, so that most people prefer the Domeboro Otic. Burrow's solution or Burrow's tablets can also be purchased as an over the counter medication. One can make one's own Domeboro Otic by mixing 1 part Burrow's solution with 1 part water and 1 part 70% isopropyl alcohol.

Assuming no tympanic membrane perforation, wax can be softened with 2 drops of mineral oil placed in each ear once or twice a week. Flushing or washing out ear wax with a bulb syringe is generally safe. Cleaning the outer ear with Qtips is practiced by millions, but never recommended by physicians because of the risks of injury by those who are too aggressive. For additional information click here: Cerumen.

Itchy Ears

Itchy ears is called otitis externa and is caused by irritation of the very delicate external ear canal skin, most commonly by Qtips or by hearing aids. The obvious solution is to stop using the Qtips or, if caused by hearing aids, give your ear canal a rest once a day for 1 hour and for at least 8 hours each night. Drying the ear canal after removing the hearing aid is beneficial. A hair dryer is ideal.

Otitis externa is easily treated with Domeboro Otic. Two drops are placed in the affected ear(s) twice daily until symptoms abate, and then twice weekly after bathing. If the condition is chronic, prophylactic treatment is required; the usual recommendation is 2 drops in the affected ear(s) twice weekly after bathing. You only need to treat the affected ear(s) and you can begin with 2 drops twice daily until symptoms abate.

To make your own ear solution, look at the recommendations under the previous section, Cerumen. For additional information on otitis externa, click here: Otitis Externa.

Decreased Hearing

Hearing diminishes with age. For some this is faster, for some it is slower. Loud noise exposure also causes hearing loss. The two conditions together are additive. The hearing loss of aging is insidious in onset, and symmetric. The diagnosis should be confirmed with an audiogram and ear examination. When the diagnosis is confirmed, several recommendations are made.

The audiologist will recommend hearing aids. These are excellent devices, but all too often are purchased and never used. Remember, you have a 30 day full return option. If the hearing aids are not what you expect, return them. Hearing aids cost anywhere from several hundred dollars to several thousand dollars.

A simpler amplification system is available from stores like Radio Shack. These will give you some idea whether or not you like amplification and, for many, are all that is needed. The best device at Radio Shack is a stereo amplified listener with 3 band equalizer. The Radio Shack catalog number is 33-1094 and the list price is $30. Ear plugs or ear phones are required. Because hearing losses are not equal across all frequencies, the equalizer adjustment option is strongly recommended. You will need to adjust this to determine the appropriate settings.

A second option is a headset amplification system. This is sold as catalog number 33-1095 for approximately $60. This, too, has individual frequency adjustments.

Next, you need to make several living adjustments. You can not communicate in a noisy environment. If you wish to talk with someone, you and they must stop other activities and pay full attention to each other. Turn off radios, turn off televisions and get away from background noise. Look each other in the face and communication will be facilitated. Gone are the days when one can communicate while watching TV with another person washing dishes in another room. Background noise must be eliminated, and people need to look at each other in order to take full advantage of other cues such as facial expression, lip movement, etc. Avoid restaurants that are noisy, and when eating out request a corner, a wall, or some relatively quiet place. The same adjustments need to be made at work. People need to face you and you need to communicate in a quiet environment.

Tinnitus

Tinnitus or ringing is a noise which comes either from your ear or your brain. Typically, it can only be heard by the patient. Tinnitus is most commonly associated with hearing loss. It can be a symptom of serious ear disease, so an audiogram and medical evaluation are required.

Assuming the diagnosis is sensorineural hearing loss associated with aging or noise exposure, there is no great treatment. The condition can not be medically or surgically treated. The best explanation for tinnitus is the following. In your inner ear there are thousands of little hair cells which, when stimulated, help you to perceive sound. Associated with aging or noise exposure or other injury, the hair cells die. Each of these hair cells is connected to the hearing centers of your brain by the acoustic nerve. The signal from the hair cell to the brain is a frequency-modulated signal, therefore stimulation is communicated by an increase or decrease in the rate of firing. When the hair cell dies and no signal is generated, the brain perceives this as a decrease in the rate of firing and interprets this as a noise.

The current recommendations for the management of tinnitus are the following. First and foremost, simply stop listening to it. This is a time when mind over matter is the best treatment. Secondly, avoid those quiet situations in which the tinnitus is most annoying. Maintain a certain amount of background noise with radios, televisions, etc. The most difficult time is bedtime, for at this time everything is quiet and the tinnitus is most annoying. One can play a radio as background noise. Some like to tune the radio between stations so that a white or static-type noise is generated. Alternatively, one can purchase devices which will make the sound of the waves at the ocean or a babbling brook, and play these as continuous background noise. This is sold at Radio Shack as a Sleep Machine, catalog #63-657 for approximately $40.

While most complain bitterly about their tinnitus, most cases are solved with the above recommendations.

If significant hearing loss exists, a hearing aid will mask the tinnitus. Even those with very limited hearing loss may perceive benefit from amplification. Always remember, you have purchased this with a 30 day guaranteed return. If the device does not work in the first 3 weeks, return it.

Lastly, there are devices called tinnitus maskers and there are clinics specializing in the evaluation and treatment of tinnitus. If all of the above has failed, tinnitus maskers are worth a try. Medications and other manipulations are not recommended.

Commentary: "My Pets, the Spider and The Cricket."

Tinnitus Weblinks

American Academy of Otolaryngology-Head and Neck Surgery, Patient Information on Tinnitus
This is the patient information booklet from the American Academy of Otolaryngology-Head and Neck Surgery. The information is accurate but limited.

Health Touch - Tinnitus
This is information provided by the American Speech-Language Hearing Association, the professional organization of audiologists. The materials are understandably slanted towards devices such as hearing aids and tinnitus maskers sold by this organization.

Aging Rhinitis

As one ages, one's mucous membranes and secretions are changed. Typically, less water is secreted and hence secretions become thicker. This results in thick postnasal discharge and a nasal secretion which becomes increasingly difficult to expel by either blowing one's nose or snorting. Other symptoms of an aging rhinitis are postnasal drip, often accompanied by cough and throat clearing. Men, in particular, seem to be afflicted and will cough, sputter, and snort. Voice changes may develop.

The standard treatments are increased fluid consumption and increased room humidification. These rarely provide much benefit.

The treatment we, at the UCSD Nasal Dysfunction Clinic, recommend is irrigating the nasal passages twice daily with a Waterpik. While at first this seems a bit unusual, a special nasal adaptor has been made for the Waterpik. The bowl is filled with warm tap water; 1 teaspoon of salt is added and then each nasal cavity flushed with 250 cc. of warm, salt water. This irrigation washes away the nasal mucous and, when performed twice daily, provides tremendous benefit for the aging nose. To obtain instructions and the appropriate adaptor for Waterpik nasal irrigation, you will need to contact one of the Nasal Dysfunction Clinic nurses who can provide instructions on its proper use.

Bloody Nose

A bloody nose is called epistaxis. It occurs to individuals of all ages, but is most annoying to the aging nose. As one ages, the mucous membranes thin. They are subject to drying, cracking, scabbing and bleeding. In addition, many take aspirin as prevention against heart disease, and many take nonsteroidal anti-inflammatory agents to alleviate musculoskeletal pains. Both of these medicines impair platelet function and leave one at greater risk for nose bleeds.

The treatment for these recurrent nose bleeds is multifaceted. Step one for those using aspirin is to use the least amount of aspirin possible. If you are taking aspirin prophylactically for your heart, one baby aspirin (80 mg) a day is all that is recommended. If you have questions, consult your physician. For those with arthritis and other musculoskeletal pains, use the nonsteroidals sparingly. The second step is to increase humidification. During hot weather we use air conditioners which dry the air, and during cold weather we often use heaters which also dry the air. Limit their use and, if the house is dry, a cold mist humidifier may provide benefit. The third step is to apply a vaselinated ointment to the nasal septum, for this moistens the scabs, promotes healing and diminishes the occurence of nose bleeds. Any vaselinated ointment is satisfactory. My preference is vaseline, but some prefer bacitracin or mycitracin ointment. Neosporin and other antibiotic ointments are not recommended for some develop allergic reactions to the antibiotics. Healing ointments such as aloe vera or vitamin E have not been shown to provide any extra benefit. I call the ointment nasal chapstick for, just as with chapped lips, the vaseline needs to be applied 5-10 times a day during difficult periods, and 2-4 times a day during the good periods. Picking or otherwise manipulating the nose is counter productive. The best way to apply the vaseline is to put a little bit on your finger and then apply the finger directly to the nostril. Do not try to push the vaseline in with a Qtip or with the finger tip. Simply press it up against the nostril, squeeze the nostrils and it will coat and cover the mucous membranes.

If the simple treatments recommended above fail to provide benefit, consultation with your physician is recommended, for epistaxis can be a symptom of other illness such as infection or tumor. For additional information, click here: Epistaxis.

Allergic Rhinitis

Allergic rhinitis affects as many as 30-40% of the American people. Fortunately, it tends to decrease as one ages. However, for some, particularly those with polyps, asthma, or very bad allergies, it can persist. Much of the evaluation and treatment of allergic rhinitis is medical and is not further discussed here. However, the key to the management of allergic rhinitis is environmental control. If you could remove all of the allergens from your environment, you would have zero symptoms. This is, unfortunately, not possible, but it is possible to greatly diminish many of the common allergens. For those wishing additional information, you are encouraged to read the section written by myself in Ambulatory Health Care Pathways for Ear, Nose and Throat Disorders. For those wishing additional information, click here: Allergic Rhinitis.

Sore Throat

The common cold begins with a sore throat. Most individuals will feel sick and may have an elevated temperature. Within a day or two the sore throat resolves and a runny nose ensues. At first, the nasal discharge is clear, but then typically turns yellow or green. Some colds are short lived and resolve within 3 to 5 days. Others last longer and may take as long as 10 - 14 days to completely disappear.

The cold is caused by a virus. To date, medicine has not discovered medication which provides significant benefit. The best current medical advice is to rest and maintain good hydration. Aspirin, nonsteroidal anti-inflammatory agents and Tylenol may provide some benefit. To whatever degree the nasal congestion is uncomfortable, steam, nasal irrigation and decongestants may provide benefit. The only natural herb scientifically shown to provide benefit is garlic, for this increases nasal secretion, loosens the secretion, and decreases the pain or pressure associated with the nasal congestion.

Antibiotics play no role in the treatment of a cold. The patient incurs a risk of becoming sensitive to the antibiotic, developing yeast infections, developing diarrhea and developing antibiotic resistance in their own bacteria.

An occasional individual develops bacterial sinusitis, typically after 2 or 3 days of a purulent nasal discharge, and just about the time one is beginning to improve, an intense pain and pressure develops over one or several of the nasal sinuses. Fever and chills may ensue and one may again begin to feel sick. In these cases antibiotics are recommended and you are advised to consult your primary care provider to obtain these.

Any other sore throat should be considered abnormal and brought to medical attention.

The standard viral cold is transmitted from person to person. The tired, stressed or overworked individual has an impaired immune system and is not only more susceptible to catching the cold, but will then be sicker during the cold and take longer to resolve it. The cold virus is typically spread by direct contact. Most people are infected 12-36 hours before they are symptomatic, and then carry and shed live virus for the first 2 or 3 days while they are sick. Secretions from their nose or mouth are typically wiped on their hands; their hands then touch a bannister, a door knob or some other fixture. Another person comes along and touches the same fixture, be it at home, at work, or elsewhere, and as humans are so inclined to do, then places their fingers in their mouth, their nose, or their eye. The viruses are transmitted and the susceptible patient becomes ill. If someone in the family develops a cold, they should be careful about spreading their secretions. Others in the family should be careful about not touching potentially contaminated fixtures and be certain to wash their hands before eating or placing one's hands in one's mouth, nose or eyes.

In younger individuals, there is always question about bacterial vs. viral causes of the sore throat. For additional information, you are encouraged to read the algorithms written to distinguish bacterial from viral infections. If interested, click here. Sore Throat.

Some also find benefit by irrigating their nose with a Waterpik.

Cough

Cough is a very common problem and can be a symptom of numerous maladies. It may be a symptom of pneumonia or it may be a symptom of a laryngeal tumor or infection, so any new cough should be brought to the attention of your primary care provider. There are some chronic coughs that appear to develop insidiously, and when illnesses such as tuberculosis, pneumonia, lung cancer, etc. are excluded, are frequently evaluated by ENT physicians. The 2 most commonly made diagnoses are postnasal drip and gastroesophageal reflux disease.

As discussed at the beginning of this document, postnasal drip is very common as one ages. Typically, the nose generates as much as a quart and a half of fluid daily. This is transported to the back of the nose and then swallowed. Unfortunately, as secretions thicken, they are no longer easily swallowed and individuals find themselves snorting, coughing and clearing their throat. Even when the diagnosis of postnasal drip seems obvious to the ENT physician, it is not always obvious to the patient, hence treatment is often empirical.

The other common cause for cough is gastroesophageal reflux disease. As one ages, the sphincter between stomach and esophagus begins to fail. As the gastric acid percolates up into the esophagus, one may develop symptoms typically called heartburn. Some individuals are not particularly aware of heartburn or other discomforts. When sleeping, the gastric acid refluxes up the esophagus and is not felt by the patient until it reaches the back of the voice box. It is then perceived and, without awakening, the patient automatically swallows. This unfortunately goes on all night long. The back of the voice box is irritated and burned. When one awakens, one has a foreign body sensation and typically will cough or repeatedly clear the throat.

The treatment for the postnasal discharge is Nasal Irrigation. The treatment of gastroesophageal reflux disease is controversial. Many physicians treat with medications which suppress gastric acid and, while this is certainly effective, it is needlessly expensive. Conservative treatment frequently works equally well, and is safer and cheaper. For additional information on reflux precautions, click here: GERD Precautions.

The key to the GERD Precautions are, first and foremost, raise the head of the bed on blocks. One or two pillows does not suffice. The bed has to be tilted so that gravity keeps the acid from percolating up the esophagus and injuring the voice box. Secondly, go to bed on an empty stomach; you simply can not eat a large meal and then go to bed, for the food stimulates acid secretion and predisposes to reflux. If dinner is a large meal it should be eaten at least 4 hours before bedtime. If it is a small meal, keep it bland and eat as far before bedtime as possible. If snacks are required, bland food such as crackers, milk, and popcorn are recommended. Prior to going to bed, eat one or two antacids, for these will neutralize the gastric acid. If none of this works, consultation with your primary care physician is strongly recommended.