Dr. Francisco Tejeira - Otolaryngologist (Ear, Nose, and Throat Specialist)
Dr. Francisco Tejeira is an ear, nose, and throat specialist in Panama City. He's been treating me for more than five years for a chronic nasal problem (from flying lots of hours on leaky Air Force planes) and tinnitus. I sat down with him recently to gather some information about hearing loss, and asked him some additional questions about the problems and patients he attends have most frequently here in Panama. 
What Is An Otolaryngologist? Otolaryngology (pronounced oh/toe/lair/in/goll/oh/jee) is the oldest medical specialty in the United States. Otolaryngologists are physicians trained in the medical and surgical management and treatment of patients with diseases and disorders of the ear, nose, throat (ENT), and related structures of the head and neck. They are commonly referred to as ENT physicians.
Their special skills include diagnosing and managing diseases of the sinuses, larynx (voice box), oral cavity, and upper pharynx (mouth and throat), as well as structures of the neck and face. Otolaryngologists diagnose, treat, and manage specialty-specific disorders as well as many primary care problems in both children and adults.
What Do Otolaryngologists Treat?
- The Ears - Hearing loss affects one in ten North Americans. The unique domain of otolaryngologists is the treatment of ear disorders. They are trained in both the medical and surgical treatment of hearing, ear infections, balance disorders, ear noise (tinnitus), nerve pain, and facial and cranial nerve disorders. Otolaryngologists also manage congenital (birth) disorders of the outer and inner ear.
- The Nose - About 35 million people develop chronic sinusitis each year, making it one of the most common health complaints in America. Care of the nasal cavity and sinuses is one of the primary skills of otolaryngologists. Management of the nasal area includes allergies and sense of smell. Breathing through, and the appearance of, the nose are also part of otolaryngologists' expertise.
- The Throat - Communicating (speech and singing) and eating a meal all involve this vital area. Also specific to otolaryngologists is expertise in managing diseases of the larynx (voice box) and the upper aero-digestive tract or esophagus, including voice and swallowing disorders.
- The Head and Neck - This center of the body includes the important nerves that control sight, smell, hearing, and the face. In the head and neck area, otolaryngologists are trained to treat infectious diseases, both benign and malignant (cancerous) tumors, facial trauma, and deformities of the face. They perform both cosmetic plastic and reconstructive surgery.
Hearing Loss: Millions of people have some degree of hearing loss. Most of them have lost their hearing gradually with increasing age. I had no idea that over half of people aged over 60 are hard of hearing or deaf. Hearing loss can also occur at a younger age. There are many people over 16 who were born hearing but have developed severe or profound deafness.
Sound consists of vibrations of air in the form of waves. The ear is able to pick up these vibrations and convert them into electrical signals that are sent to the brain. In the brain, these signals are translated into meaningful information, such as language or music with qualities like volume and pitch. The volume of sound is measured in decibels (dB).
There are many possible causes of hearing loss. These can be divided into two basic types, called conductive and sensorineural hearing loss. Conductive hearing loss is caused by anything that interferes with the transmission of sound from the outer to the inner ear. Sensorineural hearing loss is due to damage to the pathway for sound impulses from the hair cells of the inner ear to the auditory nerve and the brain, such as occurs in age-related hearing loss - the decline in hearing that many people experience as they get older.
It's most common for those diagnosed with hearing loss to require a hearing aid. I was also surprised to find out that only one out of five people who could benefit from a hearing aid actually wears one. It is the job of the otolaryngologist to determine the cause, type, and extent of your hearing problem and whether hearing aids will help you.
Hearing aids are electronic devices that fit inside or behind the ear and help amplify sounds. Hearing aids are helpful, but they do not restore normal hearing or eliminate background noise. Whether you choose analog over digital, or adjustable over programmable, you and your audiologist can determine if a hearing aid is the right device for your type of hearing loss. Before purchasing any hearing aid, ask if the warranty covers repairs and if there is a trial period. Adjusting to a hearing aid is a gradual process; it involves learning to listen in a variety of environments and becoming accustomed to hearing different sounds.
Your own voice may sound too loud. Your audiologist may or may not be able to correct this problem. Most people get used to it over time. You may hear a whistling sound or feedback. This is caused by the fit of the hearing aid or by earwax or fluid buildup.
Dr. Tejeira referred me to an expert on hearing aids, and a company that sells them here in Panama. I'm going to be contacting them shortly to gather additional information as to what is available here in Panama, how much they cost compared to other places, and things such as service, batteries, and other issues.
Sinusitus: This is a very common condition in any tropical enviroment, and especially in Panama. Many people who move here develop sinusitus for a variety of reasons.
Usually symptoms start with coughing and sneezing, and you feel tired and achy. Most people thing they are just getting a cold. When over the counter meds stop working, and you develop a terrible headache, you eventually you drag yourself in to see the doctor. After listening to your history of symptoms, examining your face and forehead, and perhaps doing a sinus X-ray, the doctor says you have sinusitis.
Sinusitis simply means inflammation of the sinuses, but this gives little indication of the misery and pain this condition can cause. Chronic sinusitis, sinusitis that persists for at least 3 weeks, affects an estimated 32 million people in the United States. Americans spend millions of dollars each year for medications that promise relief from their sinus symptoms.
Sinuses are hollow air spaces, of which there are many in the human body. These cavities, located within the skull or bones of the head surrounding the nose, include the frontal sinuses over the eyes in the brow area; the maxillary sinuses inside each cheekbone; the ethmoids just behind the bridge of the nose and between the eyes; and behind them, the sphenoids in the upper region of the nose and behind the eyes.
Each sinus has an opening into the nose for the free exchange of air and mucus, and each is joined with the nasal passages by a continuous mucous membrane lining. Therefore, anything that causes a swelling in the nose - an infection or an allergic reaction - also can affect the sinuses. Air trapped within an obstructed sinus, along with pus or other secretions, may cause pressure on the sinus wall. The result is the sometimes intense pain of a sinus attack. Similarly, when air is prevented from entering a paranasal sinus by a swollen membrane at the opening, a vacuum can be created that also causes pain.
Sinusitis has its own localized pain signals, depending upon the particular sinus affected. Headache upon awakening in the morning is characteristic of sinus involvement. Pain when the forehead over the frontal sinuses is touched may indicate inflammation of the frontal sinuses. Infection in the maxillary sinuses can cause the upper jaw and teeth to ache and the cheeks to become tender to the touch. Since the ethmoid sinuses are near the tear ducts in the corner of the eyes, inflammation of these cavities often causes swelling of the eyelids and tissues around the eyes, and pain between the eyes.
Other symptoms of sinusitis can include fever, weakness, tiredness, a cough that may be more severe at night, and runny nose or nasal congestion. In addition, drainage of mucus from the sphenoids (or other sinuses) down the back of the throat (postnasal drip) can cause a sore throat and can irritate the membranes lining the larynx (upper windpipe). On rare occasions, acute sinusitis can result in brain infection and serious complications.
Most cases of acute sinusitis are preceded by virus-induced "colds." These viral "colds" do not cause symptoms of sinusitis, but they do cause inflammation of the sinuses. Both the "cold" and the sinus inflammation usually resolve without treatment in two weeks. However, the inflammation might explain why colds increase the likelihood of developing acute sinusitis. For example, the nose reacts to an invasion by viruses that cause infections such as the common cold, flu, or measles by producing mucus and sending white blood cells to the lining of the nose, which congest and swell the nasal passages. When this swelling involves the adjacent mucous membranes of the sinuses, air and mucus are trapped behind the narrowed openings of the sinuses. If the sinus openings become too narrow to permit drainage of the mucus, then bacteria, which normally are present in the respiratory tract, begin to multiply. Most healthy people harbor bacteria, such as Streptococcus pneumoniae and Haemophilus influenzae, in their upper respiratory tracts with no ill effects until the body's defenses are weakened or drainage from the sinuses is blocked by a cold or other viral infection. The bacteria that may have been living harmlessly in the nose or throat can multiply and cause an acute sinus infection.
Sometimes, fungal infections can cause acute sinusitis. Although these organisms are abundant in the environment, they usually are harmless to healthy people, indicating that the human body has a natural resistance to them. Fungi, such as Aspergillus, can cause serious illness in people whose immune systems are not functioning properly. Some people with fungal sinusitis have an allergic-type reaction to the fungi.
Chronic inflammation of the nasal passages (rhinitis) also can lead to sinusitis. Allergic rhinitis or hay fever (discussed below) may be complicated by episodes of acute sinusitis. Patients with allergic rhinitis also often have chronic sinusitis. Vasomotor rhinitis, caused by humidity, cold air, alcohol, perfumes, and other environmental conditions, also may be complicated by sinus infections.
Patients with asthma have a particularly high frequency of chronic sinusitis. Inhalation of airborne allergens (substances that provoke an allergic reaction), such as dust, mold, and pollen, often set off allergic reactions (allergic rhinitis) that, in turn, may contribute to sinusitis. People who are allergic to fungi can develop a condition called "allergic fungal sinusitis."
Sleep Apnea:The Greek word "apnea" literally means "without breath." There are three types of apnea: obstructive, central, and mixed; of the three, obstructive is the most common. Despite the difference in the root cause of each type, in all three, people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer.
Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. In central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Mixed apnea, as the name implies, is a combination of the two. With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality.
Sleep apnea is very common, as common as adult diabetes, and affects more than twelve million Americans, according to the National Institutes of Health. Risk factors include being male, overweight, and over the age of forty, but sleep apnea can strike anyone at any age, even children. Yet still because of the lack of awareness by the public and healthcare professionals, the vast majority remain undiagnosed and therefore untreated, despite the fact that this serious disorder can have significant consequences.
Untreated, sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, impotency, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and motor vehicle crashes. Fortunately, sleep apnea can be diagnosed and treated. Several treatment options exist, and research into additional options continues.
Balance Disorders: Dr. Tejeira also told me he often treats patients with balance disorders. He has specialized equipment called called an Infrared Videonystagmography or VNG which he uses to diagnose these disorders. VNG is a method of recording eye movements that uses digital video image technology to determine eye position. During the testing, patients wear specialized goggles which block all outside light while a small infrared video camera in the goggles records the eye movements. Once the eye movement information is recorded, it is then analyzed by medical personnel and a computer to determine if signs of a balance disorder are present.
During the VNG, eye movements are recorded while performing various head movements as well. This helps to determine the presence of positional vertigo, which Charnond identified as the most common balance disorder. He explained that positional vertigo occurs when the head is put into a particular position which elicits dizziness.
The cause of most balance disorders is the shifting of tiny particles located in the inner ear. The shifting of these particles causes the dizziness felt by the patients suffering from vertigo and other balance disorders.
The elderly are the most susceptible to the development of balance disorders. As people get older, their hearing often declines. And, because balance and hearing/ear function are so closely linked, the balance system of the elderly often declines along with their hearing. Their hearing and their balance system usually go hand-in-hand. In addition, declining vision also contributes to the increase in balance disorders among the elderly.
Among younger balance disorder sufferers, severe inner ear infections often trigger the problem. Athletes who suffer blows to the head, such as boxers, soccer players, hockey players and football players, are also at risk of developing balance problems.
The risk of falling is the major danger associated with balance disorders. Falls are especially dangerous to the elderly because they are far more likely to suffer broken bones during those falls. Dizzy spells during driving activities also pose a risk to balance disorder sufferers of all ages, as well as to other motorist and pedestrians. Anyone who suffers from unexplained dizziness and unprompted falls should seek professional help to determine if they suffer from a balance disorder.
The limitations of traditional methods For years, the medical community has searched for a less invasive solution for the treatment of upper-airway disorders. Surgical therapies have succeeded in reducing obstructions in some patients, but carry significant risks and almost always result in significant postoperative pain. Nonsurgical methods have offered patients some relief, but often prove ineffective because of variable compliance and widespread patient discomfort.
Patients with chronic nasal obstruction from enlarged turbinates often endure the prolonged use of intranasal sprays and systemic medications. Some carry significant side effects – and compliance over time can be inconsistent. The morbidity associated with surgical procedures includes pain, bleeding, the need for nasal packing, adhesion, crusting, dryness and infection.
Those who suffer from obstructive sleep apnea have often been treated with continuous positive-airway pressure (CPAP). CPAP has a disturbingly low compliance rate (25% to 50%) and is only a palliative treatment. Uvulopalatoplasty (UPPP) procedures can be extremely painful, and variably effective. In more extreme cases, patients have been subjected to genioglossal advancement and tracheotomies.
Somnoplasty, from Gyrus ENT, is an office-based procedure performed using local anesthesia to treat upper-airway obstructions. Somnoplasty uses controlled, low-power radiofrequency energy to create one or several submucosal volumetric lesions. Over a period of 6 to 8 weeks, the lesions are naturally resorbed, reducing tissue volume and stiffening remaining tissue in the desired area. Reducing chronic nasal obstruction Chronic enlargement of turbinates affects over 1.5 billion people worldwide and is irreversible except through surgical intervention. Through a partially insulated electrode, Somnoplasty reduces turbinate tissue with minimal, if any, crusting or bleeding. The procedure typically takes less than 2 minutes per turbinate. One study demonstrated that 89% of patients were no longer using medication for nasal obstruction at the end of 8 weeks9 multiple lesions have resulted in improved response rates10.
In recent studies, chronic nasal obstruction patients experienced: • Improved breathing in 100% of participants • Decreased degree and frequency of nasal obstruction— 81% • Minimal adverse effects—no bleeding, crusting, dryness, foul odor or need for nasal packing
Somnoplasty is an effective and minimally invasive choice for the treatment of obstructive sleep apnea syndrome. Delivering radiofrequency energy submucosally to the base of tongue, Somnoplasty creates limited zones of coagulation beneath the tissue surface. As lesions resorb, they stiffen and reduce the tissue in the base of tongue. A study published for OSAS/UARS reported a 55% reduction in the mean respiratory disturbance index (RDI) from baseline for all subjects – with an overall mean reduction in tongue volume of 17%6.
Patients seeking treatment for sleep-disordered breathing (SDB) were treated with Somnoplasty,6 demonstrating: • Decreased daytime sleepiness – as determined by Epworth sleepiness scores • No infections • No airway compromises • Limited, short-term postoperative pain • Decreased snoring – 77%
It is estimated that over 40 million North Americans are affected by habitual snoring – often resulting from the narrowing and partial obstruction of the upper airway due to abnormal size and positioning of the soft palate and uvula.11-12 Somnoplasty provides a relatively painless procedure to treat habitual snoring – reducing soft-palate tissue volume in a precise minimally invasive manner.4,8 Snoring has been shown to decrease following tissue – volume reduction,1,5 and recent studies have shown post-treatment pain to range from negligible to mild.1
In a recent multicenter study,13 Somnoplasty treatments were shown to: • Deliver a 85.3% success rate for up to two Somnoplasty treatment sessions • Reduce mean snoring index 60.6% • Reduce mean Epworth Sleepiness Score 37.5%
Somnoplasty has proven to be an excellent option to relieve upper-airway obstructions with minimum intraoperative and postoperative pain. In a recent study on habitual snoring,14 9% of patients undergoing Somnoplasty needed narcotic analgesics, as compared to 100% of patients undergoing LAUP and UPPP upper-airway procedures. Somnoplasty has also been shown to effectively reduce tongue-tissue volume for the treatment of obstructive sleep apnea. It is a feasible and safe method for palate-tissue reduction for the treatment of habitual snoring. And Somnoplasty has also proven effective in the improvement of nasal obstruction caused by turbinate hypertrophy. With an ever-expanding list of potential clinical applications, the Somnoplasty platform technology promises a future of continued innovation and leadership in the treatment of upper-airway obstructions.
To Contact Dr. Francisco Tejeira:
* Note: All of these phone numbers are located in the Republic of Panama. You must first dial your international access code (usually 011) then the Country Code for Panama (507) followed by the remaining digits.
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