Breathing Easy: Insights on ENT Health in Nepal

Dr. Sriti Manandhar is an Associate Professor of ENT and Head & Neck Surgery and a Senior Consultant Rhinologist renowned for her expertise in endoscopic sinus and anterior skull base surgery. With over twelve years of dedicated clinical practice, she has significantly advanced ENT care in Nepal. Dr. Manandhar earned her MS from B.P. Koirala Institute of Health Sciences and pursued specialized training through a two-year clinical fellowship in Rhinology and Anterior Skull Base Surgery at MAA ENT Hospital in Hyderabad, India. She further refined her skills in Rhinoplasty at Asan Medical Center, Ulsan University in Seoul, South Korea. Currently, Dr. Manandhar provides expert ENT and Head & Neck services, focusing particularly on rhinology and endoscopic procedures, at Blue Cross Hospital in Kathmandu. Here, she shares her insights on the most common ENT issues faced by patients like chronic sinusitis, excessive snoring, or recurrent tonsillitis and offers valuable advice on prevention and treatment.

1. What are the most common ENT issues you encounter in your practice in Nepal?
In my daily practice, I encounter all kinds of Ear, Nose, and Throat problems.
 Ear:
– Middle ear infection (Otitis Media)
– Hearing loss

 Nose:
– Chronic rhinosinusitis (sinus problem)
– Nasal polyp
– Deviated Nasal Septum
– Allergic rhinitis

 Throat:
– Tonsillitis, Pharyngitis, Upper respiratory tract infections

 Neck:
– Thyroid disorders

2. In Nepal, are there specific environmental or cultural factors that contribute to ENT problems that are different from other regions?
There are multiple factors like:
 Environmental factors:
– Fluctuating weather patterns
– Air pollution – Rhinitis, sinusitis, Allergic pharyngitis
 Crowd, poor hygiene – ENT problems
 Low socio-economic conditions- use of wood for cooking stove – contributing to upper airway problems
 Cultural practices:
– Alcohol consumption, tobacco – Oral Cancer, Head and Neck Cancer
– Putting oil in ear – ear problem
 Limited health access
 Lack of health awareness
 Upper airway problems leading to early ear problems in early childhood

3. With an increase in air pollution as winter approaches, are you seeing more respiratory or throat issues in your patients? How can people protect themselves?
Yes. As winter approaches, in Kathmandu as well as other parts of Nepal, I come across increased numbers of patients with respiratory and throat-related issues due to the rise in air pollution level.
The colder temperature and worsening quality of air, use of wood-burning stoves, and household fires are contributing factors for sinusitis, allergic rhinitis, pharyngitis, and laryngitis. This may later lead to lower airway problems like chronic bronchitis, exacerbation of asthma, coughing, wheezing, and shortness of breath becoming more frequent.

People can protect themselves by:
 Use of facial masks
 Staying indoors on high pollution days
 Use of electric cooking devices, gas stoves (less smoke-producing appliances)
 Adequate hydration
 Drinking warm water, keeping oneself warm
 Avoid outdoor physical activity
 Intake of fresh fruits, green vegetables, spices like ginger, turmeric during the cold season
 Avoid smoking / use smoke-free spaces
 Use of alternative heating options

4. Sinus problems are a frequent complaint. What suggestions would you recommend for managing chronic sinusitis?
Sinusitis is indeed a frequent problem in all seasons but especially during winter, in areas with high air pollution.

Recommendations for managing chronic sinusitis:
 Lifestyle modification
 Regular exercise
 Good hydration
 Use of humidifier
 Steam inhalation
 Avoid allergens – Dust, smoke
 Use of mask
 Good quality sleep
 Healthy food
 Early consultation with an ENT specialist for proper investigation, diagnosis, and treatment for prevention of complications.

5. For people who snore excessively, at what point should they seek medical attention, and how can an ENT specialist help?

Alarming signs for medical attention:
 Pausing in breathing during sleep – Obstructive Sleep Apnea (OSA)
 Morning headache; daytime sleepiness, fatigue
 Gasping, choking, snoring
 Difficulty in concentrating & memory problem
 High blood pressure
 When you snore so loud that it is affecting your partner’s sleep

ENT specialist can help by performing:
 Detailed assessment & diagnosis
 ENT specialist will evaluate the nasal passage, throat, and airway anatomy to identify the level of obstruction (by endoscopic evaluation)
 Sleep study (polysomnography) – to confirm a diagnosis of sleep apnea

Treatment modalities:
 Lifestyle and behavioral counseling
– Weight management
– Avoid alcohol

1. Use of medical devices:
 CPAP – continuous positive airway pressure for OSAS
 Oral appliance – reposition the jaw structure
2. Surgical:
– Uvulopalatopharyngoplasty
– Radiofrequency
– Nasal or Septal Surgery
– Palatal implants
3. Follow up care & monitoring

ENT specialists can offer targeted treatment thereby improving sleep quality, overall health, and well-being. Early diagnosis and prompt treatment to avoid complications of untreated sleep apnea as heart disease, stroke, and diabetes.

6. Should you be concerned if your child is snoring?
Yes, occasional snoring may not indicate a problem, but regular or loud snoring in children could point to obstructive sleep apnea, generally due to enlarged tonsils, adenoids, or nasal obstruction, obesity, or medical condition.

Alarming signs are:
pauses in breathing, mouth breathing, gasping during sleep. Daytime sleepiness, poor growth, weight loss.

7. What could be the best treatment modalities for snoring problems?
1. Tonsillectomy and/or Adenoidectomy
2. Addressing allergies, nasal obstruction
3. Weight management
4. Positive airway pressure therapy
5. Orthodontic treatment
6. Behaviour and Lifestyle Adjustment with follow-up & monitoring

8. What advice do you have for children or adults suffering from recurrent tonsillitis?
Recurrent tonsillitis can significantly impact quality of life and may sometimes lead to cardiovascular and kidney disease in patients under 15 years of age. Consulting an ENT specialist and seeking prompt management is essential.

There are some preventive measures:
1. Good Hygiene Practices
– Practice regular hand washing, avoid sharing utensils, and keep personal items separate.
2. Boost Immune System
– Follow a balanced diet, including:
■ Nepali Thali (traditional balanced meal)
■ Multivitamins if necessary
■ Fruits, green vegetables, whole grains
■ Zinc-rich foods, nuts, and probiotics (like yogurt)
– Ensure adequate sleep and rest.
3. Stay Hydrated
4. Manage allergies and Sinus issues and asthma.
5. Avoid Smoking and Alcohol
6. Appropriate Use of Antibiotics

Note when to consider surgery:
1. Frequent recurrence – 7 or more episodes/year
– 5 episodes/year for 2 consecutive years
– 3 episodes/year for 3 consecutive years
2. Chronic or persistent tonsillitis
3. Sleep disturbance
4. Difficulty in swallowing or breathing

Tonsillectomy will provide substantial relief for individuals who experience frequent and severe tonsillitis.

9. Hearing loss is a growing concern and it has been linked with excessive use of earphones & earbuds especially among young people. What are the early signs to look out for & how can you prevent it?

Signs:
1. Difficulty in hearing in noisy environments
2. Needing higher volume while watching TV can be a sign of hearing loss
3. Ringing in ears / Tinnitus
4. Muffled or distorted sound
5. Difficulty in understanding speech
6. Poor discrimination of sound
7. Ear discomfort / Pain

Preventive measures to protect hearing:
 Follow 60/60 Rule
– limit use of earphones/earbuds
– use for max 60 min at a time
– volume should not exceed 60% of the maximum volume of the device.
– take a break between use
 Use over-ear headphones instead of earbuds.
– It has lower volume by decreasing noise and external noise cancellation, preventing direct exposure to the eardrum.

Limit exposure to loud music
Educate on safe listening habit
Get regular checkups with ENT specialists for early intervention.

10. How can individuals maintain good ear health and what are the common misconceptions about ear care?

For Good Ear Health:
1. Practice safe listening habits
2. Avoid inserting any object into ear canal
3. No self ear cleaning or wax removal
4. Avoid water entry into the ears while bathing & swimming
5. Avoid smoking and passive smoking
6. Regular hearing check-up

Common Misconceptions About Ear Care
1. Cotton swabs are safe for cleaning ears
– Fact: Cotton swabs should not be used to clean ears as they can push wax further into the ear canal.
2. Ear wax is dirty and should be removed regularly
– Fact: Ear wax has protective qualities and typically does not need to be removed unless causing a blockage.
3. Ear infections only affect children
– Fact: Ear infections can affect people of all ages, though they are more common in children.
4. Loud sounds are only dangerous if they cause pain
– Fact: Loud sounds can be damaging even if they don’t cause immediate pain.
5. Home remedies are effective for ear cleaning, like using oil inside the ear
– Fact: Inserting substances like oil without professional guidance can cause harm. Professional advice is recommended for safe ear care.

11. You are a Specialist in Rhinology and Endoscopic Sinus Surgery. Please describe the conditions that require this kind of surgery for treatment.
Endoscopic Sinus Surgery is a minimally invasive procedure primarily used to treat conditions affecting nasal passage, sinuses particularly when medical therapy alone is ineffective.

Common Conditions That Often Require Rhinologic and Endoscopic Sinus Surgery include:
 Chronic rhinosinusitis
 Recurrent acute sinusitis
 Nasal polyp
 Fungal sinusitis
 Sinus and nasal tumors
 Cerebrospinal fluid (CSF) leak from the nose
 Orbital and optic nerve decompression
 Revision sinus surgery

12. What final message do you have for the public in terms of preventing ENT disorders and seeking timely treatment?
To prevent ENT disorders, ensuring timely treatment is very important to prevent further damage.

Some key message are:
1. Prioritize Ear, Nose, and Throat (ENT) Hygiene
2. Avoid Smoking and Alcohol Intake
3. Stay Aware of Allergies and Environmental Triggers
4. Practice Safe Swimming and Water-Related Activities
5. Do Not Ignore Ear, Sinus, and Throat Problems
6. Educate Yourself and Raise Awareness

Early action and prompt management are essential for maintaining ENT health and improving quality of life. Don’t delay in seeking professional care for ENT-related symptoms.