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					FREQUENTLY ASKED QUESTIONS

    Ears
             What causes an ear infection (otitis media)?
             How is otitis media treated?
             What are tympanostomy tubes and how do they work?
             What causes swimmer’s ear?
             Why do I have earwax?
             How do I remove earwax?
             What is dizziness?
             What is vertigo?
             How can my dizziness / vertigo be treated?
             What is Meniere’s disease?
             Ears and altitude
             What are the signs of hearing loss?
             What causes hearing loss?
             Have your hearing checked if you:
             What about hearing aids?
             Where do I purchase hearing aids?
             What is tinnitus (ringing or roaring in the ears)?
             How is tinnitus treated?
             What are cochlear implants and BAHA implants?

    Nose /Sinuses
             What causes a nosebleed?
             How can I prevent nosebleeds?
             How can I stop a nosebleed?
             What are sinuses?
             What is sinusitis?
             What does sinus surgery accomplish?
             What is balloon sinuplasty?

    Throat
             What are tonsils and adenoids?
             Why are adenoids removed?
             Why are tonsils removed?
             How are tonsils and adenoids removed?
             What is voice and how do I know if mine has a problem?
             What is the most common cause of voice changes?
             What causes laryngitis?
             What can be done to prevent and treat laryngitis?
             Could me medication be affecting my voice?
             What causes a sore throat?
             When should I see a doctor for a sore throat?
             Tell me about early detection of head and neck cancer.
             Symptoms of head and neck cancer.
             What should you do?
             What are the dangers of snoring and sleep apnea?
Other Pediatric Concerns

           Is my baby’s hearing normal?
           What happens if my child has a hearing loss?
           What are the dangers of daycare?
           When should your child remain at home instead of daycare or school?
           Foreign Bodies in the Ear, Nose and Airway
           Children and secondhand smoke
Ears

What causes an ear infection (otitis media)?

An ear infection occurs when fluid collects behind the eardrum. The direct cause of this is malfunction of
the Eustachian tube which connects the nose to the ear. This tube allows air to enter the ear and equalize
the middle ear pressure like when traveling in a plane or diving deep underwater. When this tube doesn’t
open, usually in the setting of allergies or an upper respiratory infection, the middle ear fills with fluid
which is called Otitis Media with Effusion (OME). Since the eardrum cannot vibrate properly, the individual
may experience hearing problems and a feeling of fullness or pressure. This fluid can also become
infected resulting in Acute Otitis Media (AOM). Young children experience more ear infections than adults
because the eustachian tube, is immature and they tend to have more frequent viral infections and
allergies.

How is Otitis Media treated?

Acute Otitis Media (AOM) is usually treated with Antibiotics by mouth. This reduces the duration of the
infection by several days and can minimize the risk of progression to more severe infections. After the
acute infection is treated, the fluid behind the eardrum will usually persist for several weeks. Six out of ten
children will still have fluid one month after an infection, and one in ten will still have fluid three months
later. While fluid is in the middle ear, children are at risk for developing another infection. Antibiotics do
not clear the fluid from the ear, and other medications and nasal sprays have shown only limited benefit.

What are tympanostomy tubes and how do they work?

Ear tubes (i.e. tympanostomy tubes or myringotomy tubes) are small
pieces of plastic that are placed through the eardrum to allow air into the
middle ear. This prevents fluid from building up under the eardrum and
although they don’t necessarily prevent ear infections, infections are
easier to treat, tend not to hurt, and don’t cause hearing loss.
The tubes are placed in the operating room, requiring minimal anesthesia
and the procedure last about 5-10 minutes. Most children are ready to go
home shortly after the procedure and are normal by the end of the day with no restrictions. The tubes last
1-2 years and then usually fall out on their own. While they are in place, they need to be monitored every
6-9 months to be sure they fall out normally. Scarring of the eardrum is usually less than damage due to
recurrent infections and rarely causes hearing loss. Children do not feel or see the tubes while they’re in
place and cannot reach them. Five out of six children have one set of tubes and have no further troubles.
One in one hundred children will have a small hole in the drum where the tube was which may need to be
patched. There is little scientific evidence that getting water in the ears causes infections however, if this
becomes a problem, our nurses can fit your child with inexpensive ear plugs right in our office.

What causes swimmer’s ear?

Swimmer’s ear (otitis externa) is typically a bacterial infection of the ear canal; this differs from otitis
media which involves fluid behind the eardrum. Otitis externa is most commonly caused by water getting
trapped in the ear canal. It can also follow injury to the skin of the ear canal caused by aggressive
“cleaning” with cotton swabs, bobby pins, match sticks or other devices. Your doctor may prescribe
eardrops containing antibiotics to fight infection and corticosteroids to reduce itching and inflammation.
Oral medications may also be recommended to treat more severe infections.

Why do I have earwax?

Earwax (cerumen) is normal in healthy ears intended to moisturize and protect the skin of the ear canal. It
is a natural antibiotic and antifungal as well as a moisture barrier, which prevents the skin of the ear canal
from becoming swollen like dishpan hands. When this is missing, the ear canal is more prone to
infections, which is exacerbated by the use of q-tips which cause small abrasions in the ear canal skin
allowing bacteria to enter and cause infections. Cerumen is formed in the outer part of the ear canal and
normally, makes its way to the outer opening of the ear canal, flakes and falls out. The absence of earwax
may result in dry, itchy ears.

How do I remove earwax?

Under ideal circumstances, ear canals should never have to be cleaned. However, that isn’t always the
case. To clean the ears, wash the external ear with a washcloth, but do not insert anything into the ear
canal. Avoid too much moisture and never probe the ear canal with bobby pins, matchsticks or cotton
swabs. Foreign objects can scratch the delicate skin of the ear canal creating an opportunity for infection.
Cotton swabs only push impacted cerumen deeper and may cause a blockage that can be more difficult
and painful to remove. Home treatments are available to soften wax and dry up excess moisture in the
ear canal. Ear candling is an ancient practice that has recently gained popularity, but may cause injury
and has not been shown to be effective. If the blockage is severe enough that it causes hearing
impairment, tinnitus, earache, a feeling of fullness or occasionally dizziness, one of our physicians can
remove the wax buildup in the office.

What is dizziness?

Some people describe their balance problem by saying that they feel dizzy, unsteady or lightheaded. This
feeling of imbalance without the sensation of turning or spinning is called disequilibrium and is sometimes
due to an inner ear problem. Dizziness with lightheadedness is usually caused by insufficient blood flow
to the brain usually related to standing up from a seated or laying position. The blood temporarily pools in
the legs and the brain senses this as dizziness. Other causes include chronic low blood pressure,
diabetes, high cholesterol or cardiac insufficiency.

What is vertigo?

The word vertigo comes from the Latin verb for “to turn”. Individuals with vertigo often say that they or
their surroundings are turning or spinning. Vertigo is often caused by an inner ear problem which may
result from infection, allergy, head injury or neurological diseases.

How can my dizziness / vertigo be treated?

Your physician will ask you to describe your symptoms, whether lightheadedness or spinning sensation.
He’ll want to know how long and how often the symptoms have troubled you, how long an episode lasts
and whether it is accompanied by hearing loss or nausea and vomiting. You’ll be asked to cite specific
circumstances that bring on an episode and general questions about your health, medications, recent
infections or past injuries. The physician will examine your ears, nose and throat and do tests of nerve
and balance function and possible hearing tests or audiograms. Depending on your diagnosis, you may
undergo skull x-rays, a CT or MRI scan of your head and may recommend blood tests or cardiac
evaluation. The course of treatment will depend on the diagnosis, but may include medication, vestibular
rehabilitation, medications, physical manipulation and/or life style changes.

What is Meniere’s disease?

Meniere’s disease is a disorder that produces a group of symptoms: sudden attacks of whirling dizziness,
tinnitus, a feeling or pressure in the ear and fluctuating hearing loss. While the underlying cause is not
known, it is believed to result from a fluctuation in the pressure of fluid that fills the inner ear. An attack
may last from a few hours to several days. Following a severe attack, most people find they are
exhausted and must rest. Attacks vary in frequency from every few weeks to every few years. The
disorder affects five out of ten thousand people, most of whom are over 35 years old. Acute attacks can
be managed with medications prescribed by your ENT physician and often dramatically improve with an
injection of medication into the middle ear. Occasionally, surgical treatment may be effective in correcting
potential problems in the inner ear. For a well written explanation, please see:
www.tchain.com/otoneurology/disorders/menieres/menieres.html

Ears and Altitude

Ear problems are the most common medical complaint of airplane travelers, and while they are usually
simple minor annoyances, they occasionally result in temporary pain and hearing loss. Air travel is
sometimes associated with rapid changes in air pressure, especially during takeoffs and landing. These
rapid changes can cause problems, especially if the eustachian tubes are blocked. Swallowing usually
serves to equalize air pressure in the eustachian tubes, relieving the discomfort. When flying, chewing
gum or sucking on mints can make you swallow more often – yawning works even better. If swallowing
and yawning are not effective, pinch the nostrils shut, take a mouthful of air, and direct the air into the
back of the nose as if trying to blow the nose gently. If you hear a pop, you’ve successfully equalized the
pressure. You may have to repeat this maneuver several times during descent or ascent to maintain
comfort. Many experienced air travelers use a decongestant pill or nasal spray before flying. This can
shrink the nasal membranes and help ears pop more easily.

Babies and small children cannot intentionally pop their ears, but popping may occur if they are sucking
on a bottle or pacifier. Feed your baby during the flight, but do not allow the infant to sleep during takeoff
and landing. Giving older children chewing gum or a lollipop if appropriate can help them with ear
pressure. Children are especially vulnerable to blockages because their eustachian tubes are narrower
than in adults.


How does hearing work?

The sense of hearing involves the transduction of sound waves (waves of pressure transmitted through
the air) into electrical impulses to the brain. Sound waves enter the ear canal and are collected and
amplified by the shape of the outer ear and ear canal. The pressure waves move the tympanic membrane
(ear drum), which is connected to the ossicular chain (three bones of the middle ear) The ossicular chain
acts as a lever to change the air pressure into mechanical movements of the last of the three ear bones—
the stapes. The stapes acts like a plunger into the inner ear, creating fluid waves in the tunnel of the
conch shell shaped inner ear. Lining the tunnel is a series of cells, which act as switches specific to a
particular pitch. When a sound wave enters the ear, the switch corresponding to that frequency is
triggered and the brain receives a signal indicating stimulation at that pitch. The switches are laid out like
a keyboard with the highest pitches closest to the plunger. As very loud noises are transmitted into the
ear, these cells bear the brunt of that force and this explains why high pitch hearing is usually the most
effected.

What are the signs of hearing loss?

Hearing loss one of the most common health problems, particularly as people age. Most people over the
age of 65 have some hearing loss, and by age 80, almost everyone does. Because hearing loss usually
occurs slowly over the years, you may not realize your hearing ability has gotten worse over time. One of
the most common initial symptoms is difficulty hearing in noisy environments, especially restaurants and
church halls where you may have particular trouble understanding what people say; they may seem to be
mumbling. You may also experience a ringing or other sound in your ear (tinnitus) which could be the
result of the hearing loss.

What causes hearing loss?

Aging and noise exposure are the most common causes of hearing loss. Just as we lost muscle mass
and bone mass as we age, we also lose some function of the cells of the inner ear.

Have your hearing checked if you:

    •   Have to strain to hear normal conversations.
    •   Have to watch other people’s faces very carefully to follow what they’re saying.
    •   Need to ask people to repeat what they’ve said.
    •   Often misunderstand what people are saying.
    •   Turn the volume of the television or radio up so high that others complain.
    •   Find that the effort to hear leaves you feeling tired and irritated.
    •   Notice, when using the phone, that you hear better with one ear than the other.

What about hearing aids?

If you’re losing your hearing, there’s good news; hearing aids can help you hear what you’ve been
missing. Not everyone who has hearing loss needs hearing aids. But, if your hearing loss is keeping you
from communicating with others, hearing aids will most likely help you. Advances in technology have
made today’s hearing aids better and more versatile than ever. After getting used to your new hearing
aids, you may find that:

    •   You hear and understand speech better in many situations.
    •   You’re able to join in when talking with a group of people.
    •   You can hear certain speech sounds more clearly.
    •   You can hear warning signs that help you stay safe, such as a smoke alarm or car horn.
    •   Life is more enjoyable for you and the people around you.

Where do I purchase hearing aids?

Just are there are many different kinds of hearing impairment, there are different kinds of hearing aids
available. It’s important that your hearing loss be assessed by a professional, so the best hearing aid
recommendation can be made. Because some hearing problems can be resolved medically, you should
first have your ENT physician examine your ears. In our office, the physician can then order a hearing
assessment from one of our staff audiologists to determine your ability to hear pure tone sounds and to
understand words. Once the degree and type of hearing loss has been analyzed, the audiologist can
recommend the best hearing aid style for your needs and custom-fit them for you. Many options are
available in hearing aids and considerations such as your listening needs, the size and shape of your ear
and ear canal and the dexterity of your hands will be considered in deciding what type of hearing aid is
best for you. Since there’s a wide range in price according to style, electronic features and local market
conditions, it’s important that you and the audiologist decide together what best fits your budget as well as
your hearing needs. As you become accustomed to your aids, you will likely require several return visits
to refine the fit and program of you aids to ensure they are most comfortable and most helpful for you.
Thereafter you may need to have semiannual audiograms to continue to accommodate changes in your
hearing with changes in your aids programming. Our office is always available to help with service
including repairs, service, cleaning, replacement batteries and new aids.

What is tinnitus (ringing or roaring in the ears)?

Tinnitus can be either a pulsing sound or an annoying continuous sound in one or both ears. The pitch
may range from a low roar to a high squeal or whine. The most common cause of constant high-pitched
tinnitus is sensory neural hearing loss. Tinnitus is very common and can be annoying and distracting.
Unfortunately, we have limited understanding of what tinnitus actually is. The easiest analogy, though
incomplete is that of “phantom pain” which is pain and person with an amputated limb experiences in the
missing body part. In tinnitus, the brain is looking for stimulation in a certain frequency and when it is
missing—as is the case in hearing loss, the brain begins to make up its own sound. Other causes include
Aspirin use, Lyme disease and some medications.

Pulsatile tinnitus can be regular or irregular. When it is regular it is usually related to the flow of blood
through the large vessels passing the ear going to and from the brain. Ear infections or effusions can
increase the sense of this sound while changes in blood flow related to thyroid disease, high blood
pressure or even pregnancy can increase the perception of the sound. Irregular spasms of the muscles
attached to the ear bones occur much like spasm of the eyelids with fatigue or heavy caffeine. In the ear
this produces a thumping noise with an irregular pattern.


How is tinnitus treated?

In most cases, there is no specific treatment for ear and head noise. If your ENT physician can find a
specific cause for your tinnitus, he or she may be able to reduce or eliminate the noise. That
determination can involve x-rays, balance tests and laboratory work. However, most causes cannot be
identified. Occasionally medication will help the noise. Things you can do to lessen the severity of tinnitus
are:

    •   Avoid exposure to loud sounds and noises.
    •   Have your blood pressure checked. If it’s high, get your doctor’s help to control it.
    •   Decrease your intake of salt. Salt can impair blood circulation.
    •   Avoid stimulants such as coffee, tea, cola and tobacco.
    •   Exercise daily to improve your circulation.
    •   Get adequate rest and avoid fatigue.
    •   Stop worrying about the noise. Recognize tinnitus as an annoyance and learn to ignore it as
        much as possible.

Relaxation exercises can help reduce the intensity of tinnitus. Masking tinnitus with some kind of white
noise can make it less noticeable. Hearing aids may reduce tinnitus and sometimes make it go away
temporarily if it’s accompanied by hearing loss. One of our audiologists can assist you in determining
whether hearing aids will help you.


What are BAHA implants and cochlear implants?

The BAHA (bone-anchored hearing appliance) implant is a surgically implantable system for treatment of
hearing loss that works through direct bone conduction. It is used to help people with chronic ear
infections, congenital external auditory canal malformation and single-sided deafness that do not benefit
from conventional hearing aids. The system allows sound to be conducted through the skull bone directly
to the nerve fibers of the inner ear, bypassing the external auditory canal and middle ear. The BAHA is a
simple design, combining a sound processor with a small titanium implant and post, which is placed
behind the effected ear. Surgery is minor and BAHA users report a wide range of advantages over other
hearing devices. Insurance coverage is complex in all areas, but particularly so for BAHA. We can check
your benefits to determine the amount covered by your plan and any out of pocket costs.

A cochlear implant is a small, complex electronic device that is surgically implanted within the inner ear to
help persons with certain types of deafness to hear. The implant does not just amplify sound like a
hearing aid. Instead, it picks up and arranges sound from the environment, converts it into electrical
impulses and transmits those impulses directly to the inner ear. Patients who have lost all or most of their
hearing later in life, particularly after learning to speak, are the most likely to benefit from cochlear
implants. Prelingually deaf children (deaf before learning to speak) outcomes are harder to predict
children who receive cochlear implants in infancy tend to have neurological development closest to that of
hearing children. For children who are born deaf, a cochlear implant can markedly increase the child’s
chance or being able to function effectively in mainstream school classes.




Nose / Sinuses

What causes a nosebleed?

Nosebleeds can be dramatic and frightening. Luckily most nosebleeds are not serious and can be
handled fairly easily. They are divided into 2 types, depending on whether the bleeding is coming from the
anterior (front of the nose) or posterior (back of the nose). Anterior nosebleeds make up more than 90%
of all nosebleeds. The bleeding usually comes from a blood vessel at the very front part of the nose and
most commonly occur due to digital manipulation of the nose (aka nose picking). They are easy to
control, either by measures that can be performed at home or by a doctor. Posterior nosebleeds are
much less common, much more severe and tend to occur more often in elderly people. These
nosebleeds are more complicated and almost always require management by an ENT physician.

The nose can bleed for a variety of reasons:
    •   Allergies, infections or dryness can cause itching and lead to picking of nose.
    •   Vigorous nose blowing can rupture superficial nasal blood vessels in the elderly and the young.
    •   Clotting disorders that run in families or are due to medications
    •   Fractures of the nose or base of the skull can cause bleeding and should be regarded seriously
        when the bleeding follows a head injury.
    •   Rarely, tumors (both malignant and benign) have to be considered, especially in the older patient
        or in smokers.
    •   Drugs, such as anticoagulants or anti-inflammatories


How can I prevent nosebleeds?

    •   Keep the lining of the nose moist by using a salt water spray frequently throughout the day as
        well as a coating of petroleum jelly or antibiotic ointment applied gently with a cotton swab three
        times a day, including bedtime.
    •   Keep children’s fingernails short to discourage nose picking.
    •   Counteract the effects of dry air by using a humidifier
    •   Quit smoking. Smoking dries out and irritates nasal passages. Plus is causes cancer, which is
        bad.

How can I stop a nosebleed?

    1. Stay calm, or help an your child stay calm. When a person becomes agitated, their blood
       pressure increases which may make the bleed harder to stop.
    2. Do not pack the inside of the nose with gauze or cotton.
    3. Keep the head higher than the heart by sitting upright.
    4. Lean slightly forward so the blood won’t drain in the back of the throat or be swallowed.
    5. Gently blow any clots in the nose out and use a decongestant spray (Afrin, NeoSynephrine)
       immediately after. Spray two sprays into each nostril.
    6. Using the thumb and index finger, pinch all the soft parts of the nose and hold pressure without
       letting go for a full ten minutes. (Watch the clock, it will seem like much longer)
    7. Apply ice – crushed in a plastic bag or washcloth – to the nose and cheeks.
    8. After the ten minutes is up, check to see if it is still bleeding. If so, hold it again for an additional
       10 minutes.

Call a doctor if bleeding persists after 30 minutes. If the bleeding flows down the back of the throat even
when the patient is sitting up, it may be a posterior nosebleed. Since these nosebleeds are often more
severe, you should call a doctor immediately. If frequent nosebleeds, however light, are a problem, it’s
important to consult an ENT physician. If a nose bleed occurs after an injury to the head somewhere
other than then nose, it is important to get medical attention.

What are sinuses?

Sinuses are the hollow spaces in the bones of your face. Six pairs of sinuses are connected to the nose
by small openings: the frontal sinuses are in the forehead, the maxillary sinuses are in the cheeks below
the eyes, the ethmoids are many small sinus cavities deep in the nose between the eyes, and the
sphenoid sinuses are in the center of the head. Sinuses help reduce the weight of the head; they act like
the crumple zone in a car in the case of facial trauma, and allow the voice to resonate within the face and
head. The sinuses contain defenses against dust, pollen and viruses and bacteria. Humans produce one
liter of fluid per day that cleanses the passageways and provide necessary moisture to the lining of each
sinus. Tiny little movable hairs, called cilia, line the sinus membranes and sweep the fluid through in a
constant carwash-like motion. Under normal conditions, air passes in and out of the sinuses and mucous
fluid drains from the sinuses into the nose, trapping and eliminating bacteria and pollutants.

What is sinusitis?

Sinusitis is the inflammation causes the very small holes that drain the sinus cavities to swell shut. Mucus
production increases during inflammation and this is unable to escape the sinus through the normal
cleansing process. This drainage thickens over time and has high concentrations of sugars and proteins
which bacteria-- normally present in the sinuses-- feed on resulting in an infection. This infected sinus is
what produces the symptoms of sinusitis.

Acute sinusitis usually lasts less than 6 weeks or occurs no more than 3 times per year with each episode
lasting no longer than 10 days. Medications including antibiotics and nasal sprays are usually effective
against acute sinusitis. Some people experience recurrent acute or chronic sinusitis despite maximal
therapy with antibiotics and drugs for relief of symptoms. There are several possible causes of this
problem and there is considerable debate among doctor about the mechanisms by which this happens.
Almost certainly some dysfunction of the immune system is involved like that seen in allergies. There are
some medications which can improve the symptoms and surgery can help as well, though a definitive
cure is harder to guarantee.

What does sinus surgery accomplish?

Sinus surgery is performed with a fiber optic camera through the nostrils under anesthesia. The surgery
enlarges the natural opening to the sinuses while leaving as many cilia in place as possible. The goal is to
correct any obstruction of the sinus opening, to remove any infected material and allow for visualization in
the office. During the surgery, nasal polyps can also be removed and a crooked nasal septum can be
straightened, leading to improved airflow.

What is balloon sinuplasty?

Balloon sinuplasty is a minimally-invasive, FDA-approved procedure that has proven to be highly effective
at improving the quality of life for sinus sufferers. The procedure uses a small, flexible sinus balloon
catheter to open up blocked sinus passageways, restoring normal sinus drainage and function. When the
sinus balloon is inflated, it gently widens the sinus opening while maintaining the mucosal lining of the
sinus. The procedure is safe and effective, causes less bleeding than traditional sinus surgery, generally
shortens recovery time and does not limit future treatment options. The use of this tool is somewhat
limited by the presence of polyps within the nose.
Throat

What are tonsils and adenoids?

Adenoids and tonsils are lymph nodes back of the nose and throat. They are a small part of the immune
system, which normally help to identify whatever is entering the body and mount an immune response to
anything it sees as dangerous. However, in some cases, they become more problematic than helpful,
especially when they become chronically infected and are the source rather than the response to the
infection. Bacterial infections can generally be managed with antibiotics alone, but sometimes removal of
the adenoids and tonsils may be recommended. Removal of the tonsils and adenoids has not been
shown lead to increased severity or frequency of infection of any kind. Rather, removal of enlarged or
chronically infected adenoids and/or tonsils often reduces the risk of ear and sinus infections and throat
infections.

Why are the adenoids removed?

The most common reasons for removal are:


    •   Enlarged adenoids causing nasal obstruction, snoring and possibly sleep apnea.
    •   Repeated or persistent infection of the adenoids or sinuses.
    •   Repeated ear infections, chronic fluid build-up or eustachian tube malfunction.

Why are the tonsils removed?

The most frequent reasons for removal of both are:


    •   Frequent infections (tonsillitis) usually 5-7 in a year or 3 a year for more than two years
    •   Severe infections leading to greater than 2 weeks of missed school or work
    •   In adults chronic throat pain has been show to improve after tonsillectomy
    •   Breathing difficulties at night (sleep apnea and snoring) due to oversized tonsils and adenoids.
    •   Having persistently infected tonsils (a “strep carrier”).
    •   Tonsil infection with a pus pocket failing to respond to medicine (peritonsillar abscess).
    •   Difficulty swallowing solids / failure to gain weight due to enlarged tonsils.
    •   Asymmetric progressive enlargement of a tonsil or adenoid suspicious for a tumor.
    •   Chronic foul breath due to small white particles in the tonsils


How are tonsils and adenoids removed?

Adenoids are removed in the operating room under general anesthesia during a procedure, which typical
takes 15 minutes. They rarely hurt significantly, though you may have a sore throat for several days due
to the breathing tube. Patients also frequently have bad breath for about a week after the surgery.
Removal of the tonsils is more complicated mainly in that it hurts quite bit more. This is because the
muscles under the tonsils raw and sore for about seven days. Pain is managed with liquid medication and
usually resolves completely after day 7 or 8. Patients with chronic infections tend to experience more pain
because the scarring associated with frequent infections makes the tonsils harder to remove. Most people
also have symptoms of ear pain due to the irritation of the nerve which provides sensation to the middle
ear rather than actual ear pathology. The tonsils also have a 2-4% risk of bleeding for up to two weeks
after the procedure.

What is voice and how do I know if mine has a problem?

The voice is created by vibration of the vocal cords, which are pulled together by muscles attached to the
voice box. This causes them to vibrate as air passes through them. The sound is then shaped by the
throat, mouth and nose and resonates in the throat and face like an organ pipe. By using the muscles of
the voice box, you change the length and tension of the cords and this changes the pitch and sound of
your voice. Voice problems occur when a change vibrations of the vocal cords causes a change in the
voice, often described as hoarseness, roughness or raspiness. People with voice problems often
complain about loss of higher pitches, breaks in pitch (like an adolescent), loss of voice, loss of
endurance and sometimes sharp or dull pain associated with voice use. Other voice problems may
accompany a change in singing ability, most notable in the upper ranges. Any of these problems or
changes should be checked out by your ENT physician.

What are the most common causes of voice changes?

Voice changes sometimes follow an upper respiratory infection lasting up to two weeks. Typically an
upper respiratory infection, a cold or bronchitis causes swelling of the vocal cords and changes their
vibration resulting in an abnormal voice. Resting the voice typically brings improvement. If the voice does
not return to its normal characteristics and capabilities within 2-4 weeks, an evaluation by your ENT
physician is recommended. A throat examination after a change in the voice lasting longer than a month
is especially important for smokers. (Note: a change in voice is one of the first and most important
symptoms of throat cancer. Early detection significantly increases the success of treatment.)

Ask yourself the following questions to determine if you have an unhealthy voice:

            •    Has your voice become hoarse or raspy?
            •    Does your throat often feel raw, achy or strained?
            •    Does talking require more effort than usual?
            •    Do you find yourself repeatedly clearing your throat?
            •    Do people regularly ask you if your have a cold when in fact you don’t?
            •    Have you lost your ability to hit some high notes when singing?
            •    Do you feel as though you have a lump in your throat

Answering yes to any of these questions may indicate a problem caused by a medical condition. Make an
appointment to see your ENT physician and have it checked out.

What causes laryngitis?

Swelling of the vocal cords prevents them from functioning properly, which can change the voice or cause
complete loss of voice. Acute laryngitis usually occurs to due swelling caused by viral infection or irritation
caused by excessive voice use such as screaming at a sporting event or rock concert. Most of the causes
of laryngitis are not serious. Prolonged laryngitis, however, may require that you see your ENT physician.

What can be done to prevent and treat voice changes?

    •   If you smoke, quit. Besides it causes cancer, which is bad.
    •   Avoid secondhand smoke.
    •   Avoid substances that dehydrate the body, such as alcohol and caffeine.
    •   Drink plenty of water.
    •   Humidify the air in your home.
    •   Watch your diet – avoid spicy foods.
    •   Try not to use your voice too long or too loudly.
    •   Do not whisper, it is harder on your voice than speaking softly.
    •   Seek professional voice training.
    •   Avoid speaking or singing when your voice is injured or hoarse.
    •   If you use your voice professionally (singing or public speaking) don’t say a word you’re not
        getting paid for.
    •   Take acetaminophen or ibuprofen for pain relief


Could my medication be affecting my voice?

Some medications, including prescription, over-the-counter and herbal supplements can affect the
function of your voice. Most medications affect the voice by drying out the protective mucosal layer
covering the vocal cords, which is the portion of the cord which vibrates. Hydration is an important
component of vocal health. Medications can also affect the voice by thinning blood in the body, which
makes bruising or hemorrhaging of the vocal cord more likely if trauma occurs, and by causing swelling of
the vocal cords. Medications which can adversely affect the voice include: antidepressants, muscle
relaxants, diuretics, blood pressure, allergy and asthma medications or high doses of Vitamin C. Other
medications and conditions that may affect the voice are ACE inhibitors, oral contraceptives, estrogen-
replacement therapy, blood thinners and an inadequate level of thyroid replacement medication in
patients with hypothyroidism. Lastly, it’s important to remember that many herbal remedies are not
harmless and should be taken with caution. Many have unknown side effects that may include voice
disruption.

What causes a sore throat?

Sore throat is a symptom of many medical disorders. Infections cause the majority of sore throats and are
contagious. Those infections are caused by viruses such as the common cold, influenza or
mononucleosis or by bacteria such as streptococcus (strep throat). Bacterial infections respond to
antibiotic treatment – viruses do not.

Viruses: Most viral sore throats accompany flu or colds along with a stuffy, runny nose, sneezing and
generalized aches and pains. These viruses are highly contagious and spread quickly, especially in
winter. The body builds antibodies that destroy the virus, a process that takes 7-10 days. Other viral
infections may cause sore throats, such as measles, chicken pox, whooping cough and croup. One viral
infection takes much longer than a week to be cured – infectious mononucleosis or “mono”, causes
enlargement of the tonsils and swollen glands in the neck, armpits and groin. It creates a severely sore
throat and sometimes, serious breathing difficulties. It causes extreme fatigue that can last for six weeks
or more.

Bacteria: Strep throat is an infection caused by a particular strain or streptococcus bacteria. The
bacteria can cause damage to the heart valves (rheumatic fever), kidneys (nephritis) and cause scarlet
fever, or infect the tonsils, lungs (pneumonia), sinuses and ears. Because of the possible serious
complications, strep throat should be treated with an antibiotic. Strep is not always easy to detect by
examination and a throat culture may be needed. Other bacterial infections that cause sore throat may
not be detected by a throat culture, like tonsillitis, diphtheria or sinus infections.

Allergy: The same pollens and molds that irritate the nose when inhaled can also irritate the throat. Cat
and dog dander and house dust are common causes of sore throats for people with allergies to them.

Irritation: During winter months, dry heat may create a recurring, mild sore throat with a parched feeling,
especially in the mornings. Increase fluid intake and installing a humidifier can help. Patients with chronic
stuffy nose, causing mouth breathing, may also suffer with a sore throat. Pollutants and chemicals in the
air can irritate the nose and throat, but the most common air pollutant is tobacco smoke. Other irritants
include smokeless tobacco, alcoholic beverages and spicy foods.

Reflux: Occasionally a morning sore throat is caused by regurgitation of stomach acids into the back of
the throat. To avoid reflux, tilt the bed frame so the head is 4-6 inches higher than the foot end. You
should also avoid eating within 3 hours of bedtime, eliminate caffeine, alcohol and spicy foods and may
find antacids helpful.

Tumors: Tumors of the throat, tongue and larynx are usually, but not always, associated with long-term
use of tobacco and alcohol. Sore throat and difficulty swallowing, sometimes with pain radiating to the
ear, may be symptoms of such a tumor. Often, the sore throat is so mild or chronic that it’s hardly noticed.
Other important symptoms include hoarseness, a lump in the neck, unexplained weight loss and/or
spitting up blood in the saliva or phlegm.

When should I see a doctor for a sore throat?

Whenever a sore throat is severe, persists longer than the usual 5-7 day duration of a cold or flu, and is
not associated with an avoidable allergy or irritation, you should seek medical attention.

Tell me about early detection of head and neck cancer?

More than 55,000 Americans will develop cancer of the head and neck, most of which is preventable, this
year; nearly 13,000 will die from it. Tobacco is the most preventable cause of head and neck cancers, but
as more Americans quit smoking, many turn to smokeless (chewing) tobacco, believing it a safer
alternative. So while the incidence of lung cancer may be decreasing, head and neck cancers are on the
rise. Fortunately, most cancers of the head and neck produce early symptoms and most are curable if
caught early. Knowing and recognizing the signs of head and neck cancer can save your life.

90% of head and neck cancers arise after prolonged exposure to specific factors. Use of tobacco
(cigarettes, cigars, chewing tobacco or snuff) and alcoholic beverages are closely linked with cancers of
the mouth, throat, voice box and tongue. Lip and gingival (gum) cancer is commonly associated with
chewing tobacco and has an unusually high rate of metastatic spread. In adults who neither smoke nor
drink, cancers of the mouth and throat are nearly nonexistent. Prolonged exposure to sunlight is linked
with cancer of the lip, and is also an established major cause of skin cancer.

Symptoms of head and neck cancer:

A lump in the neck… Cancers that begin in the head or neck usually spread to lymph nodes in the neck
before they spread elsewhere. A lump in the neck that lasts more than 4 weeks should be examined by
your ENT physician as soon as possible. While not all lumps in the neck are cancer, a lump can be the
first sign of cancer of the mouth, throat, larynx, thyroid gland or of certain lymphomas. Such lumps are
generally painless and continue to enlarge steadily.

Change in the voice… Most cancers in the larynx cause some change in voice. Any hoarseness or other
voice change lasting more than 2 weeks should alert you to see your ENT physician. While most voice
changes are not caused by cancer, you shouldn’t take chances.

A growth in the mouth… Most cancers of the mouth or tongue present as a sore or swelling that doesn’t
go away. These sores and swelling may be painless unless they become infected. Bleeding may occur,
but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, be very
concerned. Your ENT physician can determine if a biopsy is needed and perform the procedure for you.

Coughing up blood… This is often caused by something other than cancer. However, tumors in the
nose, mouth, throat or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than
a few days, you should see your ENT physician.

Swallowing problems… Cancer of the throat or esophagus may make swallowing solid foods difficult.
Sometimes liquids can also be troublesome. One of the most common findings among people diagnosed
with head and neck cancer is unexplained weight loss and poor nutrition. If you frequently have trouble
swallowing, you should be examined by your ENT physician.

Changes to the skin… The most common cancer of the head and neck is basal cell cancer of the skin,
which appears most frequently on sun-exposed areas like the forehead, nose, cheeks and ears. Basal
cell cancer is a relatively low grade cancer with rare instances of spread to distant sites. Other kinds of
cancer, such as squamous cell and malignant melanoma also appear on the skin of the head and neck
and are more aggressive with frequent and dangerous spread to lymph nodes and other organs of the
body. Most squamous cell cancers appear on the lower lip and ear and, like basal cell cancers, are
usually easily treated and cured if caught early. Malignant melanoma classically produces dense blue-
black or black discolorations of the skin. Characteristics of melanoma are summarized by the ABCD
criteria:

        A - Asymmetric or irregularly shaped lesions.
        B - Borders with irregular shape.
        C – Color which is not uniform across the lesion and
        D – Diameter of lesions which are increasing in size

Any sore or ulcer on the skin that fails to heal, or any black or blue-black spot on the skin, particularly if it
changes size or shape, should be seen as soon as possible by a dermatologist or ENT physician.
Persistent Earache… Constant pain in or around the ear when you swallow can be a sign of infection or
tumor growth in the throat. This is particularly serious if it is associated with difficult in swallowing,
hoarseness or a lump in the neck. These symptoms are best evaluated by an ENT physician.

What should you do?

All of the symptoms and signs described here can occur with no cancer present. In fact, many times
complaints of this type will be due to some other condition altogether. But, you can’t tell without an
examination. Remember, when found early, most cancers of the head and neck can be cured with
relatively little difficulty. Cure rates for these cancers could be greatly improved if people would seek
medical advice as soon as possible. So, play it safe. If you think you have one of the warning signs of
head and neck cancer, see your ENT physician right away.


What are the dangers of snoring and sleep apnea?

Snoring is the noise produced by vibrations of the palate when breathing at night. As the muscles of the
throat relax, the throat narrows and the airflow increases, causing the tissues to flap like a flag. In
general, snoring has no medical significance unless it keeps you or others from sleeping. Problem
snoring is more common in males and overweight persons, and it usually grows worse with age.
Excessive snoring can be remedied by such simple methods as changing sleep positions, avoiding
alcohol, and losing weight. There are also clinical treatments available that can shrink or stiffen the soft
tissues in the back of the throat that vibrate causing noise.

However, a more serious problem related to snoring can occur when those same soft tissues block the air
passages at the back of the throat when you sleep, interfering with your ability to breath. This condition is
called obstructive sleep apnea and it can directly affect your health. Sleep apnea is the temporary
stoppage of breathing during sleep and can be dangerous if left untreated. The airway obstruction causes
the level of oxygen in the blood to fall, increases stress on the heart, elevates blood pressure and
deprives the patient of quality, restorative sleep. Obstructive sleep apnea typically affects middle-aged,
overweight men, and may be aggravated by alcohol, sleeping pills or tranquilizers taken at bedtime. The
symptoms of sleep apnea include loud snoring and/or an abnormal pattern of snoring with pauses and
gasps. Other symptoms include excessive daytime sleepiness, memory changes, depression and
irritability. In some patients, sleep apnea can contribute to high blood pressure, heart failure or stroke.
Sleep laboratories are now available to monitor different stages of sleep, diagnose sleep apnea and
assess its severity and design treatment. One effective treatment is CPAP (continuous positive airway
pressure), in which a mask is worn over the nose during sleep while compressed air is gently forced
through the nose to keep the airway open. There are also successful surgical techniques available to
treat obstructive sleep apnea.
Other Pediatric Concerns

Is my baby’s hearing normal?

If your baby:

             o   Does not startle, move, cry or react in any way to unexpected loud noises
             o   Does not awaken to loud noises
             o   Does not turn his/her head in the direction of your voice
             o   Does not freely imitate sound,

he or she may have some degree of hearing impairment.

Approximately 3 of every 1,000 children in the United States are born deaf or hard-of-hearing, making
hearing loss the most common birth disorder. Many studies have shown that early diagnosis of hearing
loss is crucial to the development of speech, language, cognitive and psychosocial abilities. Treatment is
most successful if hearing loss is identified early, preferably within the first month of life. Still, one in every
four children born with serious hearing loss does not receive a diagnosis until age three or older. In the
Michigan there is a law mandating that newborns be screened for hearing loss; this is usually done in the
newborn nursery prior to discharge and results should be made available to you. If you baby was born
outside of a hospital, be sure to have a hearing screening performed in the first month. Should test results
indicate possible hearing impairment, seek further evaluation by your ENT physician as soon as possible,
preferably before the child is six months old.

Hearing loss can also occur later in childhood. Parents, grandparents or other caregivers are often the
first to notice that something may be wrong with the child’s hearing. Even if your child was tested as a
newborn, you should continue to watch for signs of hearing impairment.

What happens if my child has a hearing loss?

Hearing loss in children can be temporary or permanent. It is important to have hearing loss evaluated by
your ENT physician who can rule out medical problems that may be causing the hearing loss, such as ear
infection, excessive earwax, congenital malformation or a genetic hearing loss. If it is determined that
your child’s hearing loss is permanent, hearing aids may be recommended to amplify the sound reaching
your child’s ear. Ear surgery may be able to restore or significantly improve hearing in some instances.
For those with certain types of profound hearing loss who do not benefit sufficiently from hearing aids, a
cochlear implant may be considered. Unlike a hearing aid, the cochlear implant bypasses damaged parts
of the auditory system and directly stimulates the hearing nerve, allowing the child to hear.

You will need to decide whether your deaf child will communicate primarily with oral speech and/or sign
language and seek early intervention to prevent language delays. Research indicates that habilitation of
hearing loss by age six months will prevent subsequent language delays. Other communication strategies
such as auditory verbal therapy, lip reading and cued speech may also be used in conjunction with a
hearing aid or cochlear implant, or independently.

Your child with hearing loss can succeed – in school, in work and in life. It’s important to keep this as your
focus, whatever your child’s age or degree of hearing loss. While you’ll have the support of many
professionals, ultimately you as parents will make many decisions about what is in the best interest of
your child. As with all children, there is no magic formula for raising a child with a hearing loss. It helps to
maintain a positive attitude, educate yourself about hearing loss, seek out the best resources and take an
active role in your child’s education. Most of all, keep in mind that your child is a child first, and a child
with hearing loss second.

While some mild-to-moderate hearing losses can be surgically or medically corrected, most hearing loss
is a permanent condition. Thus, your child’s life will have its challenges. However, these challenges
sometimes turn into advantages. The ability to work hard and concentrate more, coupled with the routines
of audiologic and language therapy, frequently produces children who are self-disciplined and focused.
Moreover, the outcomes for children with hearing loss have greatly improved in the last two decades due
to major advances in technology and emphasis on programs of early detection and early intervention.

What are the dangers of daycare?

Daycare establishments are defined as those primarily engaged in care of infants or children or in
providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary
function. Some may or may not have substantial educational programs, and some may care for older
children when they are not in school. So what are your child’s risks of being exposed to a contagious
illness at a daycare center?

When your child is in a daycare center, the risk is greatest for viral upper respiratory infection, the
common cold, ear infections and diarrhea. Some studies have linked asthma to daycare. Other studies
suggest that being exposed to all the germs in daycare actually strengthens your child’s immune system.
Can you prevent your child from becoming sick at a daycare center? The short answer is “no”. Exposure
to other sick children will increase the likelihood that your child may catch the same illness, particularly
with the common cold. The primary rule is to keep your own children at home if they are sick. To minimize
the risk, however, teach your child basic hygiene practices, such as washing the hands before eating and
after using the toilet. Infection is spread most easily by children putting dirty toys and hands in their
mouths, so check your daycare’s hygiene cleaning practices.

When should your child remain at home instead of daycare or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow
are:

    •   When your child has a temperature higher than 100 degrees, keep him/her home. A high fever is
        a sign of potentially contagious infection even is the child feels fine.
    •   When other children in the daycare facility have a contagious infection, such as chicken pox,
        strep throat or conjunctivitis, keep your child at home.
    •   Children taking antibiotics should be kept at home until they have taken the medicine for one or
        two days.
    •   If your child is vomiting or has diarrhea, keep the child away from other children. Other signs of
        illness are an inability to take fluids, sunken eyes, a depressed soft spot on top of an infant’s
        head, crying without tears and dry mouth.

Have your child examined by your physician before enrollment in a daycare center or school. During the
examination, the physician will look for inflammation in the ears, review with you any allergies the child
may have, and examine your child’s tonsils for infection and size. Alert the daycare manager when your
child is ill and include the nature of the illness. While daycare has become a necessity for millions of
families, it is possible to monitor the health of your child and prevent unnecessary sickness.

Foreign Bodies in the Ear, Nose and Airway

Ears: It’s a fact of life – children have a propensity for putting things into just about any orifice possible.
They’ll often put such things as pebbles, erasers, food or small toys into their external auditory canal.
Treating this is usually a fairly easy process that can be dealt with in the office. Most commonly, the child
ear may exhibit pain, redness or drainage, or hearing may be affected if the ear canal is blocked. The
ENT physician has a number of techniques and instruments designed to remove a foreign object.
In general it is not an emergency to have something in your ear with the exception of any possibility of
damage to the middle or inner ear. If the middle or inner ear has suffered damage, the child may have
suffered sensorineural hearing loss and may feel dizzy. Immediate treatment of this can reduce the risk of
permanent hearing loss. The other exception is watch or hearing aid batteries in the ear, which should be
removed immediately. If the physician suspects damage, or if the child is uncooperative, it may be
necessary to remove the foreign object under general anesthesia. Once the object has been removed,
the physician will re-examine the ear to see if there has been any harm to the ear canal or eardrum, and
may prescribe antibiotic drops to treat any possible infection. Beware of repeated attempts to remove the
object without proper instruments and equipment. This can sometimes push the object deeper into the
ear canal, cause damage and make the child terrified of anyone making further attempts to remove the
object.

Noses: Children often place objects in their noses as well, such as tissues, crayons, clay or pieces of
toys. They may do so because they’re simply curious or copying other children or they simply get
overenthusiastic when smelling something. The most common symptom is nasal drainage on the affected
side of the nose, often accompanied by a bad odor. The child may also have a bloody nose. If your child
cooperates you can try to have them blow it out into a tissue however if it remains lodged, the object must
be removed by your ENT physician. Occasionally, removal will require general anesthesia. After removal,
the physician may prescribe nose drops, antibiotic ointments or oral antibiotics to treat any possible
infection. Again, this is usually not an emergency unless the object is caustic such as a battery or
chemical.

Airway obstruction: FOREIGN BODIES IN THE AIRWAY ARE A MEDICAL EMERGENCY AND
REQUIRE IMMEDIATE ATTENTION. A foreign body can get stuck in many different places within the
airway. Airway Foreign bodies cause nearly nine percent of accidental deaths in children under five years
of age. Children tend to put things into their mouths when they are curious. The child may then inhale
deeply and the object may become lodged in the trachea, instead of the esophagus. A large piece of food
may cause an obstruction in children who do not have a full set of teeth to chew completely or in children
who do not chew their food well. Children’s lack of coordination between the mouth and the tongue can
also lead to problems. Children between the ages of seven months and four years are in the greatest
danger of choking on small objects, such as seeds, toy parts, grapes, hot dogs, pebbles, nuts and
buttons. The most commonly aspirated object is a Peanut. Always watch your child closely to avoid
choking emergencies. Each child may experience choking symptoms differently, but the following are the
most common symptoms:

            •    Choking or gagging when the object is first inhaled.
            •    Coughing at first.
            •    Wheezing – a high-pitched sound usually made when the child breathes out.
            •   Stridor – a high-pitched sound usually heard when the child breathes in.

Although the initial symptoms mad subside, the foreign body may still be obstructing the airway. The
following symptoms may indicate that there is still an airway obstruction:

            •   Stridor - a high-pitched sound usually heard when the child breathes in.
            •   Cough that gets worse
            •   Being unable to speak
            •   Pain in the throat area or chest
            •   Hoarse voice
            •   Blueness around the lips
            •   Wheezing - a high-pitched sound usually made when the child breathes out.
            •   Not breathing
            •   Loss of consciousness

A FOREIGN BODY IN THE AIRWAY IS A MEDICAL EMERGENCY AND YOU SHOULD CALL 911
IMMEDIATELY. If the airway is completely blocked, the child will be unable to breathe or talk and his or
her lips will turn blue. Sometimes, surgery is necessary to remove the object. Children who are still talking
and breathing but show other symptoms still need to be evaluated by a physician immediately. THE RISK
OF DEATH IS 50% IN PATIENTS WITH A FOREIGN BODY IN THE LARYNX (VOICE BOX)

Children and secondhand smoke

Secondhand smoke is a combination of the smoke from a burning cigarette and the smoke exhaled by
the smoker. Also known as environmental tobacco smoke (ETS), it contaminates the air and is retained in
clothing, curtains and furniture. Many people find ETS annoying and irritating to the eyes and nose. More
importantly, it represents a dangerous health hazard. Although ETS is dangerous to everyone, fetuses,
infants and children are at the most risk, because ETS cam damage developing organs, such as the
lungs and brain.

The fetus and newborn: Maternal, fetal and placental blood flow change when pregnant women smoke.
Some studies suggest that smoking during pregnancy causes birth defects such as cleft lip or palate.
Smoking mothers produce less milk, and their babies have a lower birth weight. Maternal smoking is also
associated with neonatal death from Sudden Infant Death Syndrome, the major cause of death in infants
between one month and one year of age.

Children’s lungs and respiratory tracts: Exposure to ETS decreases lung efficiency and impairs lung
function in children of all ages. It increases both the frequency and severity of childhood asthma and can
aggravate sinusitis, rhinitis, cystic fibrosis and chronic respiratory problems such as cough and postnasal
drip. It also increases the number of children’s colds and sore throats. In children under two years of age,
ETS exposure increases the likelihood of bronchitis and pneumonia. Children of parents who smoke half
a pack a day or more are at nearly double the risk of hospitalization for a respiratory illness.

The ears: Exposure to ETS increases both the number of ear infections a child will experience and the
duration of the illness. Inhaled smoke irritates the eustachian tube, causing swelling and obstruction
which lead to more pain, fluid retention and infection. Ear infections are the most common cause of
children’s hearing loss.
The brain: Children of mothers who smoked during pregnancy are more likely to suffer behavioral
problems such as hyperactivity than children of non-smoking mothers. Modest impairment of school
performance and intellectual achievement have also been seen in these children.

Cancer: You have just read how secondhand smoke harms the development of your child, but did you
know that your own risk of developing cancer from ETS is about 100 times greater than from outdoor
cancer-causing pollutants? Did you know that secondhand smoke causes more than 3,000 non-smokers
to die of lung cancer each year?

What can you do to avoid secondhand smoke?


                       •   Stop smoking, if you do smoke. Consult your physician for help, if needed.
                       •   If you have household members who smoke, help them stop. If it’s not
                           possible to stop their smoking, ask them, and visitors, to smoke outside of
                           your home.
                       •   Do not allow smoking in your car.
                       •   Be certain your children’s schools and day care facilities are smoke-free.
                       •   Avoid public places, such as restaurants, that allow smoking inside.

				
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