Common Disorders of the Ear, Nose, and Throat: A Clinical Update

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Urenus

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By Joan Lewis, MD
Otorhinolaryngologist

Introduction

Disorders of the ear, nose, and throat (ENT) are the cause of many patient visits to a primary care physician. Some of the common ENT disorders include acute and recurrent otitis media (OM); acute, chronic, and recurrent tonsillitis; and allergic and recurrent rhinitis and chronic rhinosinusitis (CRS). However, the common cold remains one of the most frequent upper respiratory tract infections (URIs). Approximately half of the cases of colds in children can be attributed to a wide variety of up to 200 different viruses that are seasonally active, such as rhinoviruses in the early fall, spring, and summer. Other viruses that might cause URIs include coronavirus, parainfluenza virus, adenovirus, enterovirus, and respiratory syncytial virus.¹

The subsequent development of recurrent sinusitis²–³ and OM⁴ commonly has been related to viral URIs that last longer than a week. A child can be expected to have 6 to 10 colds annually, whereas adolescents may have only 2 to 4 colds per year. In developing countries, URIs tend to be more severe, such as pneumonia and influenza, with a higher risk of complications. Therefore, URIs can be a leading cause of death for children younger than 5 years.⁵

An increased understanding of the pharmacoeconomic incidence, relevance of antibiotic resistance, physician involvement, and anatomical and physiological features of each of the common ENT disorders will improve clinical outcomes. An integrative medical approach that uses complementary and alternative therapies, such as antihomotoxic medications, in addition to mainstream medical therapies is a therapeutic strategy that shows much promise in reducing the current disease burden and preventing further recurrences.

Pharmacoeconomic Incidence

The annual cost of time lost from school for adolescents and from work for adults because of URIs is substantial and is estimated to be as high as $15 billion in direct treatment costs by practitioners, with more than half of that amount being for ambulatory care centers in hospitals. The indirect cost of wages from URIs is estimated at $9 billion.⁶

The over‑the‑counter cough and cold remedy market was identified as being the “most competitive category in North America,” with sinusitis showing the most potential growth. Figures extrapolated from a survey of 4,000 US residents suggested that a total economic burden of $40 billion, including income lost from time off for these occurrences, was related to noninfluenza viral URIs alone.

Antibiotic Resistance

In 2007, prudent antibiotic use was not correlated with appropriate knowledge of microbial resistance;⁷ thus, the reduction of unnecessary antibiotics as treatment options for the virally associated common cold was identified in 2008 as a public health priority.⁸

Recent public opinion polls show an increased understanding of the relationship between the development of resistant bacterial strains and inappropriate antibiotic use and also report a significantly higher level of trust in physicians who did not prescribe antibiotics for the common cold.⁹ However, 45% of respondents in the United States in 2008 and 41% of a population in Belgium in 2001 still did not understand the lack of efficacy of antibiotics in treating viral illnesses.¹⁰ These data suggest that there is still a considerable opportunity to better educate patients and health care providers.

Environmental Impact

In the pediatric population, the close proximity of children in day‑care centers contributes to the transmission of respiratory tract disease.¹¹ Childhood exposure to common environmental pollutants, such as firsthand or secondhand smoke, and common household allergens, such as aerosolized cleaning products, in persons with a genetic predisposition might be associated with later development of asthma and allergic conditions through inappropriate sensitization.¹² Furthermore, asthmatic children have URIs more frequently than their nonasthmatic classmates. The polycyclic aromatic hydrocarbons present in diesel exhaust particles have recently been shown to stimulate the release of interleukin (IL)‑4, IL‑8, and histamine from basophil cells,¹³ suggesting that other common environmental pollutants also can play a role in the development of asthma and allergic rhinitis.

Physician Involvement

Most persons with ENT disorders visit their health care practitioners early in the disease process because the associated signs and symptoms are readily apparent to both the patient and practitioner and frequently affect activities of daily living. The mechanical and physical appearances of structures (e.g., teeth, palate, gingiva, and tongue) indicate a variety of physiological states and can be used diagnostically with a minimal investment of time. For example, fasciculations of the tongue might indicate neural disorders; a glossy tongue is associated with nutritional deficiencies, such as a deficiency in vitamin B12. Dental caries or loss correlates with impaired immune systems, smoking or tobacco use or exposure,¹⁴ and poor nutritional status. Xerostomias are linked to poor hygiene, and temporomandibular joint disorders can be attributed to trauma or articular disorders.¹⁵

Relevant Anatomical and Physiological Features

Lymphatic tissue in the Waldeyer ring is designed to protect the body from pathogens and toxins encountered in this vulnerable area; therefore, it is strategically placed to protect critical respiratory and digestive functions. It is the first protective barrier encountered by orally ingested and inhaled toxins, viruses, and bacteria. An interaction with the body’s lymphatic tissues provokes a reaction that includes copious nasal discharge, sneezing, coughing, and mucosal engorgement as a mechanism to remove the offending substance. The resultant reaction, with its associated signs and symptoms, is diagnosed as the common cold or rhinitis. Further progression to include fever and exhaustion, and the presence of clusters of similar infections in the community and a documented influenza virus infection, would lead to a diagnosis of the flu.

Treatment for these uncomfortable reactions is largely symptomatic.

Pathological Conditions

A short review of the relevant pathological features of each of the common ENT disorders is included to provide further insight into potential therapeutic strategies.

Otitis Media

Acute OM
Acute OM is the most frequent ailment encountered by pediatricians. Persistent middle ear effusion from a failure of the mucus and microbial and immune system debris in the middle ear to drain via the Eustachian tube to the pharynx is associated with recurrent OM.¹⁶ Implicated factors include functional obstruction of the Eustachian tube, anatomical differences in the infant’s Eustachian tube, and a more horizontal position when bottle feeding an infant in a supine position, favoring a retrograde flow of milk. Furthermore, passive smoke environments impair normal ciliary movement that sweeps away debris, and immune system disorders are associated with increased mucus production.

Recurrent OM
Preexisting antibiotic treatment is associated with an increased rate of recurrent OM in young children, supporting the hygiene hypothesis, in which interruption of a normal inflammatory response during childhood leads to an imbalance in Th1/Th2 cell regulation, predisposing a child toward allergy.¹⁷ Novel otopathogens can be cultured in those with recurrent OM after a month‑long course of antibiotics for acute OM.¹⁸ Long‑term morbidity, with recurrent OM occurring before the age of 3 years, might affect the child’s subsequent decreased comprehension when reading.¹⁹

Bioregulatory Treatment
For acute OM, use the basic/symptomatic approach as follows: prescribe Belladonna-Homaccord (8–10 drops twice daily) and Traumeel (8–10 drops or 1 ampoule warmed and instilled into the affected ear twice daily). If resolution does not occur within a reasonable time, individualize therapy:

  • With confirmed bacterial etiology and significant inflammation, prescribe Echinacea compositum: 1 tablet every 30–60 minutes up to 12 tablets per day for acute conditions; for chronic conditions, 1 tablet dissolved in the mouth three times daily. Injectable route (IM, SC, ID, or IV) 1–3 times per week may be used if within regulatory framework.†
  • With confirmed viral etiology, prescribe Engystol: 1 tablet three times daily or 1 ampoule daily (injectable routes as above for acute situations).
  • For marked restlessness, fever, and agitation, prescribe Viburcol suppositories: adults, 1 suppository 2–3 times daily; infants under 6 months, half a suppository up to one per day.

If signs and symptoms persist, consider the 3‑pillar regulation approach (detoxification and drainage; immunomodulation; cell and organ support).† During latent phases, Mucosa compositum (± Coenzyme compositum, Ubichinon compositum) supports cells and organs; Traumeel for immunomodulation; and the Detox‑Kit (comprising Lymphomyosot, Nux vomica-Homaccord, and Berberis-Homaccord) for detoxification and drainage. Persistent effusion may require referral for myringotomy.

Tonsillitis

Acute Tonsillitis
Tonsils are antigen‑presenting lymphatic tissue in the Waldeyer ring, mounting an appropriate B‑cell response. Acute tonsillitis presents as erythematous, swollen tonsils with stertorous breathing. Hypertrophied tonsils can cause sleep disorders and daytime inattentiveness in children. Microbiological evaluation (culture or rapid antigen tests) is required to exclude streptococcal pharyngitis, which necessitates antibiotics to prevent cardiovascular or renal complications.²⁰

Chronic Tonsillitis
Generally bacterial in etiology and more prevalent in adults. Crypts containing pus can form; surgical excision is controversial due to postoperative pharyngitis despite no visible recurrent infection. Post‑tonsillectomy changes in oral flora suggest the chronically infected tonsil may harbor anaerobic bacteria, and removal may restore normal flora.²¹

Recurrent Tonsillitis
In children, recurrent tonsillitis differs from adult chronic forms by higher antigen presence in acute stages. If peritonsillar abscess occurs, immediate tonsillectomy may be first‑line.²² Antigen presentation and B‑cell function remain intact; if possible, avoid tonsillectomy to preserve natural killer cell maturation.

Bioregulatory Treatment
For acute tonsillitis: prescribe Angin-Heel (initial: 1 tablet every 15 minutes for 2 hours; then 1 tablet three times daily), Vinceel spray (once daily), and Mercurius-Heel (1 tablet three times daily). If unresponsive:

  • Bacterial etiology: Echinacea compositum as above.
  • †Regulation approach: use detoxification, immunomodulation, and organ support as outlined for OM.

References

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†The 3‑pillar regulation approach comprises detoxification and drainage; immunomodulation; and cell and organ support.