Why Does My Voice Sound Different on Recording and Treatment Options

Every so often, I have a patient who presents to my office with a complaint that their voice sounds different on recording than what they themselves hear.

In particular, singers who come in state specifically that their vocal recordings sounds slightly flat when they thought they were singing in perfect pitch.

So why does this happen? Unfortunately, it is physics and fundamentally integrated to how the ear, skull, and sound transmission work. In other words, it can't be "treated" with surgery or medications.

What other people hear when you sing or talk is air conducted sound that gets transmitted through the ear canal, eardrum, middle ear bones, and ultimately to the cochlea hearing organ (pathway A).

Image by Chittka and Brockmann Modified from Wikipedia

The sound the individual singer/talker hears is not only sound transmitted via the air (pathway A) but also by vibration of the skull itself directly to the cochlea hearing organ bypassing the outer and middle ear completely (pathway B). The mechanical properties of the skull enhance the deeper, lower-frequency vibrations.

Therefore, when a talker/singer listens to a recording of their voice speaking/singing, the bone-conducted pathway that they consider part of their “normal” voice is eliminated, and they hear only the air-conducted component in unfamiliar isolation (what everybody else actually hears).

SO... what is a singer/talker to do if they are disturbed by the way they sound to others? Particularly, what is a singer to do when they always sing a little flat when they truly think they are singing in pitch?

One can wear earplugs in order to hear only bone-conducted vibrations and get used to their alter-voice and undergo speech/voice therapy. OR... accept that their voice IS different.

For singers, I highly recommend using HearFones Headsetwhich is a funny looking head device that allows an individual singer to hear what they really sound like and more importantly what the audience would hear! In addition, while using HearFones, the singer would be able to hear himself more predominantly over the rest of the ensemble thus helping him to improve the quality of his/her individual vocal quality output.

Over time, singers will be able to automatically adjust their singing such that they no longer will need such a device to sing in tune with others when in familiar surroundings. BUT... in new environments (new concert hall, outdoor arena, etc), it is not unusual that their singing may become off again...

This is why professional singers often wear earpieces that convey sounds recorded by microphones placed in the audience... and also why they sometimes sound flat and out-of-tune when they don't!

It's also why it is VERY important to rehearse in a new place before a concert.

On a related note, most individuals state that they do not "like" they way they sound on a recording. However, according to one study, people unconsciously prefer their recorded voice over others.

Of note Dr. Chang was mentioned on NBC news regarding this question in this story.

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Kissing the Ear Can Cause Permanent Hearing Loss

MSNBC reported 3/29/12 about a phenomenon called cochlear ear-kiss injury. This condition is when hearing loss occurs after a person kisses someone else over the ear, usually a mom over a baby's or child's ear.

Right after the kiss, a person can suffer from immediate and potentially permanent hearing loss along with other symptoms including ringing, sensitivity to sound, sound distortion, and aural fullness.

How or why does this occur?

With a kiss, a strong suction is created within the ear canal that pulls on the eardrum which tugs on the middle ear bones that can lead to turbulence within the inner ear.

Infants are particularly susceptible to this condition given their ear canals are SO small and the suction created by an adult kiss over the ear can be so strong.

There are other variations of this type of ear/hearing injury.

Barotrauma of the ear can lead to similar type issues due to sudden pressure changes from flying, parachute jumping, diving into water, SCUBA, snorkeling, etc.

Getting slapped over the ear can do the same thing as cochlear ear-kiss injury, but in reverse. Rather than suction from a kiss creating strong negative pressure within the ear canal, a slap over the ear creates sudden strong positive pressure.

At times, such pressure changes can get so severe that the eardrum can rupture.

Source:
Innocent 'kiss of deaf' can cause permanent hearing loss. MSNBC 3/29/12

The kiss of deaf: Four-year-old's big smooch left her mom with partial hearing loss. Newsday. June 7, 2008

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Strong Sneeze Broke Woman's Neck

Fox News reported yesterday about an Australian woman, Monique Jeffrey, who sneezed SO hard that she broke her neck... literally.

According to the neurosurgeon the patient eventually saw, her C1 and C2 vertebrae had dislocated and were displaced which resulted in her symptoms of excruciating pain with her head locked to her right shoulder and in too much pain to move anything but her right arm. Her left arm was also numb with tingling.

She was placed in a halo traction for three months with weights to gradually move the vertebrae back in alignment.

Source:
Super-strong sneeze puts mom in traction for three months. Fox News 3/27/12

Melbourne mum dislocates neck by sneezing. 9 News Melbourne. 3/27/12

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FDA Approves New "Dry" Steroid Nasal Spray

On March 26, 2012, the FDA approved of a new type of steroid nasal spray in the treatment of nasal allergies that puffs powder into the nose rather than a liquid. Liquid formulations such as nasonex, flonase, veramyst, nasacort, and rhinocort has been until now the only delivery medium of administration.

This new spray made by Teva Pharmaceuticals is called QNASL which puffs a steroid beclomethasone dipropionate. For those who know pharmaceuticals, it is the same active ingredient as (liquid) beconase nasal spray.

Just like the other nasal sprays, administration is 2 puffs (sprays) in each nares daily.

This spray does pretty much the same thing (and has similar side effects) as the other established nasal sprays. However, QNASL may be better tolerated in those patients who HATE the drip down the back of the nose after liquid nasal spray use.

Drug should be available for prescription starting in April 2012.

Source:
Teva Announces FDA Approval of QNASLTM (beclomethasone dipropionate), a New Nonaqueous Nasal Aerosol, for the Treatment of Allergic Rhinitis. Teva Pharma 3/26/12

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How is a Hole in the Eardrum Repaired?

If a hole in the eardrum does not heal closed and a decision has been made to pursue repairing a hole in the eardrum (also known as tympanic membrane perforation), it is not uncommon for patients to get confused among the different surgical techniques used to fix it.

There are 3 major "flavors" of eardrum hole repair. 

• Paper patch: Paper patch technique involves putting a thin membrane (film paper, gelfoam, etc) OVER the eardrum hole.
• Medial or Underlay Tympanoplasty: In the underlay technique (also known as medial tympanoplasty), patient's own tissue (temporalis fascia) is used as a graft to reconstruct the eardrum by laying it UNDER the eardrum and ear canal wall skin.
• Lateral or Overlay Tympanoplasty: In the overlay technique (also known as lateral tympanoplasty), patient's own tissue (temporalis fascia) is used as a graft to reconstruct the eardrum by laying it OVER the eardrum extending from placement UNDER the ear canal wall skin.

Technically, the paper patch is easiest to perform and the overlay tympanoplasty the most technically difficult to perform.

There is a fourth type you can read about here.

SO... here's what a normal ear looks like (image by Chittka and Brockmann modified from Wikipedia):

Here's a hole in the eardrum:

Paper patch technique (graft shown as a purple strip). Note the paper patch is laying OVER the ear canal skin and eardrum.

Medial or Underlay Tympanoplasty: Note the graft is laying UNDER the ear canal skin and eardrum.

Lateral or Overlay Tympanoplasty: Note the graft is laying UNDER the ear canal skin and OVER the eardrum.

Read more about eardrum holes and a fourth type of repair here.

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FDA Approves New Surgical Reflux Treatment

On March 22, 2012, the FDA approved the LINX Reflux Management System to treat gastroesophageal reflux disease (GERD). Developed by Torax Medical, the

"LINX system is composed of a series of titanium beads, each with a magnetic core, connected together with independent titanium wires to form a ring shape like a bracelet of beads. It is implanted at the lower esophageal sphincter (LES), a circular band of muscle that closes the last few centimeters of the esophagus and prevents the backward flow of stomach contents. The force of the magnetic beads is designed to provide additional strength to keep a weak LES closed. Upon swallowing, the magnetic force between the beads is overcome by the higher pressures of swallowing forces, and the device expands to accommodate a normal swallow of food or liquid. Once the food passes though the LES, the device returns to its resting state."

Traditionally, surgical management of reflux entailed a stomach wrap called Nissen Fundoplication which is analogous to cinching a belt and is currently the gold standard. Trans-oral incisionless fundoplication is a newer approach to the Nissen fundoplication and is in essence an "internal" stomach wrap.

It is only a matter of time to see whether this new LINX system is as effective if not more effective than fundoplication over a long period of time or whether it will go the way of the Dodo bird.

An immediate disadvantage of this system... Patients can never undergo a MRI scan in the future (LINX uses magnetic beads... MRI which utilizes a strong magnet... Visualization of beads being yanked out of the human body in a MRI machine...)

Reference:
FDA approves LINX Reflux Management System to treat gastroesophageal reflux disease. FDA 3/22/12

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Celebrity Chef Grant Achatz With Stage 4 Tongue Cancer

Chicago news recently published a story about their very own celebrity chef Grant Achatz who suffered from Stage 4B squamous cell carcinoma of the tongue.

Grant Achatz, chef and co-owner of Alinea/Next/Aviary, approached multiple physicians throughout the country who essentially told him the oral cancer was terminal. In the end, he underwent treatment at University of Chicago successfully, though he certainly is not out of the woods yet.

There are several approaches in the treatment of tongue cancer, especially one as advanced as Mr. Achatz's, each with its own advantages and disadvantages.

In one approach is surgery first to remove all visible disease followed by radiation and chemotherapy to get rid of microscopic tumor cells. Surgery is huge... it entails removal of most of the tongue, involved jawbone, and removal of lymph nodes in the neck (neck dissection). Given how much tissue is removed, reconstruction of the defect is typically performed using bone, skin, and muscle typically taken from the arm (radial forearm free flap). Given how massive the surgery is, a tracheostomy as well as stomach feeding tube is placed. Hospitalization is typically 1-2 weeks long.

An alternative approach is surgery second. Radiation and chemotherapy is done first to shrink the tumor. Once this course is completed, surgery is performed to remove residual disease. The amount of surgery depends on the degree of residual cancer that is left. This course of action is what Mr. Achatz chose to pursue.

Regardless of what step is pursued, there are lots of side effects from cancer treatment including:

• loss/alteration in taste and smell
• dry mouth
• difficulty with swallowing
• stiff neck
• poor teeth (often they get removed prior to cancer treatment)
• leathery skin

Unfortunately, cancer being cancer, risk of recurrence is VERY high especially for stage 4 tongue cancer no matter how well the initial response appears to be. Regularly monitoring over the next 5 years is absolutely essential starting with an exam every 2-3 months for the first two years as that's when the risk of cancer recurrence is highest.

Source:

Celebrated chef gives back. WGN 3/22/12

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Recipe How to Make Snot Boogers

British researchers are at it again!

The British Society for Immunology have developed a recipe to make your very own authentic-appearing snot of various colors of tan thru green.

Of course, you can make your own the natural way, but here's a more sanitary way with kitchen supplies.

You need:

• 1 tbsp Gelatine powder
• 1 tbsp Hot water
• 2 tbsp Sugar syrup (corn syrup or golden syrup)
• Food colouring
• A plastic container/bag
• Paint brush or dropper

To make your own snot:

1) In a container, mix the gelatine and hot water together, stir quickly until the gelatin dissolves.

2) Using a paint brush or dropper add a very small amount of food colouring.

3) Add the sugar syrup and mix until it goes stringy and snot like.

4) Enjoy!

Keep your snot in the fridge or you might find something growing on it!

Source:
THE SECRET LIFE OF SNOT. British Society of Immunology.

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Government Sponsored Studies Not Getting Published

Yale researchers published a study on whether NIH-funded studies get published after research completion.

The researchers examined all clinical trials after Sept 30, 2005 funded by NIH and registered within ClinicalTrials.gov maintained by the US National Library of Medicine.

Shockingly, among 635 clinical trials completed by 31 December 2008, only 46% (294 studies) were published in a peer reviewed biomedical journal within 30 months of trial completion. The median period of follow-up after trial completion was 51 months (25th-75th centiles 40-68 months) and 68% (432) were published overall.

Why aren't more of these completed studies being published???

It was already known that industry-sponsored studies had only a 40% publication rate. One can rationalize that such pharmaceutical-sponsored studies that do not reveal promising results do not get green-lighted for publication, but such a bias should not technically occur with government sponsored trials.

However, it just may be that there may be political pressure that may influence whether one study gets published and another does not (much like what has happened with climate research which allegedly has gotten smothered by unfriendly political forces).

It is also possible that researchers just do not prioritize publishing being more interested in doing the research and not so much the writing up of their results... OR their research findings have gotten rejected by journals for publication.

OR... maybe the unpublished studies are just THAT bad such that the research is literally unpublishable... which I find hard to believe given getting NIH grants to do the research is difficult and highly competitive.

In any case, there MUST be more effort to publish research findings for many reasons, key among them being:

1) Even if the study shows no results, that in itself is meaningful (if a drug did not work, than everyone should know that)

2) Duplicate studies would not occur which one can argue would be wasteful. Why reinvent the wheel when it already has been done? (there is a role for repeating studies, but should be done in a setting of being AWARE of repeating the research)


Reference:
Publication of NIH funded trials registered in ClinicalTrials.gov: cross sectional analysis. BMJ. 2012 Jan 3;344:d7292. doi: 10.1136/bmj.d7292.

Publish or... Don't. Yale Alumni Magazine. Page 32. March/April 2012.

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Tongue Taste Map is a LIE!

As children, we all learned about the 4 different taste qualities the human tongue can appreciate: salty, sugar, bitter, and sour. Savory or umami was added in 1985. "Calcium" has been proposed in 2008 as well as more recently, "fatty" taste.

Along with the 5 (and possibly more) taste qualities we all had to memorize at some point, we also had to memorize the taste map of the tongue (yes... I know umami is missing):

Well... what a waste of time to memorize the tongue taste map because it is wrong!!! This tongue taste map was originally sketched by Edwin Boring in 1942 and has since been frequently reproduced in textbooks, wine classes, and biology courses.

The tongue taste map delineates specific areas where certain taste qualities are perceived better than in other areas like the state of Texas is distinctly a different region than Montana.

However, reality is a mish-mash patchwork spread unevenly throughout the tongue that is different for each person.

Each of the ~5000 taste buds found on the surface of the tongue contain clusters of over 100 taste cells with receptors that have different degrees of sensitivity to molecules carrying MORE than one basic taste and that these clusters are distributed across the entire surface of the tongue.

Bottom line?

Tongue taste map is a lie.


Reference:
The cell biology of taste. JCB vol. 190 no. 3 285-296, doi: 10.1083/jcb.201003144

Receptor seeks ligand: on the way to cloning the molecular receptors for sweet and bitter taste. Nat. Med. 5:381–382. doi:10.1038/7377

A Map of Taste. NYT 3/19/12

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How Many Infections in a Child is "Normal" Per Year?

Kids get a lot of infections... but at what point should a parent be concerned on how often these infections occur, particularly upper respiratory infections?

A German study went about to determine the answer to just that question... They prospectively followed 760 children born in 1990 and followed them for 12 years. Parents recorded the child’s illnesses in a diary and answered structured questions yearly up to age 12.

This is what they found... The mean number of infections per year for each age group (standard deviation):

• 0-2 years: 3.4 episodes (3.7) per year
• 3-5 years: 2.3 episodes (2.6) per year
• 6-12 years: 1.1 episodes (1.2) per year

Two standard deviations above the mean can be still considered within normal limits, though on the high side of normal:

• 0-2 years: 11 episodes per year

• 3-5 years: 8 episodes per year

• 6-12 years: 4 episodes per year

If a child gets more than this number of infections per year, one may need to consider possible immunodeficiency.

Source:

History of respiratory infections in the first 12 yr among children from a birth cohort. Pediatric Allergy and Immunology. Volume 19, Issue 6, pages 505–512, September 2008.

How many respiratory infections in children are "normal" per year? Allergy Notes by Dr. Ves.

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TV Show SMASH Portrays Ivy With Vocal Issues

In last night's episode (Episode 106: Chemistry) of the new hit TV drama SMASH, the main character Ivy who plays Marilyn Monroe in the show developed laryngitis that affected her ability to sing clearly, especially in the high registers. However, her speaking voice did sound normal.

To treat this condition, she was given prednisone which did help her voice, but suffered unfortunate side effects of mood lability, hallucinations, insomnia, etc.

Did the show accurately portray what actually happens in real life?

Yes...

Laryngitis

Ivy probably did suffer laryngitis, but more in the sense of pre-nodule formation (otherwise known as vocal cord swelling) from vocal overuse given how much singing she has been doing. With such "pre-nodule" formation, the singer is able to sound perfectly normal when talking, but suffers from pitch breaks and onset delays in the high range, especially when singing quietly. Watch a video and audio demonstrating this phenomenon.

I should also point out that this problem is also under-recognized by medical professionals including ENTs... When such singer/patients with vocal cord swelling present complaining of hoarseness, they sound normal... talk normal... and for all intensive purposes seem to be making up their perceived raspy voice.

A simple test to demonstrate vocal cord swelling is to have the singer sing a song at a high pitch (octave above middle C), but to sing the song very quietly. I typically have patients sing Happy Birthday. Listen for any vocal quality problems.

Even though the vocal issue is only in the high range, for professional (and amateur) singers, such "minor" vocal raspiness is a HUGE problem. Consider this... if this patient is singing a solo for a performance where there's several hundred people in the audience... it's hard enough to sing a solo just from nervousness. Now add the concern that you have no idea what your voice is going to do in that one part of the song where it goes high. Confidence is key to a good performance and with an undependable voice, confidence is lost and the performance overall suffers.

Prednisone

Is prednisone really as good as the show suggests? Yes... including the side effects, though they did stretch the side effects some.

Typically steroids provide almost immediate (within 4-12 hours) resolution of vocal cord swelling and inflammation. Problem is, it only works for a short period of time.

I typically prescribe decadron rather than prednisone as I feel it works faster, better, and more reliably than prednisone. I also prescribe it judiciously.

Judiciously means I prescribe it if there's a single major concert or single audition that is very important to the singer. I typically prescribe a single large dose to be taken the night before.

If it is a singer who is undergoing a series of auditions over a short period of time, I may prescribe a week long course of steroids to maintain its good effects.

The USUAL common side effects are reflux, insomnia, mood lability, and jitteriness. However, for those who are sensitive to medications can suffer many of the side effects experienced by Ivy.

NOW... for the problem with steroids beyond the side effects... Its effects are temporary and the better way of treating vocal cord swelling is behavioral changes as one can't just keep prescribing steroids indefinitely. It is much like giving morphine to a football player to mask the pain of a sprained ankle so he can still keep playing football. MORE vocal injury can occur while taking the steroids!

With steroids, I usually also recommend restricted voice use (strict voice use is even better). What this means is talk ONLY when you MUST talk and with low energy if you do. NO social talking, no whispering, no yelling, no raising voice, etc. Strict voice rest is when you are not even talking at all.

Also, work with a singing voice therapist.

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Singer John Mayer Has Recurrence of Vocal Cord Granuloma

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.

On Oct 20, 2011, he underwent surgery to remove the granuloma and was on strict voice rest for several weeks with plans to resume live singing in the first quarter of 2012.

Unfortunately, on March 9, 2012, it was found that his vocal cord granuloma has recurred in the same location. In a statement he publicly released:

"Because of this, I have no choice but to take an indefinite break from live performing. Though there will be a day when all of this will be behind me, it will sideline me for a longer period of time than I care to have you count down."

 Is this unusual that his vocal cord granuloma recurred?

Unfortunately, it is not...

Vocal cord granulomas are benign masses that commonly are due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining. An imprecise analogy of what a granuloma is would be a keloid of the skin. Unfortunately, such repetitive mild vocal trauma includes talking/singing, hence the high risk of recurrence. The key to treatment is to allow the granuloma site to heal COMPLETELY prior to any further phonotrauma (ie, talking/singing).

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential. 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. Laser and mitomycin C application has also been found to be helpful.

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

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended. Strict voice rest is preferred if possible.

2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology

3) Follow-up with steroid injections to the granuloma site. Watch video below.

4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

5) Re-excision may be required at which time mitomycin C application can be tried.

Read more about voicebox granulomas.

Source:

John Mayer's Granuloma Returns, Singer Taking "Indefinite Break From Live Perfoming". E Online 3/9/12

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Best Drops for Earwax Removal

It's about time, but some researchers actually put to the test to try and determine what is the best solution to dissolve/remove earwax.

The verdict was... WATER!

Better than mineral oil, liquid colace, and over-the-counter cerumenolytics (ie cerumol). Hydrogen peroxide was not evaluated.

How was this result determined?

Using guinea pigs, the researchers first tested whether each of these substances were safe should a hole in the eardrum be present allowing for the solution to enter the middle ear space. Colace was found to be the most ototoxic (meaning, potential for permanent hearing loss if a ear tube or a hole in the eardrum is present). Mineral oil and saltwater (normal saline) was found not to be toxic.

Next, they determined which substance provided the greatest degree of cerumen dissolving ability. Each substance was added to a cylinder filled with earwax for 5 minutes. They than determined how much weight was required for a 25G needle to fully penetrate through the earwax.

Water was found to provide far superior earwax dissolving ability compared to all other substances tested. Not surprising given water is considered the best universal solvent used to clean everything from dishes to cars to buildings.

What is the take-home message?

Given saltwater/water is completely safe for hearing even if there is a hole in the eardrum along with superior earwax dissolving ability, it seems to be a no-brainer to instruct patients with lots of earwax to use salt-water to get rid of earwax.

Reference:
Ototoxicity of intratympanic docusate sodium and mineral oil in the Guinea pig. Otolaryngol Head Neck Surg. 2012 Mar;146(3):455-60. Epub 2011 Nov 18.

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How to Make Sudafed from Meth

Given the increasing difficulty in obtaining "over-the-counter" sudafed (pseudoephedrine) to the point where it is easier to obtain the illegal drug methylamphetamine, a chemist has written a paper describing how to make sudafed from meth using reagants found in any well-stocked chemistry lab.

For those who have been living in a hole, sudafed is a good nasal decongestant medication often used for nasal congestion and allergies that is now only found behind the pharmacy counter and dispensed in limited quantities with a record kept of who has purchased. Why?

Because one can make methylamphetamine (meth) from it.

Well, with all the chronic drug shortages, it's a good thing we now have a way to make sudafed from meth.

Read the process here.

First reported in Scientific American.

(this blog article is partly in jest... partly not).

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If Computer Security Experts are Getting Hacked, Why are Hospitals/Doctors Expected to be Better?

As anyone knows from reading the newspaper recently, major computer security firms like RSA and Verisign have been hacked. Even the pentagon!

If companies that specialize in computer security get hacked, why are hospitals and doctors who do NOT specialize in computer security held to an even higher standard?

Criminal penalties against healthcare professionals and organizations are steep for computer data breaches at $100 per record with criminal penalties that can include fines of $250,000 and 10 years in prison.

Given such steep penalties, the assumption is that hospitals and physicians must be experts in computer and network security... even better than companies that specialize in this subject area... or can purchase one.

So who should healthcare organizations hire to secure their computers to avoid getting hacked as I can certainly tell you, they are most certainly not security experts?

Google? Symantec? RSA? Verisign? The pentagon?

They've all been hacked successfully... As such, how can we trust their security products?

The answer is simple... There is no company that can be contracted to provide bulletproof security.

The only way is to NOT use a computer at all!

So here's the interesting quandary...

The government is mandating hospital and physicians to transition to electronic medical records or start facing penalties for not doing so.

BUT, the electronic medical records must have bulletproof security or else criminal penalties and even jail-time can be had for any breaches.

With these mandates, the only thing doctors and hospitals can hope for is to not get noticed by hackers. Either get punished for not using a computer or get punished for not having a security system even better than the pentagon.

Source:
Why the security industry never actually makes us secure. CNET 3/3/12
HIPAA Violations and Enforcement. AMA

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Pill Rather than Allergy Shots for Ragweed

If all goes well, in 2013 there will be a pill a patient can take rather than allergy shots to tone down the immune response to not only grasses (Grazax), but also ragweed.

The active ingredient in this ragweed pill is Ambrosia artemisifolia, the chemical found within ragweed that causes allergy symptoms.

Phase III trials with this pill taken once/day for 52 weeks conducted by Merck show a significant improvement in allergy symptoms by nearly 25%. Use of allergy medications like anti-histamines and steroid nasal sprays decreased by about 40%.

Just as in allergy shots, it is felt that repeated exposure to the actual allergen will induce immune tolerance. As such, rather than treating the symptoms as with anti-histamines, this medication will theoretically prevent the allergy from appearing in the first place.

Of course, side effects were present and akin to allergies it is supposed to prevent.

There is no published data yet, but results were presented at the 2012 AAAAI meeting.

Source:
New allergy pill may tame ragweed symptoms. MSNBC 3/4/12

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Rush Limbaugh Has a Cochlear Implant

Infamous conservative talk show host, Rush Limbaugh, suffered from a rare hearing disorder called Autoimmune Inner Ear Disease.

This rare inner ear disease is principally characterized by progressive bilateral fluctuating hearing loss and occurs when the body's own immune system starts to attack the hearing mechanism of the ear... much like rheumatoid arthritis is when the body's immune system attacks the joints. Just as with any other auto-immune disorder, it is mainly treated with repeated courses of prednisone.

However, if the hearing gets poor enough, the patient may become essentially deaf for which even hearing aids are ineffective which is what happened to Mr. Limbaugh.

To restore his hearing, he underwent surgical placement of a cochlear implant at the House Ear Institute in Los Angeles. It is truly a "bionic" ear in that a computer hears the world around him and directly stimulates the hearing nerve bypassing the cochlea.

Here's a transcript of him describing what it's like.

Source:
Questions on the Host's Hearing. March 18, 2011
Rush Limbaugh's Cochlear Implant Surgery A Success. Audiology Online. 1/3/2002.

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Celine Dion Cancels Shows Due to Laryngitis

In late Feb 2012, Celine Dion who was to have performed in Las Vegas Feb 22, 2012, cancelled her show at the last minute at the Caesar's Palace due to laryngitis on the advice of her doctors. According to media reports, her doctors instructed her to rest for 7 days to ensure full recovery due to vocal cord inflammation caused by a virus.

What does that mean exactly?

When a virus infects the mucosa of the upper airway, it causes inflammation of the mucosa lining including the vocal cords. With inflammation, the vocal cords swell.

That's why with laryngitis, the pitch of the voice decreases and it becomes more effortful to talk. To use an analogy, think of a violin string where the thicker string has a deeper pitch than a thin string. It also takes more power to play the thicker string. Watch the video below of normal vocal cord functioning:


In order for voice production to occur, the lining of the vocal cords vibrates very quickly when they come together. If the vocal cords are swollen, they don't vibrate as easily.

Here's what inflamed vocal cords might have looked like for Celine Dion. Note the slight bend to the vocal cords and overall dull appearance.

Below is what her vocal cords might look like when they are at peak health!

Voice rest is absolutely important for vocal recovery as quickly as possible. With talking/singing during active laryngitis, further trauma may occur to the vocal cord lining promoting even more inflammation and swelling. It may also lead to another vocal disorder known as muscle tension dysphonia.


Source:
Celine Dion cancels act: laryngitis. UPI 2/26/12

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Unnecessary Sinus Surgery

A well-respected ENT surgeon, Dr. Salah Salman, recently wrote a book, "Scrubbed Out," critical of the American health system with its links to corporation, powerful lobbies, administrators, and bureaucrats resulting in care driven by money rather than by medical necessity.

In particular, he focuses in one part of his book on endoscopic sinus surgery in the treatment of chronic sinusitis. The excerpt from the book is quite lengthy and I encourage anybody interested to read a lightly edited version here.

In essence, there are a few unscrupulous sinus surgeons who perform sinus surgery for every patient with facial pain and pressure even though there's no evidence for any chronic sinus infection whether on CT, endoscopic exam, and other objective testing.

Indeed, in my practice, perhaps only 10% (if not less) of patients with chronic "sinus" complaints actually have pathology related directly to the sinuses that merits consideration of sinus surgery. More commonly, symptoms suggestive of a chronic sinus infection are more commonly related to allergies and atypical facial pain syndromes (ie, migraines, sluder's neuralgia, contact point headaches, etc).

Unfortunately, in many physicians' minds including patients, if multiple courses of antibiotics do not resolve pan-facial pain/pressure, the sinuses must be horrible and something more aggressive geared towards the sinuses must happen.

And there's a few ENT surgeons willing to do just that... and mistakenly so.

It's not just ENTs, but allergists and infectious disease specialists who also may accommodate what the patient wants for treatment, even if it is incorrect.

If such patients see an allergist in the belief that their symptoms are due to allergies, they will get allergy testing and allergy shots.

If they see an infectious disease specialist, they will get antibiotics.

A much neglected specialist for patients with "sinus" problems are the neurologists given so many of these patients are actually suffering from atypical facial pain syndromes... but nobody (physicians, pharmaceutical companies, hospitals, bureaucrats) gets paid much for this particular problem... and so it gets ignored.

Though sinus surgery has been abused in the past into the present, a more recent, highly reimbursed, and "sexy" sinus procedural development is balloon sinuplasty, also ripe for being abused.

Traditional sinus surgery and now balloon sinuplasty certainly have their place in the treatment of true chronic sinus pathology with astounding success, but only in highly selected patients.

As with everything, the right treatment in the right patient is the right way of doing things.


Source:
Book Excerpt: A Saga Of ‘Fishy’ Surgery For Chronic Sinus Trouble. WBUR.ORG March 2, 2012

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