A Vampire Who Knows How to Bite Correctly (Anatomically)

Take a look at the pictures below... Which victim suffered a vampire attack who knew what it was doing?

If you guessed the middle, you are correct!

The large blood vessels in the human neck (carotid artery and jugular vein) are oriented vertically, so an experienced vampire who knows the anatomy and desires a good feast of blood would want to bite in the same direction. The other bites were probably committed by vampires with a total lack of experience.

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Why Does the Nose Whistle in Some People?

Though most people like the professional nose whistler shown here require an instrument to enable the nose to whistle, in others it occurs naturally due to unique anatomic features within the nose.

Why might someone's nose whistle?

Septal Perforation

The most common reason it may occur constantly is due to a hole in the septum (septal perforation). The septum is a wall that divides the right nasal cavity from the left side. Normally, it should be straight and without any openings.

However, when a hole is present in the septum and it is in just the right size and place, whenever air is breathed in and out the nose, it will whistle. In this situation, the hole is the "window" of the whistle and the nose itself is the mouthpiece.

Correction of this problem is by either closing the hole (septal button or surgery) or making it bigger such that the aerodynamics eliminate the conditions conducive to nasal whistling. As an FYI, surgical correction of a septal perforation is quite difficult.

Septal Deviation and Some Nasal Congestion

The other situation when the nose may whistle, but only intermittently, is when there is a deviated septum. In this scenario, the septum rather than being straight, it is slightly crooked to one side making one side more narrow than the other.

Add some slight swelling of the nasal lining such that the opening of the nose is restricted to just right size and shape, and it may whistle.

This type of nasal whistling is akin to grass whistling (blowing between two thumbs holding a blade of grass).

Thankfully, the nasal conditions that lead to nasal whistling is quite rare and requires the perfect storm of just the right amount of septal deviation with just the right amount of nasal congestion.

As such, correction of this problem is fairly easy as one needs to change either the congestion causing the nasal lining to swell with a nasal spray or anti-histamine OR fix the deviated septum. If the inferior turbinates are enlarged, they can be reduced in size as well.

Of course, one can take this unusual condition and make it a positive feature worthy of a concert hall... WITHOUT the assistance of any instrument!

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Singer Adele Has Vocal Cord Hemorrhage and to have Surgery

At least that's what the LA Times reported on Oct 28, 2011. And supposedly will be having surgery to treat it in the near future.

Before going any further, the title to the LA Times story was "Adele to have surgery to treat vocal cord hemorrhage. What is it?"

I sincerely hope that whomever her surgeon is knows not to perform surgery when the vocal cord is in the middle of a hemorrhage. You do the surgery when the hemorrhage is gone and the culprit blood vessel is left behind which likely is the reason for the hemorrhage happening in the first place.

What do I mean?

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the LA times story here.

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Cold Sores Due to a Single Gene

Specifically, individuals who suffer from cold sores triggered by Herpes Virus Simplex - 1 (HSV-1) several times a year may have a single nucleotide polymorphism in their gene C21orf91 – dubbed rs1062202. Researchers have suggested it be called by the more "easy-to-remember" name Cold Sore Susceptibility Gene 1 (CSSG1).

Having this genetic change of swapping a thymine to a cytosine nucleotide was significantly associated (p=0.0047) with more frequent cold sores. Analysis has also found collections of 5 variants that are transmitted together with the C21orf91 gene of which two seemed to be neutral in terms of cold sore frequency, one was protective, and two were associated with increased susceptibility.

What does this all mean for an individual? It means if your parents get them a lot, than you may too.

Such individuals may benefit from regular use of anti-viral antibiotics to prevent such frequent recurrences.

Reference:
C21orf91 genotypes correlate with herpes simplex labialis (cold sore) frequency: Description of a cold sore susceptibility gene. J Inf Dis 2011; DOI: 10.1093/infdis/jir633.

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The Illusion of Healthcare Progress

Wellcome Film based in London has transferred numerous films dating from the early 20th century related to healthcare and medicine that anybody can view for free. Aside from the historical value, it is amazing that much of what we know and do now is not all that different than what was done in the 1920s. It makes me wonder sometimes what "progress" in healthcare actually has happened over the past century. In some things, tremendous change has occurred whereas in other areas of medicine, time might as well have stood still.

It also perhaps explains why in spite of all our "high-tech" medical equipment and sophisticated tests available in the United States that our health as a nation is still not as good as other nations without these benefits.

Take for example dizziness evaluation and understanding. Here are 3 films from 1925 that goes over dizziness evaluation and physiologic basis for it.

At its essence, nothing has really changed between 1925 and 2011. Sad really... Given this lack of progress, I would so far as to venture (with a straight face and all kidding aside) to say that American rates of dizziness is comparable to ANY other nation in the world with treatment protocols no better or worse too.

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Tonsillectomy Circa 1940s [video]

I encountered this interesting video of tonsillectomy being performed in a child with sedation (but NO intubation) performed circa 1940s.


Of course, nowadays, tonsillectomy is performed under general anesthesia with intubation for airway protection. Here's a video of the way it is now done.

That is, unless, you practice in other parts of the world where modern medicine is not up to United States standards. In those nations, tonsillectomy is STILL being performed WITHOUT general anesthesia or any sedation for that matter. In fact, here's a blog I wrote earlier this year showing a graphic video depicting tonsillectomy being recently performed in a young child WITHOUT any sedation.

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Singer John Mayer Undergoes Vocal Cord Surgery

In September 2011, grammy-award winning singer John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

Last week on Thurs, Oct 20, 2011, he underwent surgery to remove the granuloma and is now on strict voice rest for several weeks.

Though removal sounds like a great idea, vocal cord granulomas are notoriously difficult to eliminate completely as they have a high risk of recurrence. Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential with medications. However, it is not unusual that steroid injections to the granuloma site as well as even botox injection to partially and temporarily paralyze the vocal cord may need to be pursued for complete resolution.

Surgical removal of the granuloma may have looked something like this video...


Read more about vocal cord granulomas here.

Read a NY Magazine article about his surgery.

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How do Vocal Cord Cysts, Polyps, and Nodules Form?

There are MANY theories as to how vocal cord cysts, polyps, and nodules form. However, one theory that seems to make the most sense to me deals with how the vocal cord heals after a traumatic event (ie, screaming, yelling, coughing, etc).

With a cyst, the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the vocal cord lining. Vocal cord nodule for comparison's sake is just callous thickening of the vocal cord lining that occurs over time.

To use human skin as an analogy...

A vocal cord cyst is like a sebaceous cyst that commonly occurs under the skin of the face or neck (a pimple, but no opening to the surface).

A vocal cord polyp is like a blister that forms on the hand if you shovel dirt too much.

A vocal cord nodule is like a callous that forms after prolonged repetitive skin trauma (like callous on the hands after shoveling dirt for years).

Read more about vocal cord cysts, polyps, and nodules!

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New Webpage on Vocal Cord Cysts and Vocal Cord Polyps

We have uploaded a new webpage describing what vocal cord cysts and vocal cord polyps are as well as how they are treated.

Vocal cord cysts are masses below the vocal cord lining whereas vocal cord polyps are masses involving the vocal cord lining.

Read more here!

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Mind Over Body Treatment

24 years old female presents with several week history of progressive stomach pains, substernal chest discomfort, heart palpitations, loss of appetite, headache, insomnia, and growing lump sensation in her throat. Physical exam was essentially normal.

Can this previously healthy female have suddenly developed reflux, globus, paroxysmal supraventricular tachycardia, brain tumor, and throat cancer with possible overlying thyroid disorder? Or perhaps has she contracted some other horrific mystery disease?

Maybe...

But maybe none of the above...

What if I told you she will be giving a doctoral dissertation for her Master's next week for which she is ill-prepared for given a recent breakup with her boyfriend of 5 years and has a growing distaste of her school classmates who have been less than supportive.

In other words anxiety.

The point is that the mind has tremendous influence over the body and numerous physical maladies can be attributable to a patient's mental state. People can die of a broken heart or out of extreme fear. Stress can age the body dramatically (look at a picture of a presidential candidate and than another after having served 2 terms as President of the United States).

A mind under stress CAN affect the body. Reassurance helps. Elimination of the stressor is even better. If the stresses can't just go away, development of strong coping mechanisms will do much to help. After that, there are prescription drugs that help, but have addictive potential as the anxious patient will tend to take a pill rather than dealing with and learning coping skills.

But here's where the power of the mind can be "manipulated" into helping rather than hurting the body.

In my last blog, I did ridicule therapeutic hands to manipulate human body energy as total bunk (or rather a 9 year old girl did)... BUT... if a person truly believes that it does help, it probably can help some individuals just from the idea/belief/faith that it can.

Faith, trust, and sharing with another human being who lends a sympathetic ear is where questionable "medical" practices and homeopathy may provide benefit... not because such quackery directly helps the individual, but more because the individual BELIEVES it can help.

I can totally make up a quack treatment like placing an ice cube over the heart and stating that this practice can "calm" the heart palpitation down by "cooling" it to a more natural state... and if the patient believes it to be true... than the mind can potentially make it so in a significant number of people. In fact, I can state with some confidence that it will help in as many as 20-40% of patients.

How can I state such a statistic knowing my treatment is total hogwash?

It's because of the placebo affect.

Although I don't support (and perhaps even discourage) such quack medicine, as long as it doesn't harm the patient and there's no danger if a patient decides to forgo more traditional and evidence-based medical treatment, than I don't see any long-lasting harm in it.

Because as scientists and doctors know... the placebo effect is real and DOES lend improvement nearly 40% of the time! Who cares if the activation mechanism of the placebo effect is via "therapeutic hands" or "local honey" or some other "un-accepted" treatment.

After all... the patient is feeling better and that's what really counts in the end.

AND... if it doesn't work, than traditional medical treatments can be pursued.

What is evidence-based, scientifically proven medical treatment?

It's when the treatment helps people way more than the placebo (or in other words, way more than 40%).

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Even Kids Can Spot Adult Bull^!#$& ... And Publish It in a Medical Journal!

Though often adults find kids to lack intellectual rigor and devoid of rational thought, sometimes it's the other way around.

Take Emma Rosa, age 9, who debunked the idea of therapeutic touch back in 1998. She watched a TV program about nurses who practise “Therapeutic Touch”, claiming they can detect and manipulate “human energy field” by hovering their hands above a patient. Emma recognized this adult nonsense and conducted a scientific study for a 4th grade science fair to not only prove it, but also publish her results in a peer-reviewed medical journal JAMA. She found that 21 experienced practitioners of therapeutic touch were unable to no more than chance able to detect a human hand under their right or left hand hidden by a screen (so the therapist can't see).

There are other instances where kids have similarly debunked quack medical treatments, though not necessarily published in a scientific journal. Take Rhys Morgan, age 15, who after being diagnosed with Crohn's disease and while internet searching on this topic to educate himself, came across Miracle Mineral Solution (MMS) that claimed to cure not only Crohn's, but also cancer, Aids, malaria, and basically most things short of actual death. Being 15, he was able to do his own research to evaluate this "amazing" treatment through which he discovered that MMS is in essence industrial bleach. Rhys has since campaigned hard to eliminate MMS.

Beyond quackery, I often see it in my ENT clinic where elementary school-aged kids offer utterly profound observations that go way beyond their years.

In a time when potential leaders and politicians are espousing claims in the media that lack rational thought and intellectual rigor (watch the news) and even the educational system is being attacked for teaching scientific principles like evolution in favor of Biblical explanations, I sometimes wonder if we need children like Emma Rosa and Rhys Morgan to come to our rescue even if we are adults who should know better.


Reference:
A Close Look at Therapeutic Touch. JAMA. 1998;279(13):1005-1010. doi: 10.1001/jama.279.13.1005

The man who encourages the sick and dying to drink industrial bleach. Guardian.co.uk Wednesday 15 September 2010 07.30 EDT

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Cancer Drug to Treat Glue Ear in Kids??!

I read with astound that a class of cancer drugs known as VEGF Inhibitors (ie, Avastin and Erbitux) used to treat colorectal, lung, breast, and kidney cancers can also be used to potentially treat a type of chronic ear infection known as glue ear... at least in theory and in mice. Glue ear is when an individual suffers from repetitive ear infections or upper respiratory infections to the point where the fluid in the ear turns into a maple syrup consistency. It's thick, sticky and tough to get rid of with standard antibiotic medications. Standard treatment to address glue ear is placement of ear tubes to allow ventilation and drainage of the ear as well as antibiotic/steroid ear drops.

British researchers using the mouse model have determined that an underlying hypoxic (low oxygen) environment in the middle ear leads to glue ear and that by mediating aniogenesis (blood vessel growth) by regulating VEGF receptors (Vascular Endothelial Growth Factor), may prevent glue ear from occurring by addressing the root cause (hypoxic environment). VEGF inhibitors are typically monoclonal antibodies that prevent new blood vessels from forming via blocking VEGF receptors.

Given a vial of anti-VEGF costs on upwards of $10,000 versus not even $100 for an ear tube, the economics of this potential treatment just does not make sense at this time. Even if the costs were more comparative, I'm not sure most people will go for a treatment normally used to treat cancer to address a benign condition.

However, to be fair, this class of cancer medicine has been repurposed to treat other benign conditions including age-related macular degeneration (AMD) and diabetic retinopathy, so who knows?

It's also been considered for use to treat severe nosebleeds due to HHT (Osler-Weber-Rendu).

Maybe someday in the near future after further research, not only will we have antibiotic ear drops, but also anti-VEGF ear drops!!!


Reference:
HIF–VEGF Pathways Are Critical for Chronic Otitis Media in Junbo and Jeff Mouse Mutants. PLoS Genet 7(10): e1002336. doi:10.1371/journal.pgen.1002336

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New Webpage on Vocal Cord Nodules

Our office has created a new webpage on the evaluation and management of vocal cord nodules.

Vocal cord nodules also known as Singer's nodules is a common cause of a painless raspy voice that mainly affects individuals who use their voice a lot. Such individuals include teachers, singers, cheerleaders, and people who simply just love to talk a lot.

Read more about this condition here and how to treat it!

Of note, the cartoon is by Dave Walker at We Blog Cartoons.

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Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:
Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

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Working in a Salon Can Be Unhealthy for Your Nose and Throat!

We already know that small hair clippings from cutting hair can cause septal perforation and chronic sinusitis due to long-term inhalation. Worse case scenario, it can even lead to an external nasal deformity! (Read blog about this here.)

However, it seems that it's not just hair that can damage the nose, but also hair products especially to straighten/smoothen hair popularly known as "Brazilian" treatments.

In a report published by Washington Post on Oct 17, 2011, such Brazilian hair smoothing treatments often contain a known toxic chemical called formaldehyde and methylene glycol. The FDA has pronounced such products to be unsafe. These chemicals are most commonly used as a preservative to prevent dead tissue (ie, corpses) from decay.

And yet... these products are commonly used in hair salons to potentially unsafe levels resulting in health problems to not just workers, but also customers.

Common symptoms that can result from formaldehyde and methylene glycol exposure include:

• nose-running (rhinitis)
• eye tearing
• throat burning

It can also cause symptoms of chronic sinusitis, taste alteration, smell loss, dry nose, scabbing at the nose entrance, etc.

Best to avoid if at all possible!

Read the WP article here.

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Nasal Congestion Affected By How Well the Nose is Able to Cool Itself

Researchers at Monell Chemical Senses Center have figured out that nasal congestion is influenced by more than just nasal airflow. Apparently temperature and humidity influence the perception of nasal congestion just as much as how physically obstructed the nose is.

By having volunteers breath air with variations in temperature and humidity, they have determined that cool and dry air minimizes nasal congestion without any change in how open the nasal cavity is.

By taking into account other measured variables, they have deduced that nasal congestion is influenced by how well the nose is able to cool itself from the nasal airflow specifically. The more warm and humid the air is, the less able the nose is able to cool itself leading to perception of nasal congestion.

With actual nasal obstruction, it may be not so much that you can't breath that causes the feeling of nasal congestion, but rather the reduced ability of the nose to cool itself from the absence/reduction of air circulation within the nasal cavity.

So... if nasal cooling influences perception of nasal congestion, this may be one of many factors that may help explain the phenomenon of Empty Nose Syndrome. Patients suffering from Empty Nose Syndrome have an abnormally open nasal cavity from extensive surgical removal of internal nasal structures... yet complain the most bitterly about how congested their nose feels.

This information may also help guide treatment in patients with tracheostomy who also have a totally open nose, but because they breath thru an opening in the neck, have no nasal airflow in the nose which leads to the sense of nasal congestion.

Based on this new research, in these particular patient populations, providing allergy medications like steroid nasal sprays and anti-histamines may not be the best way of addressing nasal congestion.

Clearly, more research is needed on this topic, but certainly opens other new avenues of possible treatment protocols.


Reference:
Perceiving Nasal Patency through Mucosal Cooling Rather than Air Temperature or Nasal Resistance. PLoS ONE 6(10): e24618. doi:10.1371/journal.pone.0024618

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Realistic Face Masks

With halloween coming up and more face transplants occurring to address severe facial disfigurement, it was only a matter of time when a commercial company can recreate a 3-dimensional replica of a person's face. Unlike medical facial transplants which creates a face that's a cross between the donor face and the patient's face prior to disfigurement, these faces are perfect replicas down to scars, blood vessels, skin pores, etc.

Well, there's a Japanese company called Real-f 3 Dimension Photo Forms that can produce a realistic mask of yours or anybody else's face.

But... they are expensive running $4000 - $6000.

Check out more realistic face masks the company has created on their facebook page.

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Respiratory Spasmodic Dysphonia

Respiratory spasmodic dysphonia is one of the most rare subtypes of a class of laryngeal dystonia collectively known as spasmodic dysphonia. It is also known more accurately as laryngeal adductor breathing dystonia or respiratory spasmodic dystonia or respiratory laryngeal dystonia.

Introduction

Spasmodic dysphonia is a type of dystonia in which there are involuntary muscle spasms or contractions of the muscles involved in voice production. This disorder is similar to the involuntary eyelid twitches of blepharospasm. Spasmodic dysphonia should not be, but is often confused with muscle tension dysphonia or tremor. There are 2 main types of spasmodic dysphonia: ABductor and ADductor. Other much more rare types include mixed and respiratory.

ADductor dysphonia is when the vocal cords comes together suddenly while talking resulting in voice stops and effortful speech. Often, the voice chokes off. Counting from 80 to 89 is harder than counting from 60 to 69. Stressful situations often exacerbate the condition. ABductor dysphonia is when the vocal cords suddenly moves apart while talking resulting in loss of voice (breathy). These patients find counting from 60 to 69 harder than counting from 80 to 89. ABductor dysphonia is not as common as ADductor dysphonia.

Respiratory Spasmodic Dysphonia

Respiratory spasmodic dysphonia is when the vocal cords come together suddenly when inhaling. So the voice actually sounds quite normal... until the patient takes a breath in. During such inhalation, one can hear an audible choking sound.

A brief word about nomenclature. "Dysphonia" means hoarseness. As such, the term respiratory spasmodic dysphonia is not accurate. Rather, "dystonia" should be used instead which is defined as an abnormal muscle contraction.

In the video clip shown above, in the first half of the video, listen to the audio of a patient suffering from respiratory spasmodic dystonia talking. The latter half is a video of the patient's voicebox while vocalizing. Note that the vocal cords intermittently do not move apart when she is taking a breath in. Normally with breathing, the vocal cords should move apart to allow air to pass between the vocal cords.

Treatment

Treatment is the same as for ADductor spasmodic dysphonia. Botox is injected into the vocal cords which reduces the spasms when she takes a breath in.

Watch a video of botox being injected.

Click here to read more about spasmodic dysphonia.

Dr. Chang performs botox injections for this disorder every Friday afternoon.

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The Four Types of Patients Seen in a Surgeon's Clinic

Over the years, I have found that patients can be loosely grouped into 4 different types. Nothing particularly wrong with any type, but it does help me to approach patients appropriately if I can get a sense of what type they are.

The four types are:

Type A:  If a surgery can "fix" or "cure" me such that I won't have to take medications every day of my life, than let's do it.

Type B: I will never consider surgery unless it is a life-threatening situation. If a medicine can help, why do it???

Type C: I will consider surgery only as a last resort when all else fails.

Type D: They thought they were Type B or C, but over time, they realize they are Type A.

Why is this important?

Because if a patient is Type B and surgery is recommended, the patient often develops an automatic distrust of the surgeon. The patient may see the surgeon as a "gun-slinger" who likes to cut people.

If a patient is Type A and the surgeon approaches them like Type B or C, such patients may come out of a visit quite disappointed and at worst, upset that the surgeon will not do what they want.

Ultimately, for a happy clinic encounter, a mutual understanding needs to quickly happen otherwise a mutual discord may snowball ultimately leading to a second opinion with another surgeon.

Of course, there is a more complex dynamic going on, but it's a good over-simplification.

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Posterior Tongue Tie

An ordinary garden-variety tongue tie (also known as ankyloglossia) is an uncommon condition whereby the tongue is anchored to the floor of the mouth preventing the tongue tip from moving freely.

Patients with tongue tie have greater difficulty with:

• feeding if infant
• speech if school-age child
• french kissing if young adult

Treatment is tongue tie release which can be done at any time if difficulties arise. In infants and young adults, this procedure can be done in the office under local anesthesia only. In school age kids, it typically requires sedation given lack of cooperation with keeping the mouth open and tongue still.

Posterior Tongue Tie

Though tongue tie is uncommon, there is an even more uncommon (or perhaps less recognized) subtype called submucus tongue tie or posterior tongue tie.

This condition is when the tongue tie is hidden UNDER the mucus lining of the tongue/mouth. You can't see this type of tongue tie, but you can feel it if you run the finger underneath the tongue from side to side where the tongue tie would be. One would feel a tissue band (speed-bump sensation with finger sweep) where the tongue tie would be.

Treatment is a bit more complicated than a regular tongue tie release in that the mucus lining has to be incised in order to expose the tongue tie prior to release. Once the tongue tie is released, the incision is sutured closed.

Read more about this condition and treatment here.

Another less known condition is upper lip tie which may also cause breast-feeding difficulty.

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YouTube Ranks Fauquier ENT as Most Viewed for Medical Videos

I was informed that our practice's YouTube channel has been ranked as one of the most viewed channels related to medicine in the world!

As of Oct 6, 2011, our channel which contains 52 videos has received 198,064,840 views. We currently average over 500,000 views a day!

We far surpass other more "prestigious" medical organizations with a YouTube channel.

Mayo Clinic Channel Channel
4,936,943 views

University of Maryland Medical Center Channel

2,047,260 views

CDC Channel 

4,173,563 views

Massachusetts General Hospital (Harvard) Channel 

33,994 views

Children's Medical Center Channel 

318,688 views

Duke Medical Center Channel 

1,571,694 views

Medical University of South Carolina Channel 

699,002 views

UVA Health System Channel 

29,922 views

Stanford Medical Center Channel 

132,303 views

British Medical Journal Channel 

216,331 views

Penn State Hershey Medical Center Channel 

46,688 views

Scripps Health – San Diego Channel 

212,848 views

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Sedated Anesthesia for Kids Under 2 Years May Cause Learning Disability

There is mounting evidence in animals and in humans that general anesthesia might damage developing young brains.

Researchers at Mayo Clinic compared the learning skills of 350 kids who underwent 1 or more general anesthesia before age 2 to 700 kids who have never been under sedated (general) anesthesia. What they found was that before the age of 19 (after statistical normalization):

No significant difference in learning disability between kids who have been under anesthesia once (23 out of 100) with kids who have never been under anesthesia (21 out of 100).  

However, those kids who have been under anesthesia 2 or more times had increased rate of learning disability (36 out of 100). 

Based on animal studies, anesthetics are known to cause accelerated loss of brain cells during development which leads to learning and behavior problems later in life. Whether that's also true for humans has not been studied.

However, further study is required as the results were obtained based on observation and did not account for other variables (type of surgery for example).

This information, though not definitive, does warrant extra circumspection by parents and surgeons when deciding to pursue surgery in kids under age 2 years, no matter how minor the surgery including ear tubes, tonsillectomy, adenoidectomy, and turbinate reduction.

IF surgery pursued, one should perform as much as required to minimize need for a 2nd procedure at a later date. That means multiple procedures under one anesthesia would be preferable than multiple procedures at different times.

Of course, surgery should only be done if the benefits outweigh the risks including anesthetic risks.

Read the MSNBC report here.

Reference:
Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery. Published online in Pediatrics October 3, 2011. doi: 10.1542/peds.2011-0351

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New Webpage on Facial Fractures and Nasal Fractures

Our office has created a new webpage describing the evaluation and management of not only nasal fractures, but also facial fractures.

Fracture types discussed include:

• Nasal Fractures
• Orbital Fractures (around the eye)
• Maxillary Fractures (cheek)
• Zygomatic Fractures (behind cheekbone)
• Tripod Fractures (cheekbone)
• Mandible (lower jawbone)
• LeFort (upper jawbone)

Check it out here!

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Are You Able to Use Expired EpiPens Safely?

Though one should always use an EpiPen that is not expired, it is better to use an expired EpiPen to treat anaphylaxis than to do nothing at all.

Some Canadian researchers studied expired EpiPen auto-injectors 1 to 90 months past the expiration date.

What they found was that the older the EpiPen, the less effective it was due to decreased epinephrine bioavailability. The inverse correlation was 0.63 (months past expiration and decreased epinephrine content).

As long as the solution is clear without precipitates or discoloration, it's fine to use the EpiPen. BUT, still better to use an EpiPen that is not expired!!!

Reference:
Outdated EpiPen and EpiPen Jr autoinjectors: past their prime? J Allergy Clin Immunol. 2000 May;105(5):1025-30.

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New Webpage on Thyroid Mass (Evaluation and Management)

A new webpage has been uploaded to our practice website describing the evaluation and management of a thyroid mass. Surgical removal is discussed along with risks involved.

Click here to read more!

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