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Novena ENT – Head & Neck Surgery Specialist Centre
 
MAIN CLINIC:
Mount Elizabeth
Novena Specialist Centre
38 Irrawady Road
#04-21/22/34, Singapore 329563
 
SATELLITE CLINIC:
Parkway East Hospital
319 Joo Chiat Place
#03-07, Singapore 427989
 
 
 
Patient Information
  From the perspective of an experienced ENT Surgeon with a PhD research and Diploma in Acupuncture background

I am an Ear Nose and Throat (ENT) Specialist with more than 20 years of clinical experience, particularly in hearing loss and other ear disorders. My Doctor of Philosophy (PhD) training got me interested in exploring new treatments that can possibly improve treatment outcomes. I have shared my own research findings and thoughts through > 70 local or international peer-reviewed publications and > 200 clinical presentations at Conferences in Singapore and overseas including the USA, Europe, Australia and Asia. As a registered Acupuncturist, I also try to identify ENT conditions that could potentially benefit from complementing acupuncture treatment with modern Western Medicine. With these different perspectives, I share my thoughts and experience on the following issues.

  How do we hear

Sound enters the ear via the external ear canal. The sound vibrates the eardrum located at the deep end of the ear canal. The middle ear space lies behind the eardrum and is connected to the back of the nose (nasopharynx) by the Eustachian tube. The middle ear space houses the ossicular chain, which consists of 3 bones (malleus, incus and stapes). The ossicular chain serves to transmit vibrations of the eardrum to the inner ear where the cochlear hair cells transform the incoming mechanical energy into electrical energy. The electrical signals can then be transmitted along the hearing nerve to the brain where it is perceived as sound.

  Types of hearing loss

Hearing loss results from disorders of the external (eg ear wax), middle (eg ossicular chain disruption or fixation) or inner ear (eg old age, noise-induced). Hearing loss can be conductive, sensori-neural or both. Conductive hearing loss affects the sound-conducting mechanism in the external or middle ear. Sensori-neural hearing loss is the result of damage to the cochlear (inner ear) cells  or retro-cochlear nervous pathways (auditory nerve and central nervous system).

  Ear-related symptoms: Is it due nose cancer or other serious conditions?

Nasopharyngeal carcinoma (NPC) is cancer arising from the back of the nose. It commonly affects patients of Chinese origin and is the commonest Head and Neck cancer in Singapore. Early diagnosis and treatment offer excellent prognosis but unfortunately, nearly 15% have delayed diagnosis (Leong et al 1999). To aid early diagnosis, the doctor must be mindful that the tumour appearance in the nasopharynx correlates with the stage of disease (Low & Leong 2000). From my experience, clinical assessment is greatly aided by the contact bleeding sign which I had described (Low 1997). Although Epstein-Barr viral serology can be a useful tumour marker, it can be misleading and therefore should be interpreted with caution (Low et al 2000). NPC patients commonly present to the doctor with ear complaints (Low & Rangabasham 2012).

One-sided hearing loss plus ear blockage – is it NPC?

NPC can affect the Eustachian tube, resulting in Eustachian tube dysfunction (Low 1995). Sometimes, it results in fluid collection in the middle ear space (middle ear effusion) causing hearing loss and a sensation of ear blockage (Low 1996). The mechanism how NPC results in middle ear effusion has been explained by Low et al (1997). Middle ear effusion can also be caused by other etiologies such as infections of the sinuses. 

One-sided hearing loss - is it an acoustic neuroma?

Although advanced NPC can occasionally affect the hearing nerve resulting in one-sided sensori-neural hearing loss (Low et al 2000a), of greater concern is the possibility of an acoustic neuroma. Arising from the hearing nerve, an acoustic neuroma is often of insidious-onset and progressive in nature. Although benign, delayed diagnosis may result in a large and dangerous tumour which can compress the brain. An early tumour can possibly be removed with preservation of residual hearing using appropriate surgical techniques (Low et al 1995c; Low 1999b). For example, I have described a new surgical landmark based on the vestibular aqueduct which helps to excise acoustic neuroma with hearing preservation via the posterior cranial fossa in a minimally invasive way (Low 1999a).

It is emphasized that acoustic neuroma can occasionally present as sudden hearing loss. More commonly, sudden hearing sensori-neural hearing loss is of unknown etiology (idiopathic). It is important to remember that early treatment offers the best chance of recovery in sudden idiopathic sensori-neural hearing loss (Low, in press).

One-sided tinnitus – is it a bloody tumour?

Tinnitus is a hallucination of sounds, often perceived as ringing or hissing in nature. All of us may occasionally experience a few seconds of tinnitus which is physiological and therefore, considered normal. Persistent tinnitus on the other hand, affects up to 10-15% of the population. It is mostly innocuous but occasionally can be due to serious underlying conditions. For example, an acoustic neuroma if early, can present with just one-sided tinnitus without hearing loss. A glomus tumour (a bloody tumour consisting of abnormal blood vessels) in the vicinity of the ear may present as pulsatile tinnitus (hearing of pulse-like sounds). Assessments will be made by the doctor to exclude pathological conditions and the appropriate counseling and medications are prescribed where appropriate. In disturbing tinnitus, therapeutic interventions are available such as those based on musical devices (Neuromonics). This works on principle of stimulation using customized music based on the patient’s tinnitus and hearing profile, desensitisation by positively engaging the limbic system and hence, resulting in relaxation and relief. 

Giddiness/vertigo – is it a stroke?

As the inner ear also has a balancing function, it is common to experience giddiness/vertigo in inner ear disorders. The patient is evaluated to rule out serious causes such as a stroke or even a tumour (Low 1998). Investigations if needed may include electro-physiological, radiological or blood tests (Low et al 1995a). The causes and symptoms will be appropriately managed including using medical, surgical and rehabilitative (physiotherapy) solutions.

Ear infections – is it a cholesteatoma?

Ear infection usually presents with ear discharge, itch, blockage and pain. It is most commonly due to infection of the outer or middle ear when there is a perforation of the eardrum. Sometimes, it is caused by serious conditions such as a cholesteatoma (a collection of squamous debris), which can potentially result in major complications such as infections involving the brain. The common ear infections are normally treated in the Clinic by thorough cleaning (aural toilet) under microscopy and the appropriate medications applied. Surgery may be required to eradicate serious diseases and to repair eardrum perforations.

Facial weakness – is it more than Bell’s palsy?

This is most commonly due to Bell’s Palsy which is caused by a virus. However, other serious conditions such as stroke, lesions of the ear and parotid also have to be ruled out. For example, Low (2002) had reported cases of NPC causing facial weakness.

Ear pain – is it referred by something serious?

This is usually caused by simple infections of ear but occasionally, it can be due to serious conditions such as malignant otitis externa and cancers. In the absence of ear pathology, ear pain may be due to referred pain. This refers to ear pain caused by irritation of nerves which supply both the ear as well as another region of the body. For example, infection or even a cancer of the throat can manifest as ear pain. Interestingly, NPC seldom presents as ear pain but more of a sensation of fullness (Low & Rangabasham 2012)

Mass in the head and neck region – is it cancer spread?

NPC can present as a mass around the region of the ear (Low & Goh 1999). More commonly, NPC present as a mass in the neck, having spread to the lymph nodes there.  Patients presenting with a mass in the head and neck region require a thorough ENT check, including nasopharyngoscopy. Fine needle aspiration cytology is often used to evaluate, where a fine needle in used to aspirate cells from the mass for examination under the microscope.  

In patients with prior radiotherapy – assessment becomes more difficult

Evaluation of ear-related complaints in post-radiotherapy (post-RT) NPC patients can be difficult because both recurrent NPC and RT itself may result in similar manifestations.
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RT had been found to result in 20% and 45% of patients having hearing loss, which could sensori-neural or conductive in nature (Low & Fong 1996; 1998). Direct radiation damage to cochlear hair cells is an important mechanism contributing to sensori-neural hearing loss (Low & Fong 1996a). Combined ototoxicity from treatment with chemo-RT results in an even greater sensori-neural hearing loss than by treatment with RT alone (Low et al 2006). Post-RT conductive hearing loss is mainly due to radiation-induced chronic middle ear effusion (Low & Fong 1998a). 

Other complications of radiotherapy in NPC patients include osteo-radio-necrosis (Lim et al 2005) and radiation-induced cancers of the ear (Goh et al 1999). In a study on NPC patients developing radiation-induced cancers of the ear, we found that squamous cell carcinoma was more common than sarcoma, and carried a poorer prognosis than non radiation-associated cancers (Lim et al 2000).

  Childhood Hearing Loss - key issues you ought to know

Having been trained at the Royal Manchester Children’s Hospital in UK and having run regular clinics as Visiting Specialist at Singapore’s KK Children’s and Women’s Hospital for a number of years, I had long realized that children are not merely little adults and have different needs. Also with my past experience as Chairman of Ministry of Health’s Committee to Study Childhood Hearing Loss in Singapore, Director of Ministry of Health’s National Cochlear Implant Program, President of the Asia-Pacific Symposium on Cochlear Implants & Related Sciences and President of the Singapore Association for the Deaf, I share my views on some key areas relating to childhood hearing loss.

Consequences of ineffective treatment

It is well-recognised that hearing is critical to a child’s speech and language development, communication and learning. Hearing loss causes delay in the development of receptive and expressive communication skills (speech and language). The resultant language deficit also causes learning problems and reduced academic achievement.

Otitis media with effusion (OME)

The commonest cause of childhood hearing loss is probably otitis media with effusion (OME), commonly referred to as glue ear or middle ear effusion. It is normally an acquired cause secondary to Eustachian tube dysfunction and results in conductive hearing loss.

The Eustachian tube

The Eustachian tube (ET) provides a connection between the nasopharynx and the middle ear space. It is not merely a simple rigid tube but a highly complex organ consisting of a fibrocartilage portion with its mucosa, cartilage, surrounding soft tissue and peritubal muscles as well as a bony segment. The principle roles of the ET are believed to be optimization of middle ear sound transmission and protection of middle ear structures (Ars 2003). These roles are supported by maintenance of pressure regulation of the middle ear cleft as well as sterility. Dysfunction of the ET can be obstructive (including mucosal edema, inflammation and infections) or dynamic (including disorders relating to muscular functions and pressure regulation/gaseous exchange).   

The adenoid

The adenoid is an aggregate of lymphoid tissue located in the central part of the nasopharynx. Lymphoid tissue is part of the body’s immune system and tends to be more reactive in children. As such, the adenoid tends to swell during childhood and in the process can obstruct the Eustachian tube resulting in OME.

Treatment of OME – frequently asked questions

There is a tendency for children to develop OME because the Eustachian tube is still not fully matured and lies in a more horizontal position as compared to adults. Moreover, it can potentially be obstructed by a grossly enlarged adenoid. Questions often asked by parents of children with persistent OME include whether drainage of the fluid is required and more importantly, whether removal of the adenoid (adenoidectomy) or tonsils (tonsillectomy) is indicated. Parents are often confused by conflicting medical advice and are concerned if the advice given were evidence-based. 

The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery jointly appointed a subcommittee to provide a clinical practice guideline on OME, to provide evidence-based recommendations on diagnosing and managing OME in children (Rosenfeld et al 2004). When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. Antihistamines and decongestants are said to be ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

The subcommittee however, pointed out that this guideline is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to managing this problem. Clinical judgment should be exercised in recommending treatment. For example, a child with OME can have associated blocked nose due to allergic rhinitis which in my view, should be treated on its own merits. Blocked nose has been found to be associated with Eustachian tube dysfunction, headaches and snoring which could possibly be alleviated by relief of the blocked nose (Low 1994; Low & Willatt 1993; 1995). Besides the adenoids, the tonsils may also be grossly enlarged in patients who have snoring with or without obstructive sleep apnea. In this situation, there is merit in removing both the obstructive adenoid and tonsils (adeno-tonsillectomy).    

OME can sometimes be complicated by acute otitis media, where the fluid in middle ear is replaced by pus. This should be appropriately treated as occasionally, serious complications such as facial weakness and brain abscess can develop.

 

Why it is now possible for children with irreversible hearing loss to grow up normally

The desired ultimate outcome in the management of children with irreversible hearing loss is successful integration into mainstream society. In addition to treating the hearing loss and addressing the individual needs of each child, it is essential that an effective system be in place to promote early detection, effective early intervention and mainstream school support.  

I shall share my experience on how these issues were addressed in Singapore. In 1999, I chaired a Ministry of Health (MOH) Study on Childhood Hearing Loss in Singapore. It was revealed that the use of behavioural methods of hearing screening in Polyclinics resulted in late detection of childhood hearing loss. Delayed diagnosis adversely affected speech and language development as well as the subsequent academic performance. Universal Newborn Hearing Screening (UNHS) using objective tests was therefore recommended with the aim to diagnose congenital hearing loss by 3 months and intervened by 6 months of age. (MOH Report 2001). After a successful national feasibility study which I subsequently directed, UNHS was accepted as standard medical practice in Singapore (Low et al 2005).

Hearing devices such as cochlear implants can be costly and therefore, not accessible to some. I initiated and directed a MOH National Cochlear Implant Feasibility Study in 2001. After intensive rehabilitation, the majority of children studied was able to develop good speech and language and was deemed to have the potential to cope well in mainstream schools. Hence, cochlear implant was subsequently incorporated into the mainstream healthcare service under MOH’s Medical Advancement Budget.

Itinerant Support Service in mainstream schools administered by the Singapore Association for the Deaf, was also started to help hearing-impaired children cope better in the schools.

With this holistic approach, it was deemed that at least 80% of children born with significant deafness could cope well in mainstream education, integrate into mainstream society successfully and contribute effectively to society.

  Hearing Loss – What can be done to make a difference

Medications

Some patients with conductive hearing loss resulting from middle ear infections recover after a course of antibiotics and nasal decongestants. Sensori-neural hearing loss resulting from Meniere’s Disease may respond to diuretics, and that from syphilitic otitis may improve with antibiotics (Low 2005a).

Sudden hearing loss is a condition where one perceives a loss of hearing (usually in only one ear) suddenly or over a period of hours. The exact cause is largely unknown (idiopathic), but viral, vascular and auto-immune causes had been suggested. The recommended treatment includes steroids which can be injected into the middle ear for maximum benefit and possibly hyperbaric oxygen therapy. It is important that treatment be started as early as possible, in order to maximise the chances of recovery.     

Surgery to restore physiological hearing

Conductive hearing loss can generally be rectified by appropriate surgery, so that the mechanical energy from sound can reach the inner ear where it is converted to electrical energy by cochlear hair cells. For example, tympanic perforations can be repaired (tympanoplasty surgery) and the fixated stapes in otosclerosis can be replaced by a prosthesis (stapedectomy surgery) (Low 2005).

Surgery generally cannot restore physiological sensori-neural hearing, as the loss is usually a result of irreversible cochlear hair cell damage. An exception could be sensori-neural hearing loss due to disturbed cochlear function from a perilymph fistula, where successful surgical repair can restore inner ear function.

Hearing aids & assistive devices

There have been major advancements in the area of hearing technology to help people better cope with hearing impairments. Hearing aids, cochlear implants and implantable hearing devices are some of the available options (Low 2001).

Modern digital hearing aids have added features and processing schemes that were previously not possible with the analogue technology, making hearing amplification better and more comfortable. It is still a challenge, however, to develop hearing aids capable of enabling patients to understand speech in noisy environments. Besides better functioning, there is a trend towards increasing miniaturisation, which has progressed from body-worn aids, to aids worn behind the ear and in the ear canal. FM systems can be used to enhance the effectiveness of hearing aids, by improving signal-to-noise ratio. The latest in hearing aid technology features automatic digital signal processing, multiband adaptive directionality, wind noise management, multiple listening programs, data logging/learning, water-resistant technology, wireless Bluetooth capability and more (Tan et al 2011).
 
Newer hearing aid technologies include those which can be implanted into the middle ear. The potential advantages of implantable hearing aids are the elimination of feedback and the occlusion effect, as well as improved fidelity and cosmesis. There are also bone-anchored hearing aids, where the hearing aid is fitted onto a titanium screw, which bio-integrates with the mastoid bone. There is a newer version that works on the same principle but does not require the use of a titanium screw. This type of hearing aid is useful for patients who are not able to wear a hearing aid in the ear canal, such as those with chronic ear infections, stenotic ear canal or aural atresia.

Besides devices that can amplify sounds, there are assistive tools which can help the profoundly deaf cope better in day-to-day activities. For example, silent vibrating alarm clocks and door-bells with flashing lights are available.

Cochlear implants

Some patients have cochlear hair cells so severely damaged that conventional hearing aids are of inadequate benefit. Such patients may benefit from the cochlear implant, which does not rely on viable cochlear-hair cells to work. In 1997, I implanted the first child in Singapore. Since then, I have performed more than 500 cochlear implant surgeries in Singapore and overseas, and have helped to establish cochlear implant programmes in Singapore, Indonesia, Malaysia and China. I was also part of the team that performed the first pediatric brainstem implant in Singapore, a special type of hearing implant which may be considered in patients who have damaged/absent hearing nerves (Tan et al 2012). 

From my experience, the results of cochlear implantation had generally been very good (Low 1999). In children, as expected, early implantation tends to result in better outcomes (Low et al 2008a). In post-irradiated NPC patient, there is a theoretical risk that retro-cochlear auditory pathways may be damaged by radical radiotherapy, rendering cochlear implants ineffective. However, my long-term prospective study using acoustic brainstem response audiometry has shown that this concern is unwarranted (Low et al 2005; Low 2010). This has been substantiated by my subsequent clinical studies, which showed that cochlear implants could be used just as effectively in post-irradiated ears (Low et al 2006a, Soh et al 2012). When I first started cochlear implantation in 1997, implantation in only one ear was the rule. Over the years, bilateral cochlear implantation is gaining popularity as listening in both ears enable better hearing in noisy environments and better localization of sounds. There has also been increasing evidence to show that cochlear implantation is beneficial even in patients with irreversible one-sided severe to profound hearing loss (with normal hearing on the other ear), especially when of recent onset and associated with disturbing tinnitus.

The risks associated with cochlear implants are real, and can potentially be serious such facial nerve injury, meningitis or wound infections necessitating removal of the implant in order to cure the infection. Fortunately, the risks of such complications are small in experienced hands. 

Role of care-givers

Besides treating the cause of hearing loss and attempts at hearing restoration, other related issues which contribute to the well-being of the patient have to be addressed as well. For example, factors such as parental concerns, educational issues and psycho-social effects, need to be considered in a hearing-impaired child (Low & Phua 2012). Even the psychological trauma of simply undergoing ear surgery should not be overlooked.
  
Many problems faced by the hearing-impaired are the result of the ignorance of family members, friends, peers, teachers and others around them. Effective education directed at people around the hearing-impaired, is also necessary (Low 2011). As this effort results in therapeutic benefits to the hearing-impaired themselves, I have coined the term “reverse education therapy” to describe this (Low 2005).

Treatment based on Cell & Molecular Biology

In cell and molecular biology, the regeneration/repair/protection of auditory hair cells and nerves are exciting rapidly evolving fields.  Humans are born with a fixed number of cochlear hair cells with no significant regenerative capability. Interestingly, in species like birds, cochlear hair cells have ability to regenerate. Much research is being focused on understanding the cellular & molecular processes involved in hair cell viability and regeneration, with the view to develop medical interventions for protection against hair cell death and for promotion of hair cell regeneration in humans. For example, radiation-induced apoptosis of cochlear hair cells occurs (Low et al 2006a) and is aggravated in combined chemo-radiation therapy (Low et al 2010). My studies also revealed that oxidative stress in involved and that the anti-oxidant L-NAC could potentially offer protection (Low 2008). There has also been encouraging recent advances in the use of stem cells and gene therapy in treating hearing loss in animals (Chen et al 2012). When combined with cochlear implant technology in particular, I believe they could potentially produce excellent clinical outcomes in the not too distant future.

  Why Ear Surgery in Asian patients is different from Western patients?

Racial differences in anatomical structures exist not only in the context of size but also in cranial morphological structures. A fact that is not commonly known to the public nor even to most medical professionals is there are differences in mastoid morphology and that such differences had even been used in race identification during forensic and anthropology studies (Low et al 1999). It is therefore not unreasonable to expect such differences to have clinical significance in the practice of Otology and in ear surgery. Hence, in ear surgery, some of the surgical landmarks and techniques described in Western text-books may not apply in our local patients

Indeed, differences in the position of the jugular bulb between Chinese and Caucasians have been found, in that there was a tendency for it to be more medially situated in Chinese (Low et al 1995b). Another study which I did on Chinese temporal bones has revealed differences in the course of the facial nerve in the mastoid (Low et al 1999c) and the origin of the chorda tympani nerve (Low 2001a), from those described in Western textbooks. Knowledge of such racial anatomical variations reduces the risk of facial nerve injury during mastoid surgery (mastoidectomy).

  Is there a role for acupuncture in Ear Disorders?

As part of traditional Chinese Medicine (TCM), acupuncture is one of the oldest healing practices in the world that can be traced back for at least 2,500 years. The general theory of acupuncture is based on the premise that there are patterns of energy flow (qi) through the body that are essential for health. Health is achieved through balancing the forces of yin and yang, and disease is caused by an imbalance leading to a blockage in the flow of qi along specific pathways known as meridians. Acupuncture applied at specific acupoints along the meridians, has the potential to correct imbalances of the flow of qi. There are 12 main meridians with each connected with an internal organ system and named after the organ. In addition, there are 8 extra meridians and other side paths. There are a total of 361 classical acupoints interconnected through the meridian system.

By targeting the relevant acupoints on the meridians associated with the ear, acupuncture has been used to treat ear-related symptoms such as hearing loss, vertigo and tinnitus. A meridian which is of particular interest, is that of the kidney. According to TCM, the kidney opens into the ear and kidney disorders can manifest in the ear. Really, especially since the ear and the kidney are located at almost opposite ends of the torso! Let us pause and ponder. The kidney and ear lobe share a similar shape, but probably by chance. It is no coincidence however, that the ear and kidney have certain associations as observed in western medicine. Medications such as gentamicin have toxic side effects, which specifically target the inner ear and kidney. Some congenital malformations of the ear, for example the branchio-oto-renal syndrome, also affect the kidney. These observations may suggest an embryological relationship between the two organ systems. The TCM concept of using acupuncture on the kidney meridian as a means to treat certain ear conditions, may not be that far-fetched after all (Low 2010a).

Many studies in animals and humans have demonstrated that acupuncture can cause multiple biological responses. They are mediated mainly by sensory neurons to many structures within the central nervous system. There is a role of endogenous opioids in acupuncture analgesia; opioid antagonists such as naloxone reverse the analgesic effects.

Nevertheless, which of these and other physiological changes mediate clinical effects is at present unclear. Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points," the definition and characterization of these points remain controversial. Even more elusive is the scientific basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and other related theories, which are difficult to reconcile with contemporary biomedical information.

In a landmark study, entitled "Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials" published in 2003, the World Health Organization was of the view that acupuncture had been proven (through controlled trials) to be an effective treatment for ENT-related conditions like allergic rhinitis, facial pain, headache/neck pain, nausea/vomiting and post-op pain. WHO also expressed that the therapeutic effect of acupuncture had been shown but for which further proof was needed for conditions like Bell’s palsy, cancer pain, earache, epistaxis, Meniere’s Disease and facial spasm. In deafness, there had only been individual controlled trials reporting some therapeutic effects; and it was recommended that acupuncture was worth trying because treatment by conventional and other therapies was difficult.

It remains to be seen if the use of acupuncture in the treatment of deafness and other ear disorders can be supported by future solid well-designed research. To my mind, it is unrealistic to expect it to work in established hearing defects due to cochlear hair-cell loss. However, it will be interesting to find out if it is of value in treating potentially reversible conditions such as early sudden hearing loss (Low, in press). Acupuncture has been demonstrated to affect the pattern of otoacoustic emissions which is a manifestation of outer hair-cell activities (deAzevedo et al 2007). In Meniere’s Disease, it is unlikely that acupuncture could alter the course of the disease but could certainly play a complementary role in symptomatic relief of vertigo. In tinnitus, acupuncture has not been demonstrated to be efficacious as a treatment for tinnitus on the evidence of rigorous randomized controlled trials (Park et al 2000). My view is that it can possibly be beneficial in certain sub-groups of tinnitus sufferers such as those with tinnitus which can be modulated, for example by contractions of head and head muscles. How acupuncture is able to affect cochlear structures remains unknown but a possibility is via the efferent medial olivocochlear auditory pathways (Marks & Emery 1984).


  Reference
 
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  • Goh YH, Chong U, Low WK  (1999). Temporal bone tumours after irradiation of nasopharyngeal carcinoma.  Journal of Otolaryngology and Otology; 113:222-228
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  • Low WK, Pang KY, Ho LY, Lim SB, Joseph R (2005). Universal newborn hearing screening in Singapore: the need, implementation and challenges. Ann Acad Med Singapore; 34:301-6

  • Low WK (2005a). Practising Otology/Neuro-otology in Singapore. Ann Acad Med Singapore 2005; 34:279-2
  • Low WK, Burgess R, Fong KW, Wang DY (2005). Effect of Radiotherapy on Retro-cochlear Pathways. Laryngoscope; 115:1823-6

  • Low WK, Toh ST, Wee J, Fook-Chong SM, Wang DY (2006). Sensorineural hearing loss after radiotherapy and chemoradiotherapy: a single, blinded, randomized study. J Clin Oncology; 24:1904-9
  • Low WK, Gopal K, Goh LK, Fong KW (2006a). Cochlear implantation in postirradiated ears: outcomes and challenges. Laryngoscope; 116:1258-62

  • Low WK, Tan MG, Sun L, Chua AW, Goh LK, Wang DY (2006b). Dose-dependant radiation-induced apoptosis in a cochlear cell-line. Apoptosis; 11:2127-36
  • Low WK, Li S, Tan M, Chua A, Wang DY (2008). L-N-acetylcysteine protects against radiation-induced apoptosis in a cochlear cell line. Acta Otolaryngologica (Stockh); 128: 440-5

  • Low WK, Iskandar M, Krishna G (2008a). Outcomes of early cochlear implantation. Ann Acad Med Singapore; 37 (Suppl 3): 49-51
  • Low WK (2010). Current Concepts in Radiation-Induced Sensori-Neural Hearing Loss. In: Deafness, Hearing Loss and the Auditory System. Eds: Derick Fiedler, Rowland Krause. Nova Science; pp111-135

  • Low WK (2010a),. Acupuncture in the treatment of ear disorders. In: Deafness, Hearing Loss and the Auditory System. Eds: Derick Fiedler, Rowland Krause. Nova Science; pp 373
  • Low WK, Tan MGK, Kong SWW (2010). Ototoxicity from combined cisplatin and radiation treatment: an in vitro study. Int J Otolaryngology; 523976.

  • Low WK (2011). The hearing-impaired person: tips for care-givers & school teachers (ed-in-chief Low WK). Singhealth Academy 2011
  • Low WK, Phua MSY (2012). The value of the Hearing Education Arcade in Educating Caregivers of Hearing-impaired Patients. Proceedings of Singapore Healthcare 2012; 21: 3-7

  • Low WK, Rangabasham M (2012). Ear-related issues in patients with nasopharyngeal carcinoma. In: Carcinogenesis, diagnosis, and molecular targeted treatment for nasopharyngeal carcinoma. Ed Chen SS. InTech; pp 155-78
  • Low WK (in press). Idiopathic sudden hearing loss: is there a role for complementary treatment? J Alternative & Complimentary Medicine

  • Marks NJ, Emery P, Onisiphorou C (1984). A controlled trial of acupuncture in tinnitus. J Laryngol Otol.;98:1103-9.
  • MOH Report (2001). Committee to study the early detection and treatment of hearing loss in children in Singapore; Ministry of Health, Singapore.

  • Park J, White AR, Ernst E (2000). Efficacy of acupuncture as a treatment for tinnitus: a systematic review. Arch Otolaryngol Head Neck Surg; 126:489-92.

  • Rosenfeld RM, Culpepper L, Doyle KJ, Grundfast KM, Hoberman A, Kenna MA, Lieberthal AS, Mahoney M, Wahl RA, Woods CR Jr, Yawn B; American Academy of Pediatrics Subcommittee on Otitis Media with Effusion; American Academy of Family Physicians; American Academy of Otolaryngology--Head and Neck Surgery (2004). Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg; 130 (5 Suppl):S95-118
  • Soh JM, D’ Souza VD, Gopal K., Ng WN, Ong CS, Low WK (2012). Cochlear implant outcomes: A comparison between Irradiated & Non-irradiated ears. Clin Exp Otorhinolaryngology; 5 Suppl 1:S93-8

  • Tan TS, Lim CYE, Low WK, Tan NC (2011). Effective communication with hearing impaired patients: an approach for family physicians. The Singapore Family Physician; 37: 3761-6

  • Tan VY, D'Souza VD, Low WK (2012). Acoustic brainstem implant in a post-meningitis deafened child - Lessons learned. Int J Pediatr Otorhinolaryngology; 76:300-2.
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