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Spotlight on ENT by Jenifer Worden
Problems of the ear, nose and throat are usually considered to be predominantly winter illnesses but this is not necessarily the case. Although more common through the months of October to February, infections of the ENT system can occur at any time and a GP probably sees more patients with these types of ailments than any other comparable illnesses over the course of a year. Also, children are particularly prone to ENT problems and this last winter, owing to the extended mild weather, has been an unusually fertile period for these types of viruses.
Ears, noses and throats are incredibly complex and are designed to moisten air being inhaled and also to remove irritant particles such as dust and pollen.
The ear is divided into three parts. The outer ear, pinna, is the portion of the ear that can be seen. At the innermost part of the pinna is the tympanic membrane, eardrum, and behind that, the middle ear. The inner ear contains the balance mechanism, the cochlea, and connects directly via the auditory nerve to the brain. If the middle ear becomes inflamed due to an infection, then the resulting illness is called acute otitis media (AOM). Symptoms come on suddenly and AOM is diagnosed by the combination of earache, usually accompanied by a high temperature and general malaise plus signs of fluid in the middle ear. The usual indication of AOM seen by a doctor when looking into the external ear is that the eardrum, normally grey, dull and opaque like a piece of greaseproof paper, is red, shiny and bulging, because of increased pressure. If the fluid stays in the middle ear, it may thicken and lead to the condition known as “glue ear”.
AOM is common and in the UK, about 30 per cent of children under three visit their GP with this each year. Until recently, the vast majority were prescribed antibiotics. However, without antibiotics, AOM symptoms improve in 24 hours in about 60 per cent of children and in 80 per cent within three days. If antibiotics are not given, about one in a thousand children will perforate their eardrum, a condition known as supperative otitis media.
The evidence for the effectiveness of antibiotics in this condition is very limited despite their hitherto widespread use. The most effective conventional treatment has shown to be painkillers such as ibuprofen or paracetamol which relieve the discomfort of the earache. Nowadays, GPs tend towards giving “delayed prescriptions” of antibiotics. This means the parent is given a suitable prescription with instructions about how long to wait for the condition to settle spontaneously and what signs and symptoms would indicate a worsening of the problem and necessitate giving the medication. This simple measure is reducing the number of unnecessary antibiotics given to children and so decreasing the numbers of GP consultations for medication side-effects, such as diarrhoea and skin rashes.
In respect of AOM, there are familiar homeopathic remedies that can be used to treat it. Earache that comes on very suddenly, particularly after exposure to a dry, cold wind which is worse at night and with a high temperature but without sweating does well with Aconite. Ear pain with a less sudden onset but with hot, dry skin, as with the case with Aconite, but without restlessness and fear may need Belladonna. Both of these remedies can be given in 30c strength every 30 minutes for three to four doses. However, if the child does not respond after two hours, a change of remedy should be made. A word of caution; it is important that if the child becomes very hot or very drowsy, a medical opinion must be sought urgently.
If the child suffering with AOM is miserable and whining, with ears which are hot to the touch, and they respond to cuddling and affection, then Pulsatilla may help. A cross, irritable child would probably respond better to Chamomilla.
As previously mentioned, perforation of the eardrum can occur and if this happens, the discharge is usually thick, sticky yellow-green, not offensive to smell and is often described as bland. Pulsatilla 6c given three times a day until improvement is a good first choice whilst if the discharge is more watery and yellow in colour, it is worth trying Hepar sulph 6c at the same dose.
The passages of the nose are not simple tubes but consist of a complex arrangement of ridged “turbinates”. These have evolved to act as a very effective mechanism for cleaning the air we breathe in but are not without their problems. The nose links into large air spaces in the skull located above and below the eyes and behind the base of the nose. Normally these sinuses, as the spaces are known as, are filled with air and lined with a thin layer of skin (mucosa). The latter produces a thin mucus, or slime, which keeps the inside of the sinuses moist and healthy.
If the sinuses become inflamed as a result of infection or irritation, the mucosa swells and produces more mucus which can become very thick and sticky. This viscous mucus tends to drain poorly from the sinuses which then become full; this causes an increase in pressure and results in facial pain. The pain of sinusitis is typically worse on leaning forward, as the fluid in the sinuses acts like a spirit level, and tapping over the inflamed sinuses with a finger increases the pain also. The discharge from the nose via the sinuses may be green if there is only inflammation, but in the case of infection, usually with bacteria, blood or pus-stained nasal discharge may result.
Sinusitis can be very difficult to treat conventionally. Randomised controlled trials (RCTs), the “gold standard” of medical research, have failed to show significant benefit or effectiveness in prescribing penicillin-based antibiotics to sufferers of acute sinusitis (symptoms lasting less than four weeks). Neither are there any RCTs which show antihistamines, decongestants or steroid nose sprays to be particularly effective but these are still prescribed regularly by doctors wishing to help their patients. Nearly six million working days are lost in the UK every year due to sinusitis which gives an idea how extensive this problem is.
Simple measures like steam inhalations can help the symptoms of acute sinusitis but it is important to note that if used alongside homeopathy, strong odours such as camphor or eucalyptus can antidote homeopathic remedies. As stated, acute sinusitis is defined as having symptoms for less than four weeks but chronic sinusitis sufferers will have symptoms for more than that, and therefore, a more personalised remedy based on the patient as a whole is usually more effective.
A remedy that historically has been used for sinusitis is Kali bich, and although recognised to be one of the most effective treatments, the exact mechanism by which it works is unclear. It is prescribed where there are thick, sticky discharges, especially from mucous membranes, such as those of the nose, throat and lungs, hence its application in acute sinusitis. The nasal discharge is green, yellow or bloodstained and difficult to blow out and there may be sticky crusts in the nose or even ulceration.
Hydrastis is a remedy used where the sinus discharge tends to go down the back of the throat rather than down the nose. It is often felt as a lump in the throat and this is technically known as post-nasal drip and together this combination is known as catarrh. Catarrh is a troublesome discharge and, like sinusitis, difficult to treat conventionally. There is anecdotal evidence that avoiding dairy products in one’s diet can reduce the incidence of sinusitis and post-nasal drip but no firm evidence as yet.
Throat and tonsils
From the nose, we will now consider the throat and the tonsils. The latter consist of lymphoid tissue and play a part in the immune response to infection in babies and children but are usually inactive by adulthood. The decision to remove tonsils surgically to prevent recurrent attacks of tonsillitis has been a fiercely debated issue between ENT surgeons over the years. Currently tonsillectomy is avoided unless a patient is suffering from at least four severe attacks of tonsillitis per year, requiring antibiotics to settle the symptoms each time and resulting in significant time off school or work, which is a far cry from the fifties when tonsillectomy was a relatively common procedure.
Another distressing ailment of the throat is quinsy, which is an abscess on or around the tonsil. It is very painful and, if left, can be potentially serious. Anne, an elegant, well-groomed 75 year old whose looks defy her years, came to see me as she had become unwell following an earlier viral infection which she seemed unable to throw off. She developed a persistent cough and felt generally debilitated which resulted in quinsy and, despite prompt action by her GP with antibiotics, had to be admitted to hospital for incision and drainage of the abscess. Seemingly, she made a full recovery and so was distressed to develop a second quinsy two months later. Fortunately this one burst on its own but it left her very apprehensive about it reoccurring again.
Anne is an anxious person who tends to worry about her health and she has had a series of serious illnesses over the years that have added to her apprehension. Now, after two attacks of quinsy, she was frightened to go on holiday in case she became ill again. It seems that Anne has always been of a nervous disposition although, paradoxically, she is able to perform on the stage, something she has done since childhood. However, with regard to her throat, she had reached the stage where she felt she had to look at it every day to see if another quinsy was developing and also needed to keep seeing her GP for reassurance. In addition, she was also troubled by asthma and irritable bowel syndrome, both of which were made worse by anxiety and an impending sense of anticipation.
Other symptoms which led me to choose a remedy for this woman included her general activity described by her husband as “always running around”, a particular thirst for cold drinks and the fact that she did not sleep well and frequently woke around 4am. Despite being such a worrier, she still enjoyed a busy social life and had many friends. Occasionally, she would become tearful if one of her friends was upset.
On the basis of a cancer operation in the past and her general sensitivity and fastidiousness plus her physical throat, lung and bowel symptoms, I prescribed Carcinosin as a single dose of 30c, followed by a twice daily dose of Phosphorus 12c. Phosphorus is a remedy with an affinity for throat and other respiratory problems, especially tonsillitis, chest infections and asthma. Patients who do well with Phosphorus are often described as being slim, pale-skinned and either dark or red-haired but this is very much a generalisation and should not be used as an exclusion factor from treating with this remedy. They have a lively disposition but a tendency to catch colds and coughs, suffer from bowel or liver complaints and to bleed easily. Chilliness is a feature of this remedy and a desire for cold drinks. They actively seek company and reassurance but can be surprisingly confident when asked to perform. Phosphorus is a homeopathic medication which often helps actors and musicians. Fears of thunderstorms and of being in the dark are two of the factors that make this remedy beneficial to patients who suffer from these anxieties. One question that is useful to ask when deciding whether or not to use this remedy in a child, is to enquire if the child needs to go to sleep with a light on. If the answer is a resounding “yes”, from either the child or the parent, then Phosphorus should be considered as an effective medication, particularly if the other symptoms fit the remedy picture.
With Anne, I felt that her sympathetic nature combined with her sensitivity, social habits, nervousness and love of the stage, together with her physical symptoms fitted well with the prescription of a low dose of Phosphorus. To her delight, within a few weeks, Anne was feeling much more confident and had even managed to stop looking at her throat on a daily basis and was less aware of her asthma and had an increased sense of wellbeing. She continued with the remedy for several months before tailing it off and has had no recurrence of her quinsy to this day (almost seven years later) but takes the occasional short course of Phosphorus when she feels the anxiety is worsening or her throat feels a little sore, usually through the winter months.
One ENT condition that can affect all three organs is hay fever, or seasonal allergic rhinitis to give it its technical term. It can affect a wide range of age groups from primary school-age children to middle-aged adults and appears to be increasing in prevalence, although the reasons for this are still not clear. The most popular theory at present is that the infantile immune system is less challenged by severe infections these days, due to immunisation and better health in general. This means that the body reacts more strongly against what should be a minor trigger, such as pollen, resulting in hay fever symptoms. The condition is diagnosed by a combination of sneezing, itching in the nose and throat, a blocked feeling in the nose and a profuse watery nasal discharge. Other symptoms may include itchy, watery eyes, coughing, wheezing, shortness of breath, tiredness and a sensation of pressure in the head.
Hay fever can vary greatly, depending on local fauna, as these are the main triggers, but fungal spores in the autumn can also cause an attack. The season is usually said to start in the early spring with the emergence of tree pollens such as that of silver birch and finish with moulds in October. However, it most commonly affects sufferers between the months of May and August.
A family history of allergy increases the risk of developing hay fever. The peak age of onset is in adolescence but it is increasingly common to find people developing symptoms in their 20s and 30s.
Hay fever can be treated successfully with antihistamines but side-effects, such as sleepiness, may make that particular treatment less than perfect. Although there is a good selection of so-called non-sedating antihistamines, even these can cause drowsiness in susceptible patients. Therefore, because of its lack of side-effects, homeopathy can really come into its own in treating this distressing condition.
One of the most successful pieces of homeopathic research examined the treatment of hay fever sufferers with a remedy based on a combination of hay fever triggers called Mixed pollens and grasses 30c. Dr David Reilly of the Glasgow Homeopathic Hospital looked at the effect on hay fever symptoms of giving a daily dose of the above remedy and compared it to giving a placebo. The result of the study showed that homeopathy was significantly better than placebo in relieving the symptoms of hay fever and is a very powerful piece of evidence for the effectiveness of homeopathy in general. Mixed pollens and grasses 30c can be given on a daily basis at the first signs of hay fever and continued throughout the season.
Jenifer Worden MBChB MRCGP MFHom is a part-time NHS GP in Ringwood, Hampshire and has a private homeopathic practice in Highcliffe, Dorset. She treats patients with a wide range of conditions and across the complete age range.