Do Ear Candles Actually Remove Earwax? [video]

About once a week, I have a patient who presents to my clinic with a history of ear candling for earwax removal due to clogged ear sensation.

About once a month, I have a patient with ear canal and/or eardrum damage due to using an ear candle in an attempt to remove earwax.

I even have on occasion patients who I thoroughly remove earwax under the microscope, who than go home, perform an ear candle, and inform me of all the "earwax" that I missed.

Well... I've decided to make a video (see below) illustrating how ineffective ear candling is in removing earwax as well as how it could be even harmful. The other aspect of this educational video is to show how misleading ear candling is when it comes to earwax.

Please note that we are aware that the  "official" way to use an ear candling is small end down into the ear, but for this video, we have elected to use it the way most "lay" public would (small end up).

[SPOILER ALERT!!! A burning ear candle actually creates debris that looks like earwax. As such, an ear candle "works" whether it is in the ear or not.]

References:
Ear candles: Efficacy and safety. Laryngoscope 106 (10): 1226–9.

Ear candling: Should general practitioners recommend it? Can Fam Physician 53 (12): 2121–2. PMC 2231549. PMID 18077749.

Ear candles can be purchased on Amazon.com for you to "experiment" with.

Read More

ENT Uses Laser Resulting in Patient Death

In 2010, an ENT used a Sharplan laser with an Omniguide Sidefire Adapter to address a superficial lip hemangioma.

The tip of the laser probe was inserted through a small incision made to one side of the hemangioma and activated. Seconds later, the lip and surrounding tissues immediately swelled up indicating trapped gas. A second incision was made in an attempt to release the buildup of gas (analagous to popping a balloon to release air). A short time later, the patient's vital signs dropped and in spite of life-saving measures, was pronounced dead within 2 hours.

The official autopsy report declared death due to "arterial embolism." [link]

What happened?

In the operation of the Sharplan laser, there are two channels present in the laser probe. One channel carries the laser and the other channel carries compressed helium gas that flows over the probe tip to cool it down (a laser is essentially a very focused beam of light and is quite hot... just like direct sunlight which is unfocused).

The helium gas pressure flow can be varied between 50-70 psi (pounds per square inch). Just for a frame of reference, car tires are pressurized to about 35 psi.

What essentially happened at the time of the procedure was helium gas built up within the lip under too high a pressure. Some of this helium gas (as a bubble) entered the blood stream where it blocked blood flow to vital organs like the brain and/or heart resulting in death

To prevent this complication, when using a Sharplan laser, the manufacturer specifically states to keep the probe perpendicular and at least 5mm away from contact with soft tissues. The probe should be completely away from any blood vessels.

I did want to add that Sharplan lasers are no longer made. In fact, it is also appears that the company that makes this laser no longer exists.

Take home message?

A surgeon should be the master of the tools he uses. Not understanding the operation of a tool can lead to unintentional, but disastrous mistakes.

Secondary message?

Lasers are dangerous, even if used properly.

There's a reason why many ENT's (including myself) have voluntarily elected to no longer use lasers at all for any purpose. Lasers introduce additional risk to a procedure that can be performed in alternative and safer ways with just as good an outcome.

It's not just arterial embolism that can occur. Lasers can also cause life-threatening hemorrhage from blood vessel damage (death of a 5 years old child), airway fire (laser can ignite oxygen), blindness (laser can reflect off metal surfaces and bounce into somebody's eye), etc.

Smart Laser, Dumb Surgeon

If lasers must be used, depending on the procedure, there are two different "styles" of laser that can be utilized. For simplicity's sake, I'll describe these two laser types as:

1) Smart Laser, Dumb Surgeon
2) Dumb Laser, Smart Surgeon

For style #1, the "smart laser, dumb surgeon," the laser is used much like the flash of a camera. You just have to aim the laser in the general vicinity of whatever it is the surgeon wishes to address, typically a vascular lesion like a hemangioma. When the laser is activated (typically a KTP or PDL laser), the laser selectively attacks the lesion without damaging the surrounding tissue. The surgeon is "dumb" in that all he has to do is crudely aim the laser in the general vicinity and the "smart" laser will do the rest. Watch a video of this type of laser in action here.

For style #2, the "dumb laser, smart surgeon," the laser (typically a CO2 laser) is used more like a handgun. It needs to be precisely aimed, precisely activated, precisely used. If the surgeon makes a mistake in aim, activation, or use, unintentional damage (and even death) may occur. The surgeon has to be "smart" in that he needs to precisely guide the "dumb" laser which will destroy anything in its path.


Source:
California Health and Human Services Department of Health Report. Report completed 12/3/10. Received by Licensing & Certification Office 6/15/12.

Read More

Fake Botox Being Sold to US Physicians: FDA Sends Warning

It is not just patients trying to save money when purchasing medications from online pharmacies located in Canada. It's doctors as well when it comes to expensive drugs like Botox made by Allergan which costs a physician practice $550 per vial (2012 price)... but if purchased from Canada, may cost hundreds less.

Unfortunately, just like prescription drugs purchased outside the US, foreign-purchased Botox may be a product that is potentially unapproved, counterfeit, unsafe, or ineffective. Indeed, medical practices that purchase and administer such illegally obtained and unapproved medications from foreign sources are placing patients at risk and potentially depriving them of proper treatment.

To address this dangerous practice, the FDA has alerted more than 350 medical practices that they may have received unapproved medications, including unapproved versions of Botox from foreign-based suppliers, especially from Canada.

Disclaimer! Our practice has ALWAYS purchased Botox directly from Allergan, the maker of Botox, and have never purchased Botox from a third party supplier, whether US-based or not, past and present.

The ones the FDA specifically listed on a watch-list of sorts under the umbrella of online Canada Drugs include:

• Quality Specialty Products (QSP)
• A+ Health Supplies
• QP Medical
• Bridewater Medical
• Clinical Care

Per the FDA, "many, if not all, of the products sold and distributed by these suppliers have not been approved by FDA. Therefore, FDA cannot confirm that the manufacture and handling of these products follow U.S. regulations or that these medications are safe and effective for their intended uses."

The FDA has also publicly released the names of physicians and physician groups who have purchased from these online sources... public humiliation in order to persuade a change?

However, it may not be just public humiliation, but even jail-time for one physician in a particularly egregious case (Botox not meant for human use was deliberately and knowingly injected).

It's not just doctors, but even medical institutions on the list (ie, University of SW Texas Medical Center).

Source:
Letters to Doctors about Risks of Purchasing Unapproved Versions of Botox and Other Medications from Foreign or Unlicensed Suppliers. FDA 12/19/12

FDA warns doctors of counterfeit Botox. Fox News 12/24/12

Read More

How Can Nasal Obstruction Cause Post-Nasal Drainage?

Before talking about the nose, consider the way some home humidifiers work. There is a sponge, water supply, and airflow. Humidification occurs by having a fan blow air though the sponge that is soaked by a constant water supply. As the air passes through the wet sponge, evaporation occurs resulting in air humidification.

Well, the same thing occurs inside the nose. In a normal nose, about one liter of moisture is produced by the nasal mucosa every day (water supply). This nasal moisture production is what allows the air to be humidified as a person breathes (the fan) through the nose.

However, when the nose is obstructed preventing a steady airflow, there is a corresponding reduction in evaporation allowing for more moisture to be present inside the nose. With increased moisture, it may lead to the perception of increased post-nasal drainage.

So, how can post-nasal drainage be corrected in this situation?

Well, one can try to decrease nasal moisture production using medications like decongestants, anti-histamines, and/or nasal sprays. Or, one can try to alleviate the nasal obstruction to increase nasal airflow leading to increased evaporation thereby reducing the amount "drainage" (which actually is normal "water supply").

Alleviating nasal obstruction can also occur with decongestant, allergy, and nasal spray medications, but if there's not much improvement, one can consider surgical options if there are anatomic factors present.

Such intra-nasal anatomic obstructions include deviated septum, turbinate hypertrophy, adenoid hypertrophy, nasal polyps, etc.

There is a specific surgical procedure that can address each of these issues if present.

Of course, nasal obstruction does not automatically lead to post-nasal drainage. But it is only one of many other factors that may be present that can lead to this complaint.

Read More

Does WaxVac or EarVac Actually Remove Earwax?

The EarVac or WaxVac is a device that purportedly suctions out earwax. Shaped like a miniature hair dryer, one simply needs to hold it up to your ear canal in order to suction out the earwax. Recently, they have been marketing this device heavily, especially through TV commercials.

Now, does it actually work???

Not really... In fact, British researchers tested it out against the humble ear curette (Jobson-Home Probe). With their test population, the WaxVac worked in exactly ZERO percent of patients. The ear curette worked 100% of the time to restore eardrum visibility and 88% for subjective hearing improvement for the patient.

Why would the WaxVac work so poorly?

Think of a handheld vacuum cleaner. Even for a regular vacuum cleaner, it will only suck up debris only when it is right on top of it. One can't "vacuum" out a bedroom simply by holding the vacuum cleaner at the bedroom door entrance or hovering it around in the bedroom. The vacuum needs to be placed DIRECTLY over debris in order to suction it out.

Well, the same goes for the WaxVac.

Even when the ear canal is professionally vacuumed by an ENT under the microscope, it only works with some earwax types... and doesn't work at all for other earwax types.

I also wanted to point out the danger of using an WaxVac which has the potential to create high negative pressures when sealed up against the ear canal entrance which could lead to eardrum perforation as well as permanent hearing loss (similarly to kissing ear syndrome).

As such, I personally do not recommend this product. However, should you decide to purchase it, I would strongly urge people to do their homework before buying this unproven device. Even if it did work, beware that the company seems to make their money by scamming people with shipping charges [link]. 

Reference:

A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe. Clin Otolaryngol. 2005 Aug;30(4):320-3.


Watch how earwax is cleaned at an ENT office video.

Read More

New Anti-Meth Sudafed (Pseudoephedrine)

As anybody who suffers from nasal congestion and runny nose knows, the nasal decongestant medication Sudafed can only be obtained from behind the pharmacy counter after showing identification because Sudafed can be made into meth.

This restriction applies to not just sudafed, but any medication containing the active ingredient "pseudoephedrine" which is a precursor for most meth recipes.

Well, coming soon to a drugstore near you, a new nasal decongestant has been produced that can NOT be made into meth called Zephrex-D. It still contains the active ingredient pseudoephedrine.

Made by Westport Pharmaceuticals, Zephrex-D comes in a "tamper-resistant formulation that locks this active ingredient chemically so that it cannot be used in illicit methods of methamphetamine manufacture," but maintains full clinical benefits for patients.

This drug (30mg tablets) is currently available at several national and local drug retailers throughout Missouri with nationwide deployment in 2013. Combination drugs including Zephrex-D will also become available within the next year.

Obviously, this has the potential to ease purchase restrictions for nasal decongestant drugs.

Source:
Westport Pharmaceuticals launches Zephrex-D, a tamper-resistant PSE formulation. DrugStoreNews 12/4/12

Read More

Keyword Optimization for Medical Websites

As a general rule of thumb, physicians are terrible at running a business... including their own practice. This unfortunate inability also extends to managing practice websites.

When it comes to websites, most physicians take the attitude of "if you build it, they will come" which is doomed to failure. The better way of phrasing it would be "only if patients can find you, they might come."

Finding you is the first step... And one important element of accomplishing this step are keywords.

Let's take the medical condition "eustachian tube dysfunction" which is an annoying malady of the ear causing symptoms of clogged ears, pain, hearing loss, fluid sensation, etc.

Now, if you are to build a webpage on this particular condition, there are some do's and don'ts.

DO embed keywords that patients will actually use when searching about this condition.

clogged, ears, hearing, loss, fluid, sensation, treatment, pain, infection, etc

DON'T use only keywords that medical healthcare professionals will use (though it can't hurt to also include).

eustachian, tube, dysfunction, myringotomy, tube, cochlear, hydrops, auditory, aural, etc

Sounds simple? It is... but it almost never happens! Common mistakes I see regarding keywords on medical webpages include:

1) What keywords? There aren't any!!!
2) Medical terminology used as keywords rather than descriptive terms a patient would use in a google search
3) Poor utilization of keyword ranking for a given webpage

What do I mean by "poor utilization of keyword ranking?"

Google and other search engines rank some keywords more highly than others. Such ranking of keywords depends on placement within the webpage's code.

Keywords found in the following locations are very important:

• Webpage document title (typically ends in .htm or .html). This is what the webpage document on the server is actually called.
• Title of webpage (words used in the title bar of the webpage)
• Meta keywords and description: Has become less important, but still wise to utilize.

Keywords found in the rest of the webpage including the body text is not nearly as important though still taken into consideration when the above have been addressed first.

Check out this humorous video made by Google regarding the importance of keywords:

Read More

A New BAHA Hearing Aid... Without the Screw Implant

For patients with a significant conductive hearing loss or mixed hearing loss, Bone-Anchored Hearing Aids (BAHA) are an option that negates the need to place anything in the ear canal.

Traditional hearing aids require some type of ear hook that is inserted into the ear canal to allow amplified sound to reach the middle and inner ear.

BAHA transmits sound to the inner ear via a different mechanism using actual bone vibration. The bone vibration can be transmitted either via direct physical coupling (traditional) or via indirect magnetic coupling (the new way).

The traditional BAHA requires a titanium screw that is drilled into the bone behind the ear. Part of this screw sticks out of the skull through the skin to which the hearing aid is attached. Sound is transmitted into the ear by direct screw vibrations which in turn vibrates the bone that gets transmitted directly into the ear thereby allowing sounds to be heard.

 

Why would anyone want a BAHA? It would be a better option than a traditional hearing aid if the ear canal is extremely small, prone to getting infected, chronically draining, and/or absence of the middle ear anatomy including eardrum and middle ear bones.

But who wants a metal screw sticking out of their head???

That's where this "new" magnetically coupled BAHA device called Sophono Alpha 1 comes in.

Rather than a screw sticking out of the bone to transmit vibrations, magnets are used instead. First, flat magnets housed within a titanium plate is surgically screwed into the skull underneath the skin. Nothing sticks out!

Over the skin, an external base plate is magnetically coupled to the surgically screwed in plate.

The hearing aid, which is held in place to this external plate, houses a bone oscillator that uses a metal disc and spacer shim to magnetically couple to the internal component in order to deliver auditory stimulation (vibration) through the closed skin.

Early studies suggest, however, that the hearing amplification is not as great as the traditional direct coupling BAHA.

Read more about this new Sophono BAHA here.

Though our office does not offer this device, please contact your local otologic surgeon to see if (s)he offers it!

Read More

Voice Amplification for Patients with a Weak Voice

There are certain voicebox conditions that naturally tends to a weak sounding voice.

For some, the voice is weak all the time sounding breathy or just lacks projection. For others, the voice starts out OK, but than becomes weak after talking for some period of time. There are both pathological (ie, vocal cord paralysis) as well as functional (ie, muscle tension dysphonia) causes of a weak voice, but in the end, a patient just wants a better sounding voice one way or another.

Although voice therapy is a standard way of addressing vocal weakness regardless of causation as well as possible surgical interventions, patients still need to use their voice and in order to obtain an immediately improved vocal strength is to use electronic amplification.

For the same reason a pop star singer uses a microphone to amplify their voice to be heard in a gigantic stadium, a person with a weak voice can use a similar system to amplify their voice in more mundane situations.

In essence, such personal voice amplification systems contain 2 components: microphone and speaker. The microphone is placed near the mouth and the speaker placed near the person, typically on a belt.

Such systems are relatively cheap costing less than $100. Many models can be found on Amazon.comat a discount.

The "premium" voice amplification systems are by Chattervoxand cost several hundred dollars.

Some examples can be found here.

Read More

Julie Andrews and Her "Botched Throat Surgery"

It has already been well-publicized that the former singing sensation Julie Andrews underwent some type of throat surgery in 1997 after which she never regained her phenomenal 4-octave voice thus relegating her to more conventional roles of being an actress without the singing. This "botched throat surgery" per Julie Andrews lead to a lawsuit that was ultimately settled.

It is unknown precisely what type of (presumed) vocal cord pathology was present as well as what type of surgical approach was used to try and fix it. In a recent interview, she stated:

"The operation that I had left me without a voice and without a certain piece of my vocal chords"

However, given her aggressive and active singing career prior to surgery, she probably had vocal cord nodules, a benign growth that occurs due to vocal overuse, a situation not uncommon with professional singers.

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 (not unusual with professional singers whose livelihoods depend on singing), there are more aggressive ways to address vocal cord nodules with possible 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. Furthermore, as with any more invasive treatments to obtain a "quick fix", scar formation may occur leading to permanent voice changes, usually for the worse which obviously happened with Julie Andrews.

What are some of these more invasive treatments beyond voice therapy? To reiterate, these procedures 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 irreversible 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.

• Steroid injection to the vocal cord nodule(s) can possibly 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. 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).

Read more about vocal cord nodules here.

Source:
Julie Andrews' Voice Isn't Coming Back, But She's Not Staying Silent. Huffington Post 12/5/12

PUBLIC LIVES; Julie Andrews Sues Throat Surgeon. NYT 12/15/99

Julie Andrews Settles Lawsuit Against Doctors. ABC News 9/7/12

Read More

Coffee Reduces Risk of Death from Oral Cancer

In a prior blog, I mentioned that researchers found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the Journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Read a CNN report on this here.

In a more recent study (Dec 2012), researchers have found that not only does coffee reduce risk of cancer, but that consuming more than four cups of caffeinated coffee per day was associated with a 49 percent lower risk of oral/pharyngeal cancer death relative to no/occasional coffee intake.

Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk as well as cancer death.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Reference:
Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev. 2010 Jul;19(7):1723-36. doi: 10.1158/1055-9965.EPI-10-0191. Epub 2010 Jun 22.

Coffee, Tea, and Fatal Oral/Pharyngeal Cancer in a Large Prospective US Cohort. American Journal of Epidemiology, 2012 DOI: 10.1093/aje/kws222

Read More

HIPAA Compliant Text Messaging (for Free)

Let's face it...

Physicians love to text message given it is fast, easy, and convenient. However, regular instant messaging (SMS, MMS) that comes with your smartphone is not secure, saved unencrypted on a server somewhere (forever), and most importantly not HIPAA or HITECH compliant.

Enter the encrypted and HIPAA compliant messaging services.

Though most of these services cost a nominal fee per month, there are a few and growing number of services which offer free and secure instant messaging. Even better, pretty much all these services including the free ones allow sending messages with unlimited characters, pictures, video, and audio along with text.

Regardless of the service, there are two elements that allow for encrypted SMS and MMS.

1) Userid and Password
2) All your secure contacts must also be using the same service (ie, they all have to sign up before using)

The best free HIPAA-compliant messaging services that's out there that I'm aware of are qliqConnect which is geared towards health professionals and Wickr which is geared towards anybody.

There are pros and cons to both.

qliqConnect is available for use on the desktop, iPad, iPhone, and Android. Wickr is available only on the iPhone (Android coming soon).

Wickr offers complete self-destruct of messages after a certain period of time (all metadata with pictures, video and audio files, like your device info, your location, and any personal information captured during the creation of those files). qliqConnect does not.

No email is required with Wickr. qliqConnect does.

Wickr also states that messages are secured using military grade encryption that exceeds HIPAA standards and unencrypted messages are NEVER stored on any server. It is unclear whether qliqConnect offers similar level of security.

Depending on your needs, one of these free services may be more suitable than the other.

Of course, the weakest link for full adoption is that everybody you want to securely message with also needs to sign up for the same service.

In the end, if I'm a betting man... Wickr will probably win out in the end, especially once they have software available for platforms beyond the iPhone.

Read More

Embedded Earrings and Treatment

A few times a month, I have a patient, usually a young child, who presents with an earring that not only can not be removed, but is embedded within the earlobe (or ear) itself.

There are two common scenarios that lead to this unfortunate situation: infection and fiddling.

Infection is fairly straightforward. For whatever reason, the piercing gets infected and the earlobe skin starts to swell around and eventually even enveloping the earring itself. To prevent an embedded earring, immediately remove the earring!!! If you wait until the swelling is too severe, it may not be possible to remove the earring at all without surgical intervention. This type of infection can occur rapidly from being normal to rip-roaring infected swelling within 24 hours.

Fiddling is basically when the patient keeps tightening the earring backing snug with the skin as tightly as possible so the earring won't loosen and potentially get lost. However, such tightening can actually induce the skin to overgrow the earring with subsequent infection. To prevent this from happening, always make sure there is some “play” that allows the earring to push back and forth through the ear and turn easily.

Now, should the earring become embedded and manual removal not possible, surgical intervention is required.

The steps are as follows:

1) Sterilize the area with betadine.
2) Inject area with lidocaine.
3) After the area becomes anesthetized, a scalpel is used to create an "X" shaped incision over the embedded earring.
4) Toothed forceps and clamps are used to grab and pull the embedded earring out.

Aftercare typically involves oral antibiotics and application of antibiotic ointment several times a day. Once the infection clears, I typically recommend waiting a few months before re-piercing to allow scar activity to completely fade first.

Also, keep in mind that they DO make earrings that are physically impossible to tighten up against the skin to reduce the possibility of embedded earrings.

On that note, we do offer ear-piercing in our office.

Read More

Actress Jennifer Aniston Underwent Septoplasty Twice

Though not entirely recent news, actress Jennifer Aniston reportedly underwent septoplasty nasal surgery not just once, but twice. The first was done in 1994 and a revision septoplasty was performed in January 2007. [link] [wiki]

This type of surgery is performed to help improve nasal breathing, an issue that Jennifer Aniston apparently had.

Septoplasty, unlike rhinoplasty or nosejob, does NOT change the outside appearance of the nose. All the work is done internally. (Watch video here).

The explanation for why the nasal appearance does not change after septoplasty is actually quite simple. The analogy would be a house where the appearance on the outside would not change even though you may knock down a wall between two rooms inside the home.

SO... Here is a side view of the septum. The blue arrow is pointing to the nostril opening and the red arrow is pointing to the lip.

In this picture below, the septum has been removed.

As you can see, the outside appearance of the nose remains unchanged as the rim of the nose is kept intact as shown by the red arrows here:

So that in a nutshell is the explanation for why deviated septum surgery does not change the outside nasal appearance.

The way the deviated septum itself is removed can be more simply understood looking at the nose from a different vantage point.

Step 1: A small incision is made inside the nose and the mucosal lining carefully lifted away from the septum on one side. It is during this stage of the procedure that one of the complications of the procedure, septal perforation, may occur. This complication occurs when the lining gets torn resulting in a hole as the mucosa is lifted away from the septum.
Step 2: The septum is incised immediately in front of the deviation and the nasal mucosal lining is lifted away from the septum on the opposite side.
Step 3: The deviated septum is now physically removed. One removes the deviated septum completely instead of forcing it into a midline position. Why? Because just like a young tree sapling, the nasal septum has "memory" and bending or forcing it into a certain position will last only temporarily before it springs back into its original position.
Step 4: The nasal mucosal lining is reapproximated in the midline. There are several methods how this last step is performed. One method is to suture the lining back together like a quilt (NO nasal packing or septal splints are used). Occasionally, the nose is packed with septal splints or nasal packing material. Both methods are used in our practice depending on the physician and the condition of the septum itself.

Read more about the septoplasty surgery here or watch a video!

Source:
The one where Jennifer Aniston Fixes Botched Surgery. PopSugar 6/7/10

Read More

Celebrity Actors Who Have Received a Trach (Catherine Zeta Jones Included)

Image Taken From www.TopScarCream.com

Tracheostomy (also known as trach) is when a hole is made in the midline neck directly into a person's windpipe (watch video). Although many people may shy away from this deforming procedure, it can be life-saving.

On that note, here is a short list of famous celebrity actors who have undergone an emergency trach for one reason or another:

Catherine Zeta-Jones
Apparently, when she was a child, she had an emergency trach done. She still has a 1.5 inch scar from this procedure which she elected to not have removed [link].

Gary Coleman
He was hospitalized for 3 months due to complications from thyroid surgery for which he underwent an emergency trach [link].

Watch video of thyroid surgery.

Elizabeth Taylor
In spring of 1961, she developed a case of pneumonia which led to an emergency trach [link].

Christopher Reeve
Of the original Superman fame, he became paralyzed from the neck down after a horse-riding accident. A tracheostomy was required for him to breath due to ventilator dependence. [link]

Read More

Brain Fluid Leakage Out the Nose (CSF Leak)

Image by Patrick Lynch from Wikipedia

Fox News published a story today (12/3/12), describing one patient's runny nose that was not due to allergies, but in fact due to brain fluid leaking through a crack in the roof of her nose. Also known as CSF leak (cerebrospinal fluid leakage), correction of this problem can be performed endoscopically through the nose without any incisions on the face.

An interesting trivia related to CSF leaks is that actor George Clooney suffered one after a blow to the head while filming a torture scene in the 2005 movie "Syriana".

Diagnosis can be obtained simply by taking some of this nasal drainage into a red-top tube and getting it tested for beta2-transferrin which is a protein found in brain fluid, but not in normal nasal secretions.

The take-home message is that not all runny noses are due to allergies, especially if it is continuous and only occurs on one side.

Of note, the Washington Post also published a similar story of a different patient with the same problem in 2010.

Source:
Woman's running nose revealed to be leaking brain fluid. Fox News 12/3/12.

Read More

57 Maggots Removed from Woman's Ear

92 years old woman with Alzheimer's was found to have 57 maggots in her ear sparking a lawsuit. Read more from media reports.

Beyond the gross factor and questions regarding how this was allowed to happen, this story does bring up some interesting teaching points and the medicinal properties of "maggot therapy".

Media reported the patient suffered from earwax build-up and had "an enlarged ear canal from surgery performed decades earlier."

This  surgery was most likely a canal-wall-down tympanomastoidectomy often performed for a benign ear tumor called cholesteatoma or a severe chronic draining ear. This surgery essentially removes all the bone from behind the ear (mastoid) and ear canal back wall. Depending on how aggressive the surgery, the eardrum and middle ear bones (malleus, stapes, and incus) may also be removed.

With such surgery, the ear canal now 2-3 times larger than before, is prone to developing earwax impaction and requires surgical debridement or removal every 4-6 months for the rest of the patient's life.

If surgical debridement is not performed regularly in such patients, infection may set in.

With such infection, ear drops can be used as described in the story, but such treatment is bound to fail until ear canal debridement of all earwax is first performed.

What I suspect is that this poor patient did not get her ear cleaned out regularly resulting in infected earwax. A fly noting the foul cesspool located in a dark, humid environment of this enlarged ear canal probably thought this the perfect place to lay eggs and allow a maggot infestation to occur.

Gross, horrid, and astounding I know...

However, medicinal maggot therapy is actually used in hospitals... Why?

Because maggots are apparently WAY better than a surgeon in certain situations at removing dead infected tissue with or without antibiotics.

It is entirely possible that given time, the maggots might have cleaned and removed the infection that was probably present in this patient's ear. However, unlike medical-grade maggots which are "sterilized" prior to use, "natural"maggots probably harbor other microbes that could cause a secondary infection.

Such medicinal maggots can be purchased for wound control with a prescription. Monarch Labs is the exclusive USA supplier of medicinal maggots which the FDA considers a "medical device."

Here is a video produced by National Geographic on maggot therapy.

Source:
92-year-old has 57 maggots removed from ear, family sues nursing home. CBS News 11/30/12

Read More

Egg Free Flu Vaccine Approved by FDA

Why the concern of egg-allergic patients with the flu vaccine used to defend against both seasonal and pandemic flu virus?

Traditionally, the flu shot vaccine (both H1N1 and seasonal) are grown inside eggs which is where this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, during vaccine production the egg protein is filtered out such that there should be no egg contaminants in the final vaccine. However, it is theoretically possible that some egg may still be present in the vaccine.

Although there is an infinitesimal possibility of egg contaminants, studies have shown that even patients with life-threatening egg allergy can still safely have the flu vaccine.

In spite of these reassurances, there are still concerns from patients and healthcare professionals.

As such, there is now a new FDA-approved flu vaccine called Flucelvax which is guaranteed to be egg-free. Rather than being cultured in eggs, this vaccine is cultured in mammalian cells.

Downside is that latex-allergic patients are unable to safely receive this vaccine.

Made by Novartis, this vaccine is approved for use in people 18 years and older.

For more info.

Source:
FDA approves first seasonal influenza vaccine manufactured using cell culture technology. FDA 11/20/12

Read More

Is Patient Abandonment in the Operating Room Ever Justified?

I ask this question mainly because there WAS an ENT who WAS sued for NOT abandoning his patient in the operating room [link]. No way to verify, but additional details can be found in this facebook post.

Imagine this hypothetical scenario (as details from original case are not available)...

You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated.

Suddenly, you get a phone call from the emergency room regarding a patient with progressive difficulty breathing suspected to have epiglottitis.

What do you do if you are the only ENT in the hospital?

Do you "abandon" the 12 years old child in the operating room, still bleeding, still under general anesthesia and attend to the ER patient who himself might die without an emergency tracheostomy? Doing an evaluation to determine how critical the ER patient may take anywhere from 15 - 60 minutes including the tracheostomy itself. Keep in mind that 99% of the time, a tracheostomy is NOT necessary.

And, if a tracheostomy WAS needed, you are now performing two different surgeries in two different rooms simultaneously which must break some rule somewhere... perhaps JCAHO?

Or, would you finish the surgical case first, and than proceed to see the ER patient?

What if you are the only ENT available in the region let alone the hospital? No fellow ENT colleagues to call upon for help. General surgery is "unavailable" or not comfortable with performing tracheostomies especially given ENT performs all tracheostomies in the hospital?

Patient abandonment is defined as:

• Failing to transfer a patient to an appropriate level of care
• Failing to respond to calls from a hospital regarding a patient
• Refusing to care for a patient after arranging the patient's admission
• Failing to treat a patient until new coverage is arranged

Proving patient abandonment includes:

• Your doctor had a duty to treat you - a duty was created when the physician-patient relationship was established
• You had a reasonable expectation that your doctor would treat you
• Your doctor failed to treat you although he or she was obligated to do so
• You suffered injury as a result

Well, according to one lawsuit, it seems that the ENT was required to abandon his patient in the operating room and attend to the ER patient. The lawsuit stemmed from the fact that the ENT did not abandon his patient in the operating room and the ER patient did die as a result of not being attended to quickly and competent emergency tracheostomy performed. Of course, the settled lawsuit also blamed the hospital, general surgery, and anesthesiology.

However, abandoning a patient on the operating room table is also tantamount to medical malpractice according to the very definition of patient abandonment.

And, I would not be surprised if the patient on the operating room table would have sued the ENT if he DID leave the operating room in the middle of surgery to attend to another patient for a long period of time (and even starting another operation without ever finishing the abandoned patient's surgery first).

What to do?

I have no answer...

Doing an emergency tracheostomy is HARD, even for someone who has performed hundreds of elective tracheostomies. I know... I've done perhaps a half-dozen emergency trachs in my career so far. In this particular lawsuit, I found it incredible that a hospitalist (not a surgeon) was the one who finally attempted the emergency tracheostomy (albeit unsuccessfully).

Do you consider the patient you are CURRENTLY caring for has a higher priority than a patient you have never met, even if possible life-threatening illness is involved? (Keep in mind that when called for an airway problem, that 99% of the time, an emergency tracheostomy is not needed.)

OR, do you prioritize the patient you have never met given the possible life-and-death circumstances involved, even if 99% of the time, no surgical airway is required.

What would YOU do? What should you do? Feel free to comment below!

The way I see it, the ENT would have been sued no matter what decision was made. It would have been a lose-lose and lose proposition.

By deciding to stay with his current patient, the ENT was sued by the ER patient's family. If the ENT left his current patient on the operating room table, the ENT would have been sued for abandonment. If the ENT did abandon the current patient and the ER patient still died in spite of an emergency tracheostomy, the ENT would probably be sued for wrongful death by the ER patient's family AND the patient he abandoned on the operating room table.

Source:

Hospital settles wrongful death lawsuit. Curry Coastal Pilot 10/31/12

ADDENDUM 12/5/12:
Information obtained from an anonymous source reported that the ENT who was sued ultimately had charges dismissed with prejudice. It was maintained from the beginning that the ENT's obligation was to the patient on the table and that there was no doctor-patient relationship with the deceased.

I also find it interesting that the hospital where the lawsuit occurred, now does not even have ENT coverage at all. I guess that's what happens when a lawsuit occurs when there's only solo specialist coverage. I'm predicting that this hospital will have a very difficult time to recruit another ENT to work there given this case even though the ENT was ultimately found blameless.

Read More

Actor Larry Hagman Dies of Throat Cancer

Image by Toglenn from Wikipedia

Today, on November 24, 2013, media has reported that actor Larry Hagman died of complications related to his throat cancer at the age of 81. It is unclear exactly where the throat cancer was localized to (tongue, tonsil, supraglottis, hypopharynx, oropharynx, etc).

Larry Hagman is a well-known actor playing oil baron J.R. Ewing in the soap opera Dallas (1980s as well as 2012) as well as Major Nelson in  the TV sitcom I Dream of Jeannie. Most impressive was the fact that he continued to act while undergoing cancer treatment for the Dallas remake.

In June 2011, Mr. Hagman was diagnosed with stage 2 throat cancer. After treatment with radiation and chemotherapy, on Aug 29, 2012, media reported that the actor was "cancer free."

Sadly, such media reports of "cure" or "cancer free" were way premature and actually misleading given his death merely 2 months later.

I reported in my blog on Aug 30, 2012 that there's no such thing as "cure" or being "cancer free" when it comes to throat cancer, especially right after cancer treatment.

One can use words like "shrunk", "excellent response", or even "no clear evidence for cancer at this time", but terms like "cure" or "cancer free" should never be used.

Throat cancer, especially stage 2, has the potential to come back, even if there's no perceptible signs of it after treatment. There is ALWAYS the possibility of cancer coming back in the future.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Given the high risk of cancer recurrence, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Sources:
Larry Hagman is cancer-free. SFGate 8/29/12

Larry Hagman. Wikipedia

Larry Hagman dead at 81, portrayed notorious TV villain J.R. Ewing. Yahoo News 11/24/12.

Read More

ENT Surgeon Sues Spine Surgeon for Wrong Sided Surgery

Wrong sided surgery is extremely rare occurring anywhere from 0.09 to 4.5 per 10,000 surgeries performed.

It is almost unheard of when the patient is a surgeon as well.

On Nov 13, 2012, media reported that an ENT surgeon (plaintiff) sued his spine surgeon (defendant) over wrong-sided surgery.

The ENT surgeon had spine surgery in 2011 for low back pain which was allegedly due to pinched nerves. The treatment called for laminectomy surgery on the right side which entails bone removal to prevent the nerves from being pinched further thereby alleviating pain.

However, the ENT surgeon claims wrong-sided surgery in that left back surgery was performed rather than the right side. The spine surgeon claims he performed a left-sided approach to the right side.

Here's a video news report which includes radiological images that does appear to show bone removal on only the left side (rather than the correct right side).



Although it may seem like an open and shut case of malpractice for wrong-sided surgery, as in most cases of medicine, it is not that straightforward.

Given I'm not a spine surgeon, I asked my good colleague Dr. Jeffrey Wise who is a spine surgeon with Blueridge Orthopedic and Spine Center to comment further in this particular case.

After review of available publicized information, Dr. Wise felt that there were several possible explanations of what may be going on:

1. It was truly wrong-sided surgery that the spine surgeon is trying to cover up.
2. The correct surgery WAS done utilizing an opposite side technique.
3. It may be lack of informed consent on the part of the spine surgeon (the approach was not explained clearly to the patient).
4. The ENT surgeon may have misinterpreted the informed consent and not understood the procedure.
5. The correct procedure was done and the ENT surgeon did not have the result he was hoping for or he may have wanted to be disabled for secondary gain.

Some facts...  It is possible to do right-sided back surgery via a left-sided approach as illustrated in the textbook diagram shown in the video with the tubular retractors.

In fact, it is indeed easier to decompress the lateral recess and exiting nerve root of the spine from the opposite side via the open approach. The surgery can also be done via a minimally invasive approach (as in this case), but it is not considered standard approach of most spine surgeons who would usually use the tubular system and go on the same right side for a unilateral decompression.

On another note, the decision on the necessity for spine surgery is interesting because in the pre- and post-axial MRI pictures shown in the video, while there is clearly a spine defect on the left, the pre-op picture does not show any pathology that suggests surgery was even needed. Perhaps there are more images that do show the nerve compression better, but they are certainly not shown in this article.

From a legal standpoint, it would be possible to prove or disprove that wrong-sided surgery was done if there is clearly bone removal visualized from the right side (presuming spinal stenosis was the diagnosis for which surgery was performed) or a disc herniation was no longer visible (if a disc herniation was the problem). This scenario would favor the neurosurgeon.

However, if the bone on the right side (or disc herniation) was still present, that would favor the ENT surgeon.

Unfortunately, based on the limited publicized images shown, it is impossible to clearly tell from the images shown or information provided in the article. Again, the images shown do not show a surgically justifiable lesion to begin with and only show bone removal from the left spine.

- Dr. Jeffrey Wise

Source:
INVESTIGATION: Surgeon v. Surgeon in wrong-side surgery case KFOR.com 11/13/12

References:
Avoiding wrong site surgery: a systematic review. Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S28-36.

Read More

Taste Changes after Tonsillectomy

Very rarely, patients will complain of taste changes after tonsillectomy. Such taste changes (aka dysgeusia) is most often described as metallic though other taste variations or absences may be reported.

Depending on what study you look at, this complaint occurs anywhere from 0.3% to as high as 9% of tonsillectomy cases. Dysgeusia after tonsillectomy is felt to be due to a number of different causes including:

1) medication side effect
2) injury to the lingual branch of the glossopharyngeal nerve
3) zinc deficiency

Regardless of the etiology, most cases of post-tonsillectomy dysgeusia spontaneously resolves within a few months without any specific intervention.

However, there are a few things a patient can try that might help accelerate normal taste recovery including:

1) Stopping all unnecessary medications
2) Zinc gluconate 50mg 3 times per day
3) Alpha Lipoic Acid 200mg 3 times per day
4) Rinsing mouth with watered down milk-of-magnesia
5) Chewing non-mint flavored gum

I did want to point out that there are no comprehensive studies to support any of these interventions. But, it certainly can't hurt to try it.

References:
Taste disturbance after tonsillectomy. Acta Otolaryngol Suppl. 2002;(546):164-72.

Taste disorders after tonsillectomy: case report and literature review. Ann Otol Rhinol Laryngol. 2005 Mar;114(3):233-6.

Posttonsillectomy taste distortion: a significant complication. Laryngoscope. 2004 Jul;114(7):1206-13.

Taste disturbance after tonsillectomy and laryngomicrosurgery. Auris Nasus Larynx. 2005 Dec;32(4):381-6. Epub 2005 Jul 19.

Read More

Problem with Medical Protocols (and Lawsuits Because of Them)

Over the past decade working in hospitals, I've seen the proliferation of "established procedures and protocols" for literally everything under the sun...

• Chest Pain Protocol
• Discharge Protocol
• Pneumonia Protocol
• Stroke Protocol
etc, etc, etc

Protocols are essentially standing orders that are supposed to be implemented whenever a given medical situation occurs. It is supposed to follow best evidence-based practices and make it easy for healthcare personnel know what to do without thinking to hard (akin to a checklist a pilot performs before flying to ensure they did not forget something).

The problem with protocols are that it can be made so detailed as to become worthlessly bloated. To use an analogy, take the protocol, "Going Shopping Protocol."

Protocol A (Simple):
1) Make grocery list
2) Drive to supermarket
3) Pickup and purchase items on grocery list
4) Come back home

Protocol B (Detailed):
1) Pickup #2 pencil
2) Sharpen pencil to appropriate point using pencil sharpener model 15-231
3) Test pencil to ensure proper writing ability
4) Obtain 3x4 inch index card
5) Write shopping item #1 on index card using pencil (from steps #1-3)
etc, etc, etc

Now when dealing with something as complex as medicine, protocols can be a godsend or hopeless depending on how it is written and who uses it.

And, that's where protocols become problematic.

Make a protocol too detailed, and it becomes bloated to the point of being useless, especially when dealing with time-sensitive medical problems.

Take for example something as simple as "Chest Pain Protocol." Orders for EKG, aspirin, IV fluids, sublingual nitroglycerin, and morphine seem obvious (assumption being heart attack), but what if we are dealing with a 10 years old child who got punched in the stomach by a bully? What about a stabbing into the chest?

Does that mean there needs to be multiple branch-points explicitly addressed in the protocol to handle every single possible scenario of chest pain under the sun at any age for every possible scenario?

Clearly, the answer is "NO"!

So protocols are made with several assumptions:

1)  A general level of medical competence of healthcare professionals
2 ) Healthcare professionals are already familiar with a given protocol and knows when to appropriately activate it
3) Protocols are deliberately made to be not too specific as it is understood that there is variability in the care of patients. Protocols can not and should not be applied cookie cutter to every patient as there are nuances that the protocol leaves to the judgement of the doctor.

Unfortunately, by making protocols to generalized, it does open up the possibility of lawsuits.

Take an ongoing case in Georgia where the medical director of an emergency room is being sued for professional negligence in the death of a woman from a heart attack... because of a chest pain protocol he wrote. Note that this medical director NEVER provided any direct medical care, did not have an established patient-physician relationship, and was not even in the hospital when the woman came into the ER. [link]

So is the solution to avoid having any protocols in place to avoid lawsuits? Sorry... NOT having a protocol in place can also be subject to a lawsuit. In 2000, a hospital was sued for either failing to follow established anesthesia procedures or protocols or failing to have any established procedures or protocols in place. [link]

So what to do?

Well, getting sued is a risk that is inherent to the medical field, especially whenever there is a bad outcome.

As such, the default action taken by physicians and hospital administrators are to minimize or spread the risk. How?

• Have as many different physicians write-up a given protocol that is signed off by everybody (spreading the risk)
• Avoid positions of responsibility (default scapegoat for lawsuits)
• Involve many physicians in the care of a patient (spreading or transferring the risk)
• Have protocols, but do not depend on them (clinical judgement trumps protocol).
• Have MANY documented training sessions on how protocols are to be used and discuss weaknesses and strengths of them

References:
UPSON COUNTY HOSP., INC. v. HEAD 540 S.E.2d 626 (2000) 246 Ga. App. 386 UPSON COUNTY HOSPITAL, INC. v. HEAD. No. A00A1601. Court of Appeals of Georgia. October 13, 2000.

Gaulden v. Green, No. A12A1872 (Ga. Ct. App. Oct. 30, 2012)

Read More