Our ears, nose and throat are complex organs. Did you know that humans are capable of detecting over 10,000 scents through the olfactory nerve cells in our nose? And the tiniest bones in our bodies are in our ears, measuring just 3mm!
With hearing and smell making up two of our five senses, it is essential to ensure that they are in the best condition for our overall health. We explore two common conditions seen by the Department of Otorhinolaryngology – Head & Neck Surgery (ENT) at Changi General Hospital (CGH).
By Dr Maria Judith Pang, Associate Consultant, Department of Otorhinolaryngology – Head & Neck Surgery, CGH
Many people would be familiar with the terms “sinus” or “sensitive nose”. Also known as allergic rhinitis (AR), this symptomatic disorder of the nose and nasal lining is caused by a particular type of inflammation, which results from a prior exposure to an allergen.
An allergen is a substance or chemical that causes allergies. These allergies occur when a person’s immune system reacts to a substance (allergen) from the environment that is harmless to most people. Common allergens include house dust mites, cockroaches, pet allergens, pollen, insects, mould, and certain foods and medicine. Allergic rhinitis affects about 520,000 people in Singapore, with a higher occurrence in younger age groups. According to local population-based studies, more than four out of ten schoolchildren have AR.
How does allergic rhinitis occur?
When a person breathes in an allergen, it triggers the body to produce certain chemicals, including a special immunoglobulin (antibodies) called IgE. When the person is exposed to the allergen again, these IgEs attach to existing inflammation cells in the body and signal to them to release inflammation chemicals — in a bid for the body to remove the offending substance. These result in the symptoms that a patient with AR experiences, such as sneezing, congestion, itching and runny nose.
Identifying allergic rhinitis
Besides these common symptoms, CGH clinicians also look out for dark rings under the eyes, puffy eyes, and congested and enlarged turbinates, which are bony structures in the nose. Factors such as a patient’s sleep and daily activities — whether at school, work or leisure — also play a part in helping the clinicians make a more accurate assessment.
A nasoendoscopy can be performed to check for any anatomical obstructions such as enlarged inferior turbinates (which can cause nasal congestion), a deviated nasal septum (when the cartilage and bone that separate the nasal cavity is off-centre, making one nasal passage smaller), and allows ENT doctors to check for other nasal conditions that can mimic allergic rhinitis. This procedure is carried out under a local or topical anaesthetic and does not require fasting. A scope with a small camera is put through both the patient’s nostrils to assess the nose and throat.
Another common test is a skin prick test. This helps determine what allergen is causing the AR symptoms, and allows the care team to develop plans to manage the condition. This test is carried out by nurses in the ENT clinic and involves making a small scratch or puncture in the skin, inserting a small amount of the allergen, and waiting for a response, if any. Multiple allergens can be tested in one setting.
A blood test can also be performed to look for IgEs in the body. This test looks for a very specific antigen and involves drawing blood to determine the presence of IgEs.
A skin prick test can help determine the allergen causing the allergic rhinitis.
Intranasal sprays can help to alleviate the symptoms of AR.
Treatment options
As AR is triggered by a substance that is inhaled, one way to reduce these symptoms is to modify our environment and avoid the allergen. For example, if a person is allergic to house dust mites, keeping the home or work environment as dust-free as possible will help. This includes cleaning the areas in our home or workplace where dust tends to collect, for example, bedding and pillow sheets, carpets, curtains, bookshelves, etc. Removing or minimising exposure to the triggering substance will reduce the body’s production of the inflammation chemicals.
Medications can also help to minimise and control the symptoms of AR. These come in the form of tablets, nasal sprays and nasal washes. The ENT doctors will advise patients on the most suitable medicine, and some of these medicines may need to be used long-term.
Immunotherapy is another approach used for the treatment of AR. This involves the repeated administration of an allergen to patients in order to change their immune response. It is an option for patients who have had poor response to the usual medications or have experienced undesirable side effects.
Surgical options are also available to help with the overall management of AR. Surgery can help to change the nasal airway to relieve nasal obstructions or reduce the nerve stimulation of the nasal lining. This improves breathing, optimises medication delivery and reduces symptoms such as nasal blockage or runny nose. Surgery can also reduce the size of the turbinates, correct any curvature of the nasal septum or selectively destroy the nerves that are overstimulated and make the nose lining produce excessive mucus.
Is allergic rhinitis the same as sinusitis?
AR is often confused with sinusitis. AR is the inflammation of the nose and nasal lining due to a prior exposure to an allergen, while sinusitis is the inflammation of the nose and paranasal sinuses, and can be caused by a myriad of factors such as viruses, bacteria, fungi infections, dental conditions or even genetic-related conditions.
By Adjunct Assistant Professor David Low, Consultant, Department of Otorhinolaryngology – Head & Neck Surgery, CGH
Hearing loss mostly results from the inability of sound to reach the inner ear or damage to the cells of the inner ear. It can be experienced in one or both ears, and can occur rapidly or gradually.
Hearing loss has far-reaching effects on physical, mental and social well-being. Patients face difficulty communicating with those around them, leading to social isolation and depression. They are less aware of environmental sounds such as car horns and alarms, putting their safety at risk. These patients are also not able to derive joy from pleasurable sounds such as music or birds chirping.
In Singapore, some 27% of adults under the age of 70 suffer from hearing loss. The prevalence increases with age, with 95% of 80-year-old adults experiencing hearing loss. In recent years, hearing loss has been recognised as the single most important risk factor of dementia, contributing to 10% of the overall risk. As such, management of hearing loss is viewed with increasing importance, as timely intervention lowers the likelihood of a costly and devastating event in the future.
The signs of silence
Hearing loss can be rather subtle and some early symptoms are:
What causes hearing loss?
Hearing impairment can arise from damage in the outer ear, middle ear or inner ear. Sensorineural hearing loss, which occurs due to damage to the inner ear, is the most common form of hearing loss.
“Hearing loss may occur gradually as one ages. Presbycusis is the result of an accumulation of physical injuries to the inner ear over time,” adds Adj Asst Prof Low. These injuries include exposure to loud noise and certain medications, such as aminoglycoside antibiotics (as a side effect). There is also an element of genetic predisposition, with some individuals experiencing more severe hearing loss, despite a similar degree of exposure to these external factors. Less frequently seen is hearing loss that is due to infections and tumours.
When sound is unable to efficiently reach the inner ear or cochlear because of abnormalities or obstructions, it is known as conductive hearing loss.
Mixed hearing loss is a combination of both conductive and sensorineural hearing loss.
Sounding out the condition
A pioneer in bringing hearing care to the community, CGH set up Community Hearing Clinics (CHCs) in Bedok and Tampines in 2018 and 2020 respectively. These allow seniors to easily access services such as diagnostic hearing tests and the fitting of hearing aids. They are also able to attend health talks on hearing and balance conducted by the CGH care team.
Singaporeans aged 60 and above can also enrol in the Ministry of Health’s Project Silver Screen, an affordable screening programme. Where necessary, participants may be referred to CGH’s CHCs for more detailed testing and possible hearing aid fitting.
Upon referral to CGH, patients will undergo a full clinical evaluation by an ENT surgeon and audiologist. In addition, some might require specialised investigations like a nasoscopy (a scope that looks at the inside of the ears, nose and throat), or imaging diagnoses such as computed tomography (CT) and magnetic resonance imaging (MRI) scans of the ear and surrounding regions. Some of the tests used to diagnose hearing loss are performed by CGH’s allied health professionals. Read more about them below in an "All-Round Approach".
How hearing loss affects speech and language
By CGH Senior Speech Therapist Rachel Ou
A person’s speech and language abilities can be affected by hearing loss differently, depending on whether the hearing loss occurred before or after the person learned how to speak.
For someone who has had hearing loss in their early years of life (pre-lingual hearing loss), he or she would miss out on hearing sounds and words being spoken around them. As the sounds they hear are limited, the speech that they try to imitate would sound distorted. When they miss out on hearing words and sounds in sentences, they will also not develop some grammatical aspects of language like the plural ‘s’ and complex sentences such as “When I finish studying, I will do the dishes.”
In a person who developed hearing loss after learning to speak (post-lingual hearing loss), they might not be able to monitor the volume of their speech, and therefore speak too loudly. As they mishear or hear less of what others are saying — or even withdraw from social activities due to their inability to hear well — they face a risk of developing cognitive decline.
All ears
There are multiple treatment options for hearing loss, depending on the cause and underlying problem. If the hearing loss is caused by blockage from earwax or a foreign body in the ear canal, it can be removed superficially. For hearing loss caused by external ear infections, medications may help. For some forms of conductive hearing loss caused by earwax or foreign bodies, cleaning the ear out helps reverse the hearing loss completely. Conductive hearing loss due to ossicular (tiny bones in your middle ear that transmit and amplify sounds) problems may also be correctable by surgery.
Where hearing loss is not reversible, options for management include hearing aids and implants. Hearing aids amplify sounds, and are the best option for patients with mild to moderate hearing loss. A hearing aid picks up sounds through a microphone, converts them into electrical signals, processes these signals, and sends them to the receiver, which delivers sound waves into the ear canals.
For individuals with more severe hearing loss or for those who are unable to tolerate hearing aids, hearing implants may be optimal.
Cochlear implants
Globally, there has been an increase in the number of adult patients with more severe sensorineural hearing loss, and this mirrors the rising incidence of hearing loss as a whole. Many of these patients can no longer benefit from hearing aids, as the clarity of their hearing is poor. Hearing aids can amplify sounds, but are unable to make them clearer for this group of patients. These patients often complain that their hearing aids are too noisy, and do not allow them to make out the words in speech. For them, cochlear implantation (CI) may be the optimal management option for their hearing loss.
An external sound processor picks up sounds with its microphones and transmits them to the receiver/stimulator via wireless signals. These signals are then converted to digital information and picked up by the coils on the electrode array. The electrode array bypasses the damaged sensory cells to directly stimulate the hearing nerve, restoring the hearing sensation.
CGH’s Department of Otorhinolaryngology — Head and Neck Surgery (ENT) has been running a dedicated adult CI programme since 2010, and has since carried out CIs for about 100 patients. The CGH CI programme adopts a tailored approach for these patients, and reviews their general health and expectations.
Adj Asst Prof Low performing an ear microsurgery for cochlear implantation using an operative microscope.
Patients with severe hearing loss who attend CGH’s ENT clinics are jointly evaluated by CGH’s multi-disciplinary care team, and may require further specialised hearing tests and imaging. If deemed suitable, they are offered the option of CI. The surgeries are performed by otologists (ENT surgeons who specialise in ear surgery), who work together with CGH’s audiologists, speech therapists and medical social workers to provide holistic care for patients.
After the surgery, audiologists and speech therapists oversee their rehabilitation (“training the brain to listen”), which may take several months to a year. This is necessary as the brain needs to adapt to signals from the implants, before sounds are processed more naturally. Research has shown that CIs are safe and effective for all ages, and help to restore a user’s hearing ability.
Senior Speech Therapist Rachel Ou helps patients with rehabilitation exercises to enhance their communication skills.
Learning to listen
Speech therapists (ST) work alongside audiologists to help patients relearn the way they listen to sounds.
“STs do more than provide therapy for speech! As hearing through a cochlear implant is different from normal hearing or even through a hearing aid, speech therapists guide patients in becoming familiar with their new hearing ability.” says CGH Senior Speech Therapist Rachel Ou.
Prior to the implantation procedure, STs provide information counselling on what the patient can generally expect during their rehabilitation journey. This helps to prepare the patient and their family for the time and work that they will need to put in for the best therapy outcomes.
Depending on the patient’s stage in their hearing journey, STs conduct a range of rehabilitation exercises. These vary from identifying environmental sounds like the sound of a running tap and a traffic light beeping, to identifying commonly heard phrases like ‘Hi, how are you?’.
STs also help the patients practise listening to a conversation or short story, starting with a quiet environment before introducing background noise. Multimedia material such as apps, YouTube videos and audiobooks are also recommended by STs so that patients can do listening practice in their own time, for better exposure. In addition, STs also teach and encourage patients to recognise and employ useful strategies such as establishing conversation topics or requesting clarification from their communication partner.
“We set collaborative goals with patients. We also encourage involvement from family members and equip them with the skills to provide outside-therapy practice, as that is where they spend most of their time,” says Ms Ou.
Hearing you out
“As audiologists, we help patients communicate better with others despite their hearing loss. We provide counselling to help patients understand their hearing loss and the sounds they tend to struggle with, how hearing devices can help, and also communication strategies,” shares CGH Audiologist Hazel Yeo.
Two common hearing tests administered by CGH’s audiologists for patients with hearing loss are pure tone audiometry and speech discrimination testing. Pure tone audiometry is a hearing test which helps to determine a patient’s hearing levels or the softest sounds that a patient can hear. This is commonly done at least once every two years to monitor a patient’s hearing. Tones at different frequencies and volumes are played to a patient in a hearing booth. The patient then responds if he or she is able to hear the sound.
CGH Audiologist Hazel Yeo carrying out a pure tone audiometry test to determine a patient’s hearing levels.
In a speech discrimination test, audiologists say a set of words to patients, who will have to repeat them. This is an assessment of their hearing ability and is usually done to assess a patient’s performance with hearing aids.
For users of hearing aids, audiologists help to tune patients’ hearing devices if necessary to make speech sounds clearer, and also teach them how to use their devices well. For patients with hearing loss who are using CIs, audiologists see them more frequently as part of their rehabilitation journey. Mapping of the implants is carried out during the appointments, and the audiologists also counsel the patients on how to train their ears to hear with the CI.
“We partner our patients on their aural rehabilitation journey to help them learn to hear better,” says Ms Yeo.
57-year-old Mdm Lim Yean Pin started to suspect that she was losing her hearing when she found herself having difficulty making out what her friends were saying in group settings and conversations. At work, Mdm Lim found it challenging to communicate with her colleagues and bosses. Sometimes, her conversation partners would put their hands over their ears to try to convey to Mdm Lim that she was speaking very loudly. These were all results of her progressive hearing loss in both ears.
Mdm Lim Yean Pin has experienced significant positive improvements in her hearing with the help of the CGH care team.
One day, Mdm Lim came across a hearing clinic in a shopping mall and decided to give it a try. She was given a set of hearing aids, which seemed to help at first, but Mdm Lim found that their effects deteriorated quickly after a short period of time. Eventually, Mdm Lim visited a polyclinic and was referred to Changi General Hospital (CGH) for treatment.
“When Mdm Lim saw us, her hearing loss was in the profound range, and she was struggling even with hearing aids,” says Adjunct Assistant Professor David Low, Consultant, Department of Otorhinolaryngology – Head & Neck Surgery, CGH. “We did more testing, and found out that she could not make out speech at all in her poorer left ear. In her better right ear, she could only make out 15% of speech material presented to her.”
After further diagnostic imaging and counselling, Mdm Lim’s hearing loss was assessed to be severe and she took up the option of a left cochlear implant. Mdm Lim underwent a successful surgery and has been in rehabilitation since then. While it is still early days in her rehabilitation journey, Mdm Lim can already make out 45% of speech material presented to her left ear with the implant activated.
After this positive development, Mdm Lim is now able to live better. “Now I can speak to others without being too loud, and I can hear others better when speaking with them,” she says in Mandarin. “Dr Low and Hazel (CGH audiologist) were very helpful, sincere and professional. They explained the procedures well and gave me good advice. I used to struggle even with activities like watching videos. I am now able to live my life and communicate with others better,” she adds.
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