A New York City ENT doctor deals with a variety of different conditions from performing sinus surgeries to diagnosing ear, nose & throat problems.
Sinus Infection
Chronic Cough? Sinusitis May Be to Blame
01 year ago
Of all the things we experience in life, there are few more frustrating than a cough. At first, we hope it will last for just a couple of days before then disappearing. After several weeks, this is the time you should go to see a doctor because your body is telling you something. With coughs caused by viral infections or an upper respiratory infection should disappear within a week. Any cough that lasts longer than a week, a chronic cough, suggests an underlying health condition. Of course, this could be asthma, which is a common issue, but there’s another health problem we’re starting to learn more about as time goes on: sinusitis.
The Link Between Chronic Cough and Sinusitis
According to various ongoing studies and research, we now know that sinusitis is a bigger problem than we first thought. In fact, back in a 2005 Mayo Clinic study, at least 33% of all chronic cough sufferers were suffering from sinusitis (some form of inflammation of the sinuses). In the twelve years since then, this number has increased, but there are now solutions available.
If you’re wondering why this inflammation causes a cough, it comes from what we call ‘postnasal drip.’ Here, your sinuses will produce too much mucus to be of any use so some will drip backward into the throat and this triggers the cough reflex. In the medical world, this has a name of its own; upper airway cough syndrome (UACS). As a side effect of having sinusitis, this creates the link with your chronic cough, meaning you need to treat the sinusitis before anything else. If left untreated, the cough will keep returning time after time.
Allergic Rhinitis
While on the topic, we should also discuss allergic rhinitis (inflammation concentrated in the nose). It’s caused by allergens such as mold, pollen, and dust mites. With millions of people suffering from allergies in the US, this is now a huge issue and it just so happens that postnasal drip is a symptom of the problem. As we know, this will soon lead to a chronic cough which persists until you receive treatment.
Generally speaking, patients with sinusitis and rhinitis-related coughs experience a worsening of the symptoms when the sun goes down. Since we go to bed and lie down to get some rest, this horizontal position can cause a disruption in the throat which makes sleeping somewhat difficult. Furthermore, we normally have something else to focus on throughout the day. When we’re trying to go to bed, we tend to concentrate on the things that are preventing us from resting, and this places all the emphasis on the cough.
Seek professional treatment for a chronic cough as soon as you can, as these symptoms often point to more serious health concerns, such as asthma and sinusitis.
Treatment
As mentioned before, treating the cough alone in these situations is a little pointless because it won’t be long before postnasal drip brings it back again. Therefore, you need to consider tackling the cause of the issue which is the sinusitis.
If you’ve been experiencing the symptoms for more than 12 weeks, you’re now past the ‘acute’ phase and are progressing into the ‘chronic’ phase. At this stage, antibiotics aren’t likely to act fast enough, which is why some form of therapy may be required. Treatment options include including anti-inflammatory nasal sprays and the like. If the problem persists and starts to affect your life dramatically, you should see your doctor for a consultation for balloon sinuplasty.
How balloon sinuplasty works: after inserting a small camera into the nasal passage, a balloon is then sent up before being inflated. This inflation procedure works similarly to opening blocked arteries during heart surgery. Compared to more traditional options, this is less invasive and will only see you out-of-action for a couple of days.
From here, you can then treat the chronic cough (if it still exists) as you would a normal cough. Safe in the knowledge the postnasal drip has stopped, you can treat the cough without worrying about it returning anytime soon.
Ultimately, you know your body better than anybody else. Only you know when the cough is unusual in duration and severity. If you pay attention to the length of a cough, by marking it on the calendar, you’ll soon learn the right time to see a medical professional and find the underlying issue.
Home Remedies for a Sinus Infection
01 year ago
Which home remedies can help you with a sinus infection?
Is it a cold, the flu, or a sinus infection? Sometimes it can be hard to tell. Situations, where you end up sick, can occur at any time. And sometimes you can’t get to a doctor right away. So, what do you do in the meantime? Well, until you can see your physician, we suggest using these home remedies to help you ease your symptoms.
Saline Sprays and Washes
Designed to wash out your sinus cavities and nose, saline sprays and washes are your first defense against sinusitis. They provide quick relief and eliminate the nasty bacteria and other materials that cause infection. And if you are experiencing dryness, they are especially useful. They provide moisture within the nasal passageways, which prevents headaches, bleeding, and inflammation.
Stay Hydrated
You should always stay hydrated. It is especially important when you are dealing with a sickness. Like we said before, the sinuses must remain moist. A lot of water or healthy fluids will keep your body adequately hydrated and your sinus healthy.
Keeping the Air Moist
If you have noticed by now, these home remedies are all following a theme. Moisture in the sinuses means relief from pain and congestion. Another way to keep the sinus moist is to either take a steam shower or buy a humidifier. Breathing in the moist air will help you breathe easy and reduce the swelling of the sinuses.
Clean Your Home
Your symptoms can also be a result of allergies. Allergy symptoms usually don’t go away until the all the allergens in your home are gone. There are a few steps you can take to remedy this. For example, having someone clean your home for you will avoid upsetting your allergy symptoms. You can also use dust covers and run the air conditioner to prevent allergens from affecting you.
Confirm if You Have a Sinus Infection
While these home remedies will provide temporary relief, your condition can persist. It is important to know exactly what you’re dealing with. An otolaryngologist can confirm if you do indeed have a common cold or a sinus infection. Reach out to one for help.
Azithromycin and Chronic Sinusitis
03 years ago
A new study shows treatment with long-term low-dose azithromycin in combination with the conventional therapy can reduce the recurrence rate of chronic sinusitis symptoms after functional endoscopic sinus surgery, but there was no sufficient evidence to support clinical significance of azithromycin at the investigated dose.
The aim of clinical trial was to evaluate the efficacy of long–term consumption of low–dose azithromycin after a successful endoscopic sinus surgery.
Chronic sinusitis is recognized as a common disease that imposes a huge burden on the healthcare system worldwide. About 37 million Americans suffer from at least one episode of sinusitis each year. Besides the burden on the healthcare system, there is a huge burden on the individual due to missed workdays and reduced productivity that the condition causes. This study is needed because when it comes to conventional therapies, other less invasive surgeries should be considered such as balloon sinuplasty.
Method of Research
Sixty-six patients were randomly divided into intervention and control groups. The subjects received the standard conventional treatment (fluticasone nasal spray plus normal saline solution irrigation) or the conventional treatment plus 250 mg of azithromycin on a daily basis for 3 months. Evaluation was made based on the 22-item Sino-Nasal Outcome Test (SNOT-22) immediately before surgery and 3 months after surgery.
Results
The intervention group showed a significant improvement in SNOT-22 scores after the treatment and a higher percentage change after 3 months of therapy compared to the control group. Also the researchers found a significant correlation between the percentage change of SNOT-22 scores and smoking in the placebo group.
Conclusion in relation to chronic sinusitis
Treatment with long-term low-dose azithromycin in combination with the conventional therapy could statistically reduce the recurrence rate of chronic sinusitis symptoms after functional endoscopic sinus surgery. However, more evidence is needed to support clinically significant conclusion of azithromycin at the investigated dose. Thus a larger scale trial and a longer follow-up period are warranted to evaluate the effectiveness of the therapy.
Take the Taste Test: To Aid in Sinusitis Surgery Treatment Selection
03 years ago
A new study proves that your taste buds may predict post-surgery results for sinusitis surgery patients, according to a Penn study.
Taste buds pickup what is called biomarkers, that is, the existence of a certain biological state or condition, such as bitter or salt. The researchers from Penn Medicine and the Monell Chemical Senses Center reported their findings in International Forum of Allergy & Rhinology.
It might sound strange but the team discovered that a genetic biomarker—the receptor for bitter taste—could better predict post-surgery results for patients who underwent surgery for chronic sinusitis. Remember that this seasonal-related condition afflicts around 37 million Americans each year. The condition reduces daily productivity in lost worktime, and is associated with a lower quality of life. In the US, sinus infections cost more than $13 billion in lost productivity each year.
The study found people sensitive to a certain bitter compound reported breathing more easily through their nose, having fewer subsequent infections, and sleeping with ease six months after surgery than those less sensitive to the bitter compound.
Bitter taste receptors are proteins that are found in taste cells of the tongue, where they protect against the ingestion of toxic plant and bacterial products. The collaborative Penn Medicine/Monell team had earlier identified these cells lining the passages of the nose and sinuses and contributing to the natural defenses against certain bacteria.
For the study, patients were asked to taste a specific bitter chemical and report their sensations. Those more sensitive to the bitter chemical than those who were not proved to better fight off certain types of respiratory infections. This specific genetic difference correlates to how much one group is able to combat infection following surgery. Thus, the study suggests those more sensitive to certain bitter tastes fight off upper respiratory infections better, and if they do get sick enough to require surgery, they improve more than people with less sensitive systems.
The researchers warn that there is still much research to do because of the diverse functions of taste receptors, but for now, once an easy test kit is produced, ENT specialists will be better able inform and chose a treatment for their patients.
This is welcome news for otolaryngologists who can correlate surgical outcomes to bitter taste tests in order to forecast postoperative complications and results, and thus choose the best sinusitis surgery options.
Citations
Other Penn authors are Douglas Farquhar; James N. Palmer, MD; David W. Kennedy, MD; Laurel Doghramji, RN; Shane A. Morris; David Owens; and Robert J. Lee, PhD.
Other authors are Corrine Mansfield, Anna Lysenko; Beverly J. Cowart PhD; and Danielle R. Reed, PhD, all from the Monell Chemical Senses Center in Philadelphia.
Some Over-the-Counter Drugs May Be As Effective as Surgery for Chronic Sinusitis Treatment
03 years ago
A new study offers some surprising answers to offering chronic sinusitis treatment. According to the study, those with this condition may find great relief in quality of life with nasal sprays and other nonsurgical treatments. For those with chronic sinusitis, this is great news because surgery may not be the best way to treat this infection. The general rule is: the less invasive treatment is the best response to most conditions.
Chronic sinusitis treatments can include nasal sprays and antihistamines may be as effective as surgery in helping some patients achieve a better quality of life, the small study found.
The study was funded by the U.S. National Institutes of Health and published online Oct. 29 in the journal JAMA Otolaryngology-Head & Neck Surgery. Dr. Jordan Josephson, a sinus specialist at Lenox Hill Hospital in New York City, said, “Chronic sinusitis is the number one cause for chronic fatigue and is closely associated with snoring and sleep apnea.
Thirty-eight patients with chronic sinus infections were given medical therapy rather than having surgery. “Patients who have relatively minimally reduced productivity at work and minimally reduced quality of life from their underlying chronic sinusitis can avoid getting worse by continuing with medical
therapy,” said lead researcher Dr. Luke Rudmik, a clinical associate professor of endoscopic sinus and skull base surgery at the University of Calgary in Canada.
The decision to choose medical therapy versus surgery for chronic sinusitis should be based on patient preference, and the decision for each treatment should involve an honest conversation between the doctor and patient so that the patient understands the expected outcomes and potential risks.
Surgery, however, can be a good option too for people with severe sinus infections. Surgery is just an aide to the necessary long-term medical plan that is required to improve the quality of these patients’ lives. Surgery can be minimally invasive, performed with local anesthesia. During surgery, the doctor uses probes and a laser to remove tissue and bone and polyps that have developed during the infection and are narrowing the nasal passages.
With newer surgical techniques, these procedures allow most patients to be free of black-and-blue marks, with most going home the same day. After surgery, patients still need their medical treatment because the procedure doesn’t stop the running nose. The best chronic sinusitis treatment is designed for each patient.
The best news here is that traditional treatments, alternative treatments, and surgical techniques that have failed patients in the past have been renewed and improved so that for them new medical and surgical treatments may offer significant improvements for their quality of life.
Nasal Passage Infections: Bacteria in the Throat, Changing Forms to Better Adapt
03 years ago
That nasal passage infections have been an important area of research for ENT specialists is no secret. Research in morphology and bacteria have recently yielded some crucial research in infections that originate in the nasal passage ways. Some animals are physically shaped by their environment in whole, not just in part. For example, earthworms are entirely slender so that they can weave in and out of narrow spaces in the ground. Evolution plays a key role in such benefits. But does that hold for all things big and microscopic? Interestingly, bacteria come in two shapes: there’s the spherical bacterium (coccus) and the stick-shaped (bacillus)?
Biologists and morphologists wonder if there’s a reason behind why one is spherical and the other slender-shaped. After analyzing pathogenic bacteria living in the nasopharynx, the upper part of the nose, questions of shape have been answered. These bacteria have changed over time, evolving from bacillus to coccus. In an article published in the journal PLOS Genetics, Professor Frédéric Veyrier, of INRS-Institut Armand-Frappier Research Centre, along with his colleagues, demonstrated that the change may have occurred to allow bacteria to pass through the defenses of their host’s immune system.
Respiratory infections are the number three cause of death worldwide. So understanding how these bacteria, or pathogens, make it into the upper respiratory passage way is critical. These pathogens are highly evolved, some so well that bacteria like Neisseria meningitidis and Moraxella catharralis can sometimes cause severe infections in humans. Genetic analysis of the ancestors of these bacteria pinpointed a key gene: yacF. The absence of this gene makes it possible for the shape of these bacteria to evolve. The N. meningitidis and M. catharralis found today in humans are spherical and missing the yacF gene.
The bacteria’s changing from stick-shaped to spherical has allowed the composition of certain molecules on their surface to transform. These molecules, peptidoglycans, play a vital role in how the immune system recognizes bacteria.
“We have long believed that the shape of bacteria was a fixed variable,” noted Professor Veyrier. “We even use it as a way to classify bacteria. Some mystery remains as to how the various species regulate their shape. This research demonstrates that the environment in which the bacteria evolve has an impact on their morphology. These are exciting results because we were able to identify the same change in two different species–and therefore its impact could be a key aspect in the specific way these pathogens are adapting to the human nasopharynx.”
By deepening our understanding of the evolution of bacteria, researchers believe they’ll be able to create new tactics that will prevent severe infections, even those related to sinus infections. This research about bacteria evolving over time could lead to preventing and treating such nasal passage infections that attack more than your head and sinuses, but your entire body.
Sinus Surgery May Also Ease Sleep Apnea
03 years ago
Anyone with chronic sinus trouble will tell you how it causes problems with breathing and sleep. Anyone can also tell you that much research has been done about improving sinus problems. But what about those with both sleep apnea and sinus problems? In a recent study, published in the JAMA Otolaryngology — Head & Neck Surgery, researchers have found that surgery may help those with chronic sinus problems so that they can breathe easier, better, and even improve the lives of those with the sleep-related condition called obstructive sleep apnea.
In the study, researchers found 15% of people with chronic sinus problems also had the sleep disorder obstructive sleep apnea (OSA). And those who had surgery for clearing the sinuses reported a better quality of life and improved sleep, regardless of whether or not they had a sleep disorder. Of course, this is not surprising for sinusitis treatment. Improved quality of life is the purpose of many surgeries for sinusitis. However, what’s important about this new study is that patients with both sinusitis and OSA have a substantially reduced quality of life, but those with both conditions had dramatic improvements in quality of life following surgery.
OSA is a condition that causes people to stop breathing hundreds of times during sleep throughout the night. For those with OSA, the tongue and other structures might relax too much, blocking the airway and preventing breathing. There are several signs of OSA. Here are the most common ones: Snoring, choking and gasping for air, and daytime fatigue.
Dr. Jordan Josephson, an ENT specialist at Lenox Hill Hospital in New York City, says, “Sinus and nasal problems often are part of the problem leading to snoring and sleep apnea, and are often overlooked and left untreated.” Josephson was not involved in the current study, but was a reviewer of it. He added that patients with sinus problems and nasal breathing problems “should all be evaluated for snoring and sleep apnea.”
For the study, researchers studied 400 patients who underwent surgery for chronic sinus problems. They then checked the outcomes of those with both chronic sinus problems and OSA. Of this group, sixty had OSA, and following surgery these patients had improved psychologically and with their sleep problems.
The link between OSA and chronic sinus problems is still inconclusive, but might much evidence suggests how air passages through the nose and airways and how sleep affects the body’s ability to manage infection have a lot to do with both conditions.
Peter Fotinakes, a neurologist and sleep disorders specialist at St. Joseph Hospital in Orange, Calif., has one theory for the two conditions overlapping, “When we’re asleep, we prefer to breathe through our noses.” He further added, “When we can’t, we open our mouth to breathe, and when you open your mouth, it sets your tongue free.” That freed-up tongue, he said, can fall back into the airway, blocking it.
Does this mean anyone with a chronic stuffy nose and fatigue should go straight for sinus surgery? Of course, not. Patients should try noninvasive measures first, such as medication before surgery. But many patients have experienced tremendous benefits in both disease severity and overall quality of life after sinus surgery. Seeing an board-certified ENT specialist is in your best interest if you’re looking for solutions to your chronic sinusitis and you suspect a sleeping disorder.
No one likes the prospects of surgery, but the good news is that newer surgical techniques can be performed on an outpatient basis without general anesthesia with minimal discomfort and most patients can go back to work the next day. This is welcome news for those suffering from both chronic sinus problems and sleep apnea.
Bide Your Time With Acute Sinusitis
03 years ago
Antibiotics have been a wonder drug since their beginning. You can’t overstate penicillin’s impact on medicine and society, especially its role in treating bacterial infections, preventing the spread of disease and minimizing serious complications of disease.
But sometimes too much of a good thing does more harm than good. For example, what happens when antibiotics are overprescribed? They should be used for serious bacterial infections, but now, due to overprescriptions, have become less effective, even ineffective, because certain strains of bacteria have become resistant to newer and stronger antibiotics.
Some main reasons for this trend in antibiotics losing their effectiveness is due to overuse and misuse by doctors and hospitals. Both play a role in ensuring best practices of such drugs. Granted that bacteria develop resistance to any drug is normal and expected. But also the way drugs are used affects how quickly and to what extent drug resistance occurs.
If you didn’t know, a bacterium becomes more resistant to a drug when it has changed in some way that either protects itself from the drug or neutralizes that drug. And any bacterium that survives an antibiotic treatment strengthens itself and can multiply and then pass its resistant properties on. In short, bacteria become stronger and more resistant to treatment.
In general, antibiotics are only for bacterial infections, not viral ones. For example, we use antibiotics for strep throat, caused by the bacterium Streptococcus pyogenes, but it’s not the right treatment for sore throats caused by viruses such as a severe flu, because the flu originates from a virus.
If you take an antibiotic for a viral infection, the antibiotic attacks the good and bad bacteria in your body. The good bacteria can then promote antibiotic-resistant properties in harmless bacteria and that can be shared with other bacteria.
Yet many people with severe sinus ailments—like facial pain, fever and nasal congestion—want immediate relief and often wonder why their doctors don’t prescribe antibiotics right away. As mentioned in the last blog, patients and doctors need to bide their time wisely, and that means even if you’re really sick with a high fever, it’s still okay to wait out the use of antibiotics. Research shows that there’s not any greater benefit with antibiotics.
The American Academy of Otolaryngology—Head and Neck Surgery Foundation recommends “watchful waiting” for people with sinusitis before they resort to antibiotics. This is not a new guideline and has always been part of best practices for ENT specialists.
For those acute sufferers, the guideline applies to acute sinusitis, even when symptoms last 10 days or more. In addition to this time, seven more days for a total of 17 days should pass before antibiotic therapy should begin. We understand that such a wait is dreadfully painful, but in the long run, it’s essential to keeping the good bacteria strong and the bad bacteria weak by your body’s natural immune system when suffering from acute sinusitis. Remember, your body needs to keep a certain balance and part of it is its good and bad bacteria.
As little as 29% of Sinusitis Visits Adhere to General ENT Guidelines
03 years ago
We’ve known for some years that antibiotics don’t help most bronchitis cases and other respiratory problems, like sinusitis. In fact, taking antibiotics isn’t as effective for treating bacterial sinusitis as is widely believed. The American Academy of Otolaryngology—Head and Neck Surgery Foundation says antibiotics fare only slightly better than waiting for the infection to go away on its own. This scant improvement is most likely not worth taking antibiotics. Yet over-prescribing antibiotics persists—even when they don’t help and can even hurt — a study says.
A new study published last month in the American Journal of Managed Care reports that particularly with urgent care, primary care and emergency departments, clinicians seldom follow evidence-based care guidelines for the treatment of common sinusitis. The study criticizes several clinical practices such as over-prescribing antibiotics and over-ordering CT scans.
From the report, only 29 percent of adult acute sinusitis encounters followed accepted clinical guidelines for the prescription of antibiotics, according to the Kaiser Permanente study. And they found the ordering of CT scans more likely in emergency room visits, resulting in expensive imaging tests.
Sinusitis strikes nearly 31 million Americans per year, according to the American Academy of Family Physicians, costing around $3 billion because of tests and procedures, outpatient and emergency department visits, and medication. It is one of the most prescribed conditions for which antibiotics are used, but national clinical guidelines state that antibiotics should only be used when it lasts more than seven days.
Providers may be going against what is suggested by current guidelines, the researchers suggest, resulting in unacceptable standards of care. From the study, antibiotics were prescribed in 89.2 percent of the 152,774 EHR encounters. Nearly 50 percent of these encounters were with patients having symptoms for fewer than seven days.
Granted, each recorded visit entails a different set of symptoms with unique circumstances, especially for those presenting the most urgent and severe symptoms. But from the study, over 75% of the cases took place at the primary care providers’ offices. This number is much too high, considering that most patients were given antibiotics when they had only exhibited symptoms for less than 7 days. We understand the importance of immediate relief, but it’s the long-term harm that should be overriding our decisions.
Despite the frequency of acute sinusitis cases, treatment and prescription habits have not been closely monitored. “A clear understanding of current practices requires awareness of how acute sinusitis is treated in different acute care settings,” say the researchers, from Kaiser Permanente’s large, integrated Southern California system.
This study points to how we as healthcare providers need to better understand and coordinate acute care services in order to achieve the triple crown of health care: that is, improving the patient-care experience, the overall population’s health, and reducing healthcare costs.
The age-old problem of over-prescribing antibiotics may be partly due to the difficulty in differentiating bacterial sinusitis infections from the more common viral ones. To help clinicians identify patients who are likely to benefit from antibiotics for acute sinusitis, the most pragmatic and evidence-based approach is to focus on the patient’s length of symptoms.
Can Sinus Surgery Improve Allergies, Asthma and Sinusitis?
03 years ago
A growing body of research has pointed to some common problems found among western societies: That allergies, asthma and chronic sinus problems are increasing. Although the research is not conclusive, some researchers suspect one main reason for these growing problems is the “hygiene hypothesis,” also called the “cleanliness hypothesis.” This theory states that a lack of early childhood exposure to infectious organisms such as those found in gut flora, probiotics or common parasites increases the chances of allergic diseases because the immune system is naturally suppressed. In other words, the immune system’s tolerance is weakened because it hasn’t been exposed to certain bacteria and parasites that it should have at an earlier age.
Some of the microorganisms that many allergy and asthma suffers have not adapted to are allergens. People who are not routinely exposed to some allergens can develop allergies, particularly as children. When they are later exposed to an allergen, the body misidentifies the foreign substance as dangerous and then reacts with hives or other allergy symptoms.
There are many detractors of this hypothesis. But did you know that allergies and asthma are uncommon in developing or underdeveloped countries yet are increasing in developed countries?
Furthermore on increased allergies, research has shown that severe allergies are connected to chronic sinus problems and asthma. The connection to all these conditions has to do with the inflammation in the airways, which is similar in the nose and sinuses or in the lungs.
What can we do to prevent these conditions from progressing or causing greater severity in the other conditions? There is growing evidence that early management of allergies or sinus inflammation can reduce the risk of developing asthma. Immunotherapy (allergy shots, or now sublingual drops or tablets) in allergic and asthma-prone children has been shown in a couple of studies to reduce developing asthma and reducing asthma attacks.
According to Dr. Michael S. Benninger, “Sinus surgery may also be preventative in some people.” In a recently presented paper at the American Rhinologic Society’s spring meeting, researchers suggested people who underwent sinus surgery had lowered the severity of and even prevented their asthma from occurring.
Other interesting results from the paper include:
- Allergy patients with chronic sinusitis were at a higher risk of developing asthma than those with no allergies.
- Early surgical treatment (less than two years after a sinusitis diagnosis) resulted in less long-term asthma than in those who had surgery later (four to five years after a sinusitis diagnosis).
Sinuses affect the lungs and vice versa. What may cause inflammation in the sinuses may do so also in the lungs, especially for those with allergies. For those with allergies and chronic sinusitis, keeping the sinuses under control helps the lungs, and keeping the lungs under control helps the sinuses. Aggressive treatment, whether with allergy immunotherapy or sinus surgery, may help reduce the risk of developing a worse airway disease, like asthma.
What all this means is that we might be recommending surgery and immunotherapy earlier in order to relieve later symptoms.
One final though before you slather your children’s hands in antimicrobial gel: sometimes a little dirt is good for a little while. Of course, this doesn’t mean they should wash their hands regularly; it means we don’t have to be overly cautious with a little dirt sometimes because it might reduce the development of asthma and severe sinus problems.
大人気 人気
This is a topic that is close to my heart... Best wishes!
Where are your contact details though?
5 years ago