Do Nosebleeds Cause Stool Blood Tests to Become Positive?

As a general rule, an ordinary nosebleed will not cause a screening stool blood test (hemoccult or guaiac) to come back positive.

However, if the nosebleed is bad enough to consider going to the emergency room... and you are swallowing a lot of it... only than will it be likely that such stool tests will come back positive for blood.

To be precise, such stool tests turn positive only if there's at least 2+ teaspoons of blood leaking into the digestive system everyday (or swallowed from a very bad nosebleed).

Of course, there are MUCH more sensitive tests out there to determine if there's blood in the stool including heme-porphyrin or immunochemical tests, but have a high false-positive rate.

From an ENT perspective, immunochemical testing is interesting because this test uses antibodies to detect human globin epitopes which get digested in the stomach... so if there's a question of whether a patient's anemia is due to nosebleed or a lower GI tract bleed (ie, colon), immunochemical stool testing can answer the question.

Just as an FYI, if the nosebleed is severe, it is likely that you will end up getting your nose packed.

Read More

New Video on Awake Tonsil Cryptolysis to Address Tonsil Stones

A new video has been uploaded describing a minimally invasive technique to address tonsil stones called tonsil cryptolysis.

This technique accomplishes the same thing as laser cryptolysis but at lower cost and increased safety. Just like laser cryptolysis, this procedure can be done awake without any sedation using only local anesthesia (the caveat being that the patient must have minimal/no gag reflex with easy visualization of the tonsils).

Watch the video below or on YouTube. Read more about this procedure here.

Read More

Dr. Chang's 2013 Lecture Circuit

After numerous inquiries regarding conferences I will be presenting at (as well as other venues), I thought to list them all here for the year 2013...

So.. for the year 2013, here you go! There's a few national conferences and even an international conference. If you happen to be present during one of my talks, give a shout-out! 

(Full list can be found on my CV.)

• Upcoming: Christopher Y. Chang, Wei J, Eisenberg L, Simon LM. Utilization of Social Media in Medicine. Presented at the 2013 AAO-HNS Miniseminar Presentation in Vancouver, BC. October 2, 2013.

• Upcoming: Invited Lecturer. Social Media for the Busy Surgeon. American Society of General Surgeons Annual Meeting. National Harbor, MD. August 17, 2013.

• Upcoming: Invited Lecturer. Laryngo-Pharyngeal Reflux: Collaborative Treatment Between General Surgeon and ENT. American Society of General Surgeons Annual Meeting. National Harbor, MD. August 17, 2013.

• Lecturer. Botulinum Toxin Injections for Spasmodic Dysphonia. National Spasmodic Dysphonia Association Symposium. Arlington, VA. May 18, 2013.

• Christopher Y. Chang, Payne SC, Stern W. Social Media for the Otolaryngologist. Presented at the AAO-HNS BOG Spring Meeting & OTO Advocacy Summit in Alexandria, VA. May 5, 2013.

• Lecturer, “Vocal Assessment.” Performing Art Medicine Certificate Program. Shenandoah University. Winchester, VA. April 7, 2013.

• Guest Lecturer, "Vocal Abuse and Misuse." Anatomy and Function of the Singing Voice Course at Shenandoah University. Winchester, VA. March 27, 2013.

• Guest Lecturer, "Video Laryngoscopy." Anatomy and Function of the Singing Voice Course at Shenandoah University. Winchester, VA. February 13, 2013. 

Read More

How Does Neuropathy Lead to Lump in Throat or Phlegmy Throat Sensation?

To preface, have you ever been to the dentist and received a novacaine injection prior to a dental procedure? Did you notice that where the injection is performed, it feels as if the area feels really swollen and also you feel like you are drooling... but than when you look in the mirror, there's no drooling and there's no swelling either?

In this dental situation where novacaine got injected leading to a temporary induced neuropathy...  a similar phenomenon can also occur in the throat region due to neuropathy most commonly triggered by a virus or throat-level reflux (LPR). This condition is called laryngeal sensory neuropathy (LSN).

And because the neuropathy occurs in the throat region... a sensation of swollen or lump feeling in the throat (globus) may occur just like the sensation in the face/jaw after getting numbed up for a dental procedure.

Similarly, a mucus phlegmy throat sensation may also occur just like a drooling sensation of the face/jaw after being injected with novacaine.

Such a swollen throat or phlegmy throat sensation can also be temporarily induced in normal patients when the throat gets numbed up with lidocaine or other anesthetic for a surgical procedure.

How is this condition treated?

First and foremost, other non-neurologic etiologies must first be ruled out with medications and extensive testing. Also, triggers that may have led to this neuropathy must be thoroughly addressed as well. Such testing may include allergy testing, specific food avoidance, 24 hour multichannel pH impedance, manometry, etc, etc.

SELSAP is a promising test to evaluate for laryngeal sensory neuropathy.

Once laryngeal sensory neuropathy is confirmed, medications like amitriptyline, neurontin, and tramadol can be tried.

For more information, click here for globus and here for phlegmy throat.

Read More

Why Would a Zenker's Diverticulum Recur After Surgical Treatment?

Zenker's diverticulum is an extremely rare disorder whereby a pouch develops in the throat leading to food and liquids getting caught causing symptoms of swallowing difficulties and food regurgitation. One of the best ways to address this rare condition is a procedure called endoscopic staple diverticulostomy (ESD).

Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).

Why might that be?

There are some known (and unknown) issues that may lead to recurrence including:

• Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
• Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
• Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
• Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
• Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.

As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.

If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.

That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.

Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".

Of course, the barium swallow needs to be repeated as well.

Read More

Reflux Increases Risk of Throat Cancer by 78%

Brown University researchers found that frequent heartburn was an independent risk factor for not only esophageal cancer but also cancer of the throat and vocal cords. This conclusion was based on a large population study involving 631 patients with throat cancer and 1,234 without throat cancer as a control group.

The study group also did not heavily smoke, drink, or have HPV (other independent risk factors for throat cancer).

Individuals with frequent heartburn were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but not proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

The explanation for how reflux can cause throat cancer is similar to how it can also cause esophageal cancer. With repetitive mucosal injury by gastric juices to the delicate lining of the throat, there is a cycle of healing and injury that may eventually trigger cancer development. Patients with reflux that reaches the throat level have a condition called LPR or laryngopharyngeal reflux. Although symptoms may be similar to the more common GERD, it is not unusual for patients to experience only throat symptoms without the heartburn. Such atypical symptoms include:

• Chronic cough
• Phlegmy throat
• Chronic throat clearing
• Vocal cord dysfunction
• Globus pharyngeus

It is also notable that it takes far less reflux episodes in the throat region compared to the esophagus in order to trigger mucosal damage... it takes fewer than THREE episodes per WEEK! [link]

In any case, more research is needed to determine at what point cancer risk increases in individuals with LPR, what type of reflux (acid?, non-acid?, pepsin?, bile?) triggers cancer concern, to what degree of reflux prevention is required to protect against cancer development.

Also more needs to be done to figure out why antacids help reduce cancer risk, but not other types of reflux medications.

References:
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

Read More

T&A Helps with Pediatric Obstructive Sleep Apnea (But Watchful Monitoring OK Too!)

Researchers published in the New England Journal of Medicine that removal of the tonsils and adenoids absolutely helps with sleep apnea in kids along with improvements in behavior, quality-of-life, overall well-being as well as significantly greater reduction in symptoms... but apparently putting off surgery does no significant harm as well from a purely cognitive perspective.

464 children ages 5-9 years of age were randomly split into surgery or watchful monitoring groups (children with severe sleep apnea was excluded from the study). Although surgery helped in all measures tested, what surprised the researchers was that nearly half the children (46%) in the watchful monitoring group also spontaneous improved over a 7 month period of time without surgery. Furthermore, there was no difference between groups on a Developmental Neuropsychological Assessment.

Overall, surgery WAS beneficial, but it is notable that even without surgery, cognitive development was found to be no different than not doing surgery and nearly half improved to point surgery was no longer clinically indicated.

More relevant to clinicians and parents... what were the exact factors that led nearly 50% of kids with sleep apnea to improve over 7 months?

Was it a certain medication? Overall head growth? Treatment of allergies?

If there WAS an intervention, can it be replicated to all kids as something to try prior to surgical consideration?


Reference:
A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. May 21, 2013 DOI: 10.1056/NEJMoa1215881

Read More

Pitch Perfect's Vocal Cord Nodules

Becca (played by Anna Kendrick)

In the hilarious movie Pitch Perfect, Becca played by the lovely Anna Kendrick participates in an all-female a capella singing group.

During a critical juncture in the movie, one of the soloist Chloe (played by Brittany Snow) reveals she had been living (and singing) with vocal cord nodules.

The movie implies that Chloe's vocal cord nodules were surgically removed and that perhaps days later, she resumed singing, though not recovered to the degree that she's able to sing a solo. See video clip below.

Couple problems with this scenario which does not reflect reality.

Vocal cord nodules develop due to aggressive voice use, especially with poor talking or singing technique. As such, initial treatment is NOT surgical because if the underlying vocal behavior that led to vocal cord nodules is not corrected, they will just come back... and you can add some scarring as well due to the surgery itself (strict voice rest for a prolonged period of time after surgery is a must to minimize scarring complications).

Strict voice rest is also not the best course of action which will help initially, but again, if voice use resumes without the underlying bad vocal behavior being corrected, the nodules will just come back again.

So what is the correct course of action???

1) Aggressive voice therapy... Given Chloe is a singer, working with an experienced singing voice therapist would be of tremendous benefit. She can continue singing, but use of electronic amplification is a must to minimize increased compensatory volume (people tend to increase their voice in loud surroundings) and her singing should be limited to low impact vocalizations (think Silent Night rather than Ode to Joy).

2) Limit talking if at all possible and avoid being in conditions where there's a lot of noise. NEVER abuse the voice (no screaming, yelling, etc) which may be hard to do in a college setting with loud restaurants and bars.

3) If after a prolonged voice therapy and restricted voice use does not resolve the vocal cord nodules, only than would surgical intervention be considered. There are two flavors of surgical intervention: steroid injections to the nodules or excising the vocal cord nodules. Needless to say, there will be a mandatory prolonged period of strict voice rest after surgical intervention.

Read more about treatment here.

Finally, there's another scene where Chloe's voice was able to achieve an unusually low note. That does NOT happen with vocal cord nodules whether before or after surgery. Chloe's pitch range should remain the same. The only situation where her pitch would drop lower than normal would be if her vocal cords became diffusely swollen. Just like a violin string, the thicker the string or in this case vocal cord, the lower the pitch.

Read More

Hospital Charges vs Surgeon Charges

Some of the most bitter complaints I get from patients are their hospital bills. Apparently, this complaint is not unique to me given numerous media articles about perceived outrageous hospital charges for seemingly simple procedures (article #1 and article #2).

The healthcare system as it currently stands establishes 2 separate charges (surgeon and hospital) with any type of procedure performed in a hospital (even if not in an operating room). There is even a 3rd charge if anesthesia is provided.

The ONLY charge a surgeon has any control over is the surgeon's charge which often is the least expensive of the 3 charges. A common misconception is that the surgeon also has control over hospital and even anesthesia charges which is patently false.

Indeed, the surgeon is not even informed what the hospital or anesthesia charges are for any procedures performed. The surgeon also has no influence, say, or authority over what the hospital or anesthesia charges as well.

As such, if knowledge of total costs is desired with any type of procedure performed in the hospital, it is best to speak with a hospital representative of what the anticipated charges will be... not the surgeon because we actually do not know.

I should also mention that hospital charges are often 10 times or more greater than the surgeon's fees.

Read more about surgical fees.

Even for the SAME exact procedure, the charges vary greatly from one hospital to another.

In May 2013, the federal government released information on how a given hospital ranks in their charges for a given diagnosis or procedure (specifically Medicare, but all insurance base their charges on Medicare rates).

Check to see how your hospital ranks compared with other hospitals with respect to how high their charges are. The New York Times created a handy dandy map that illustrates hospitals which are "expensive" and those that are below average in terms of hospital charges.

I should mention that Fauquier Hospital where I have privileges charges at less than the US average.

Let's take an example to see how hospital charges can significantly influence how much you pay for the same exact procedure depending on which hospital you go.

Let's say you have health insurance with a 10% coinsurance and a $1000 deductible (meaning, before insurance pays for anything, you must pay at least $1000 and than an additional 10% of all remaining charges).

Let's say you decide to proceed with a tonsillectomy.

At hospital A, the surgeon's fee is $500, hospital charges are $5000, and anesthesia charges are $1000 for a grand total of $6500.

At hospital B, the surgeon's fee is $500, hospital charges are $10,000, and anesthesia charges are $5000 for a grand total of $15,500.

Clearly, whether you go to hospital A or B, you will pay $1000 deductible first.

So, at hospital A, the total charges (minus your deductible) billed to insurance will be $5,500 and at hospital B that cost will be $14,500.

Insurance pays 90% of these charges and you pay the remaining 10% (the 10% coinsurance as per the policy you have).

As such, having a tonsillectomy at hospital A will cost an additional $550 whereas at hospital B, you will have to pay an additional $1,450.

Now, it may seem the charge differences are extreme in the example, but sadly, hospital charges can truly be that dramatically different. Read this New York Times article for more information.

Of course, do keep in mind that the above example is over-simplified as reality does include things like fee schedules, allowable charges, etc.

Source:
Hospital Billing Varies Wildly, Government Data Shows. NYT 5/8/13

How Much Hospitals Charge For the Same Procedures. NYT 5/8/13

As Hospital Prices Soar, a Stitch Tops $500. NYT 12/2/13

Read More

Gwyneth Paltrow's Dad Had Throat Cancer

Image by Andrea Raffin from Wikipedia

Gwyneth Paltrow recently divulged that her father was diagnosed with throat cancer in 1998 and eventually passed away in 2002 due to pneumonia complications.

It is unclear exactly what type of throat cancer Mr. Paltrow had, but it could have been anything from tonsil cancer to vocal cord cancer.

Depending on the location, symptoms and physical signs (ie, neck mass) may have been present which ultimately would have required a biopsy. Once the type of cancer has been determined after biopsy, treatment would have included surgery, radiation therapy, and/or chemotherapy.

In any case, the actress credits her dad's cancer diagnosis as a wake-up call to a healthier lifestyle.

Source:
Gwyneth Paltrow; Father's Throat Cancer Diagnosis Encouraged Healthier Diet. Medical Daily 5/20/13

Gwyneth Paltrow Reveals Dad's Cancer Diagnosis Got Her on Healthy-Eating Track. Eonline 5/17/13

Read More

Beyonce Cancels Concert Due to Dehydration (and Exhaustion)

Image by Jingjing Cheng from Wikipedia

Media has reported the superstar pop singer Beyonce cancelled her May 14, 2013 concert in Belgium on the advice of her doctors "due to dehydration and exhaustion".

Though the rumor mill is churning with the possibility of a pregnancy, I was more interested that a concert was cancelled due to dehydration concerns.

Why is hydration so important for voice production, especially in as athletic activity as singing?

With hydration, the glands that line the throat and voicebox produce nice thin secretions. With dehydration, the secretions become thicker and stickier and can adversely affect the voice.

Keep in mind that hydration with its associated thin secretions is like the oil that makes an engine run smooth. When a person talks or sings, the vocal cords vibrate very quickly. Hydration with its thin secretions allows the vibration to occur smoothly and consistently. If dryness is present, the vibrations will not occur as easily.

Watch the video below. You can see the secretions "dancing" on the vocal cords as it should with smooth, even vibrations producing clarity in voice production.

Regardless of what may have prompted Beyonce to cancel her concert, fans hope her recovery will be speedy!

Source:
Is Beyonce Pregnant? Singer Cancels Show; Rumor Mill Reignites. Huffington Post 5/14/13

Read More

Hearing Loss May be Caused by Aspirin, Tylenol, and NSAIDS

Researchers from Harvard and Vanderbilt reported that men who regularly take aspirin, tylenol, or NSAIDS (like ibuprofen) are at increased risk of hearing loss. This increased risk of hearing loss is significantly higher the longer the duration of regular use (defined as 2 or more times per week) and if regular use starts under the age of 50 years.

For women, however, only tylenol and NSAIDS were found harmful to hearing (not aspirin).

Indeed, the conclusion is that regular over-the-counter pain killers may in fact be mildly ototoxic and that such overuse be avoided if possible and would not adversely affect health in other more important aspects (ie, especially in the absence of heart or vascular disease for which daily aspirin is often recommended).

Just goes to show you that too much of any medication is harmful.

Not only does tylenol lead to hearing loss, but it can also cause liver failure and accounts for 400 deaths in the US every year. [more info]

Ibuprofen is even worse leading to bleeding problems and 15,000 to 20,000 deaths in the US every year. [more info]


References:
Analgesic Use and the Risk of Hearing Loss in Women. Am J Epidemiol. 2012 Sep 15;176(6):544-54. Epub 2012 Aug 29. [full text]

Analgesic use and the risk of hearing loss in men. Am J Med. 2010 Mar;123(3):231-7. doi: 10.1016/j.amjmed.2009.08.006. [full text]

Read More

Woman Drinks Beer Through Her Ear

Now I am not sure if this woman is actually drinking beer through her right ear at a Czech beer festival as reported by Huffington Post, but is it anatomically even possible?

Well the answer is that it IS theoretically possible though highly improbable.

In order for this to occur, there must first be a hole in the eardrum. Given an eardrum hole, beer can be sucked up into the ear canal (1), through the hole in the eardrum (2), into the middle ear space (3), through the eustachian tube (4), and down into the throat.

Now why would it be highly unlikely that the women is drinking beer through her ear?

1) The eustachian tube opening is VERY small (< 2mm). Trying to suck beer through the eustachian tube would be even harder than trying to suck beer into the mouth through a coffee stirrer.

2) The video would have been more believable if she pinched her nose up when drinking beer into the ear.  The fact that she is not makes it unlikely adequate negative pressure can build up in the back of the nose to the point that it would suck beer up into the ear. Not pinching the nose is equivalent to trying to drink something up into the mouth WITHOUT making a tight lip seal around the straw.

Even if you could drink beer through the ear, you really shouldn't because...

1) Beer contains alcohol and if this touches the middle ear region which is very sensitive, there would be quite a bit of pain akin to alcohol touching an open skin wound.

2) Alcohol can also potentially lead to permanent hearing loss if drawn into the middle ear. It's the same reason why earwax removal drops specifically caution against using it whenever there's a hole in the eardrum.

3) Beer in the ear could lead to an ear infection.

4) Lastly, if the beer is not at body temperature, it could lead to severe dizziness due to a phenomenon known as caloric vestibular stimulation.

So... don't do it... even if you could!

Source:
Woman Drinks Beer Though Her Ear? Czech Clip Appears To Show Crazy, Dangerous Stunt (VIDEO). Huffington Post 5/14/13

Read More

Google CEO Larry Page Suffers from Bilateral Vocal Cord Paralysis

Image by Marcin Mycielski from Wikipedia

Over the past year, there has been concern over the health of Google CEO Larry Page after missing a few important meetings and having a hoarse voice that is unusually soft and prolonged.

Apparently, it's because he suffers from bilateral vocal cord paralysis. [link]

He initially suffered from a unilateral vocal cord paralysis at the age of 14 years old. At that time, his left vocal cord became paralyzed after a viral URI. Beyond a viral infection of the nerve, no other specific cause was identified.

Than during the summer of 2012, he suffered another viral URI followed by the unfortunate paralysis of his opposite right side resulting in bilateral vocal cord paralysis. It is EXTREMELY rare that both vocal cords become paralyzed in this manner in the same individual.

With bilateral vocal cord paralysis, he now suffers from an even weaker voice along with reduced ability to exercise.

Now, why is that?

First, a basic anatomy lesson...

Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

A "paralyzed" vocal cord is when one or both of the vocal cords do not move resulting in voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed? Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice.

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing. Which in essence means you can't have both good breathing and strong voice.

One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality... which seems to be the option Larry Page has gone with.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

Wondering what kind of workup is required as well as surgery to adjust the voice when both vocal cords are paralyzed? Click here to read more...

Source:
Larry Page Explains Why He Lost His Voice. Businessweek 5/14/13

Read More

Nice ICD10 Booklet for ENTs

The American Academy of Otolaryngology (AAO-HNS) has put out a sample ICD10 booklet of sorts which may come very handy once ICD10 usage becomes mandatory in 2014. ICD stands for "International Classification of Diseases" and is the way physicians code for a given medical problem. It also is one way health insurance determines what tests or surgeries will be approved or not.

The current ICD system being used is called ICD9.

Within ICD9, an acute ear infection (whether right or left side) would be coded as 382.9.

With ICD10, more detail is contained. For example, ICD10 code H66.002 is left acute ear infection without rupture.

Although ICD10 will contain much more detail about the medical condition being described, with increased detail brings more headaches as one ICD9 condition may now have 10 other related ICD10 codes that need to be specified.

Which means ENT related ICD codes which used to all potentially fit on a one page cheat sheet may now take over 10+ pages booklet.

The AAO-HNS was nice enough to compile a booklet of the most common medical diagnosis with their ICD10 codes for the otolaryngology specialty.

You can download the pdf or MS Word doc here.

Read More

Does Milk Cause Increased Phlegm or Mucus Production?

For many individuals, milk and associated dairy products definitely seem to cause an increased production or thickening of mucus in the mouth and throat... the phlegmy throat. It certainly happens to me...

Of course, perception is not always supported by research...

"Milk and dairy product intake was not associated with an increase in upper or lower respiratory tract symptoms of congestion or nasal secretion weight. [...] We conclude that no statistically significant overall association can be detected between milk and dairy product intake and symptoms of mucus production in healthy adults, either asymptomatic or symptomatic, with rhinovirus infection." [link]

However, other research support the possibility that dairy products might increase mucus production only if the milk contains beta-CM-7 protein (not all milk contains this protein). [link]

I have a different hypothesis for why milk may cause the perception of increased mucus production. I should preface that I have no research study to quote to prove this hypothesis. Might be a good research project for a medical student???

In any case, milk contains a protein called casein. When the milk is not refrigerated, it causes bacteria to  metabolize lactose within the milk leading to lactic acid production as a byproduct. When acidity is present, the casein congregate in a process called curdling. That's the "chunks of milk" seen in milk gone bad.

Now, bacteria certainly will not be playing a role in lactic acid production after fresh milk is consumed, BUT, there IS acid present in the stomach which can initiate curdling.

Now what if a patient suffers from acid reflux... and what if some of the reflux episodes reach the throat level?

So, hypothetically speaking, if somebody who suffers from acid reflux drinks a lot of milk, two things might hypothetically happen (or drinks orange juice followed by milk):

1) Milk temperature goes up from body heat (which assists in curdling)
2) Acid present from the reflux will initiate curdling

If acid is present in the mouth and throat from reflux or secondary source (like recently drunk orange juice), curdling to some degree may occur from milk residue mixing with acid residue present leading to perception of mucus production.

Now does this actually happen???

I don't know and I hope some researcher looks into this hypothesis further!

However, in the end, if dairy avoidance helps with a phlegmy throat, than it can't hurt to avoid it! I should also point out that egg and wheat does cause a similar phlegmy problem in some patients.


Reference:
Relationship between milk intake and mucus production in adult volunteers challenged with rhinovirus-2. Am Rev Respir Dis. 1990 Feb;141(2):352-6.

Does milk increase mucus production? Med Hypotheses. 2010 Apr;74(4):732-4. doi: 10.1016/j.mehy.2009.10.044. Epub 2009 Nov 25.

Read More

What is the BEST Way to Disinfect a Toothbrush?

In my previous blog article, I discussed the debate over whether a toothbrush becomes "contaminated" leading to the practice of throwing them out after a strep throat infection. Although the answer is still ambiguous whether it helps or not, the fact that even NEW toothbrushes contain harmful bacteria brings even more confusion on what to do.

Going on the assumption that bacteria on a toothbrush is harmful and if a new or old toothbrush contain such bacteria, perhaps the best practice would be to disinfect toothbrushes on a regular basis.

Would toothbrush disinfection work best by...

• Microwave
• Ultraviolet light (examples in this list from Amazon)
• Dishwasher
• Listerine
• Crest Pro-Health
• Air dry
• 3% Hydrogen Peroxide

Although the ultraviolet sanitization method is perhaps getting the most attention due to the high-tech nature, researchers have found that though this method did significantly decrease bacteria load, they also have found this method to be the least effective compared to other measures.

Rather, the best way to disinfect a toothbrush is by rinsing the toothbrush with Crest Pro-Health mouthwash for 20 minutes OR having it go through a normal dishwasher cleaning cycle.  3% Hydrogen Peroxide was also found helpful.

Interestingly, Listerine didn't work much better than air-dry alone and ultraviolet light didn't do much better.

Bottom line?

Don't waste your money on ultraviolet light toothbrush treatments.

Rather, if you already use a dishwasher regularly, stick the toothbrush in there. If you already like gargling with mouthwash, get Crest Pro-Health which can also disinfect toothbrushes effectively.


References:
Disinfection of toothbrushes contaminated with Streptococcus mutans. Am J Dent. 2011 Jun;24(3):155-8.

Germicidal activity of antimicrobials and VIOlight Personal Travel Toothbrush sanitizer: an in vitro study. J Dent. 2010 Aug;38(8):621-5. doi: 10.1016/j.jdent.2009.08.011. Epub 2009 Sep 23.

Read More

Should Toothbrushes be Thrown Out After Strep Throat?

As with so many things with medicine, this question which sounds so straightforward unfortunately has no straightforward answer.

After all, there have only been a few studies that have specifically looked to answer this question.

And the answer is decidedly ambiguous as the few studies done so far either support or disprove this practice.

Two studies have found no difference in recurrent infections whether one keeps using an old toothbrush or replaces it with a new one after a strep throat. In one study, even NEW toothbrushes contained harmful bacteria.

Of course, there are several studies that support this practice.

In fact, environmental hygiene in general is also disputed with studies supporting for as well as against this practice after an illness.

Check out a few references below to add more mud to the confusion.

Of course, with multiple recurrent episodes of strep throat, tonsillectomy surgery is quite helpful.

Also given the confusion, perhaps the safe course would be to disinfect a toothbrush regularly.


References Against Throwing Toothbrushes Out:
Recurrence rate of streptococcal pharyngitis related to hygienic measures. Scand J Prim Health Care. 1998 Mar;16(1):8-12.

How dirty is your toothbrush? Answer: Not as much as you think. NBC News 5/4/13


References in Support:
Contamination of toothpaste and toothbrush by Streptococcus mutans. Scand J Dent Res. 1978 Sep;86(5):412-4.

Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. 1998 Sep;124(9):993-5.

Read More

Actress Sofia Vergara Underwent Total Thyroidectomy for Thyroid Cancer

Actress Sofia Vergara, best known for her role in the TV hit comedy Modern Family, had her entire thyroid removed for thyroid cancer when she was 28 in 2000. This was followed by radioactive iodine therapy and now takes a daily thyroid hormone replacement for her hypothyroidism.

Image by Jenn Davis from Wikipedia

Thyroid cancer is typically first suspected on a routine examination if a neck mass consistent with a thyroid nodule is palpated. An ultrasound of the neck is typically performed to characterize the thyroid mass further which is than followed by a biopsy. Should the biopsy come back malignant, thyroid removal surgery is performed. Even if the biopsy comes back indeterminate, surgery may still be pursued to be on the safe side.

Other studies may be pursued including CT scan and a thyroid nuclear scan.

Although the type of thyroid cancer Sofia Vergara had was never revealed, she most likely had papillary thyroid carcinoma which is the most common form of thyroid cancer and is highly curable (which is where the comment of being a "good" cancer comes from).

Other less common thyroid cancers include follicular thyroid carcinoma and medullary thyroid carcinoma.

It should be mentioned that until the thyroid is removed, one can NOT be absolutely sure that thyroid cancer actually truly is present. Indeed, the president of Argentina announced that she had thyroid cancer only to find out after her thyroid was removed that no cancer was actually present. Read blog post about this "mistake".

Read more about the surgery here or watch the video below of what Sofia's thyroid surgery might have looked like.

Source:
The Workout: Sofia Vergara Hates to Exercise. NYT 5/3/13

Read More

How is a Pollen Forecast Made?

Pollen Trap from Burkard

Unlike weather forecasting which utilizes high technology, satellites, complex computer models, etc, pollen forecasting seems downright archaic, though just can be just as complex and unpredictable.

So, here's what happens...

The main "equipment" to enable pollen forecasting is a simple air trap in order to capture and ultimately count what pollen is currently circulating in the environment. This equipment known as a "Volumetric Spore Trap" is placed in an open area and sucks in a specific volume of air through a narrow slit. Within the spore trap is a rotating drum covered with sticky tape upon which pollen gets stuck on.

Spore Trap. Image from Burkard

Every morning, an aerobiologist removes the sticky tape and places it on a glass slide to look at it under 400x magnification.

Pollen spores are identified and counted by the aerobiologist.

Based on this pollen count information in combination with the weather forecast, precipitation, wind direction, etc a pollen forecast can be provided for a region.

However, a pollen forecast may not accurately reflect local conditions. For example, grass counts may be very elevated all year round where timothy grass is present as feed for horses whereas regional pollen forecast may show elevated grass pollen only during the summer.

More obviously, mold spores would be elevated inside a damp old home all year round that is not reflected in a regional pollen forecast.

In any case, allergies can be treated with medications.

   

Read More

What's That Yellow Pollen Coating My Car Windows?

Every spring, a yellow coating of pollen covers everything, most noticeably car windows. For many people with allergies, this yellow pollen is the cause of all their sinus and nasal misery triggering bouts of sneezing, sniffling, water eyes, etc.

However, this yellow pollen produced by pine trees is NOT a significant allergy trigger. When it comes to allergy, the biggest culprits are the pollen you can not see. Such springtime microscopic pollen that IS the culprit for allergies come from trees (non-pine) and grasses.

So don't demonize the yellow pollen! Unless, of course, you are upset that the car now needs to be washed/cleaned.

If you are curious what you may be allergic to, you can get allergy tested. Or, try an over-the-counter anti-histamine, many of which used to be prescriptions.

Here's a complete list of allergy medications and how they work.

Read More

Fecal Transplantation Administered Through the NOSE!

Fecal transplant is nothing new as it has been around since the 1950's... It is used to treat multi-drug resistant clostridium dificile infection by replacing the "bad" gut bacteria with normal "good" bacteria. However, what is new is the fact that such fecal transplantation is being administered through the nose using a tube threaded into the small bowel. [Thanks to @GuildfordENT who brought this to my attention!]

Historically, such fecal transplantation (aka fecal bacteriotherapy) was performed via multiple infusions via enema (uncomfortable for both the physician as well as the patient) or via colonoscope. Although first described being done in humans in 1958, it was never really seriously studied until the mid-1980's. Even before humans, it had been performed in animals by veterinarians for centuries.

In any case, there has been new literature supporting the use of nasoduodenal tubes to administer poop via the nose. With nasoduodenal tubes, a tube is threaded through the nose, past the stomach, and into the small bowel.

Now keep in mind that the stool actually NEVER comes into contact with the nose. It is contained within an impermeable tube at all times, so it is not quite as gross as you might think (though mentally, there may still be an emotional ick factor present).

Another approach being considered is encapsulating the poop inside enteric-coated capsules so a patient can theoretically swallow the pill-containing poop.

Media Mention:
Doctors save patient from deadly superbug by transplanting faeces through his NOSE. MailOnline

Reference:
Duodenal infusion of donor feces for recurrent Clostridium difficile. New England Journal of Medicine. 2013 Jan 31;368(5):407-15. doi: 10.1056/NEJMoa1205037. Epub 2013 Jan 16.

Same poop, different gut. The Scientist 11/3/105/2/13

Read More

What Makes a Voice Sound Attractive?

Ever hear a voice that sounded sexy or attractive? Ever build a mental image of what a stranger on the phone may look like purely based on the sound of the voice???

Well, according to researchers, an attractive voice reflects an attractive perceived body size.

A group of human subjects listened to the same sentence that was manipulated by altering pitch, acoustic resonance, and voice quality based on body size projections reported for animal calls and emotional human vocal expressions.

For example, a rough, low-frequency animal call suggests the vocalizer is large and aggressive whereas a more clear, higher frequency animal call suggests a small, non-threatening animal.

Not surprisingly, male listeners preferred a female voice that suggested a small body size (relatively high pitch, wide acoustic resonance range, and breathy voice). Think Marilyn Monroe...

Female listeners preferred a male voice that suggested a large body size (low pitch and narrow acoustic resonance range) akin to actor James Earl Jones. However, female listeners interestingly also preferred some breathiness in the male voice which may signal a perceived decrease in the aggressiveness associated with a large body size.

Another reason why patients undergo voice therapy, even if there's nothing medically wrong...

It is not unusual for a male lawyer to undergo voice therapy to try and achieve a lower and more aggressive vocal quality as it does correlate with success. (Read more about this link between voice pitch and success).

Similarly, women in positions of authority in the political and corporate world do the same. Margaret Thatcher underwent voice therapy for this very reason [link].

However, women with a low raspy voice often pursue treatment to try and achieve a more feminine voice (high-pitched and breathy).

Indeed, when voice therapy fails, there are even surgical procedures to try and alter a person's voice.

Source:
Voices Considered Attractive Send Body Cues. Scientific American. 4/30/13

Reference:
Human Vocal Attractiveness as Signaled by Body Size Projection. PLoS ONE 8(4): e62397. doi:10.1371/journal.pone.0062397

Read More