Chronic Cough Due to Statins

Statin drugs (simvastatin for example) are commonly used to treat high cholesterol and have many known side effects... but here's another. Statins are now believed to potentially cause a chronic dry cough according to a recent report!

This chronic cough side effect is common in other types of medications such as ACE-Inhibitors (lisinopril) and angiotensin receptor blockers (losartan) to treat high blood pressure.

Statins were not previously known to cause a chronic dry cough.

Reference:
Chronic cough as a complication of treatment with statins: a case report. Ther Adv Respir Dis. 2012 Jul 3. [Epub ahead of print]

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How Can Nasal Obstruction CAUSE Clogged Ears?

It is not uncommon that patients who suffer from a clogged nose also develop clogged ears.

Why??? There are 2 major and 1 minor reasons.

First a little anatomy lesson.

In the back of the nose, there is an opening that leads into a tunnel (eustachian tube) that goes up into the ear. When the ears get clogged, a person can get the pressure out by "popping the ears." This can be accomplished by yawn, swallow, or trying to blow out the nose that is pinched shut. When the ear pops, what happens is that the tunnel opens up allowing pressure to come out the ear. Watch video:



Mucosal Swelling

Now when the patient's nose gets obstructed, it may mean the nasal lining has become swollen making it difficult to breath. It also means the tunnel that goes up into the ear may be swollen shut as well. As such, it may become difficult if not impossible to pop the ears. This is known as eustachian tube dysfunction.

Negative Pressure Inside the Nose

However, there is a more active process that may lead to ear clogging beyond just mucosal swelling of the eustachian tube.

When the nose is obstructed, every time the patient tries to breath in thru the nose, negative pressure is built up in the back of the nose where the eustachian tube opening is located. As such, this negative pressure inside the nose can get transmitted up into the ear resulting in negative pressure to slowly build up in the ear as well which can ultimately cause a clogged ear sensation. This is just like sucking on a straw to draw fluid out of a cup, though in this case, the straw is analogous to the eustachian tube, the fluid is air, cup is the ear, and the mouth is the nose.

Bernoulli's Principle

In fluid dynamics, Bernoulli's principle states that for an inviscid flow, an increase in the speed of the fluid occurs simultaneously with a decrease in pressure.

To use an example, if you are driving a car with the window down, the fast-moving air outside the car creates a negative pressure inside the car causing things to not just blow around, but does cause some suction effect to things within the car (paper inside the car potentially getting "sucked" to the outside).

When the nose becomes clogged, airflow increases in the back of the nose (think garden hose where you have the same amount of water flow, but by changing the nozzle diameter, flow can be increased by making diameter smaller or decreased by making diameter larger). Due to Bernoulli's principle, negative pressure builds up inside the ear due to this increased nasal airflow.

This negative pressure can be transmitted into the ear causing it to become clogged.

So there you have it... 3 reasons why a clogged nose can lead to clogged ears!

That also means that often, if you just treat the clogged nose... the clogged ears will get better as well!

Reference:
Upper airway obstructions and chronic otitis media: A clinical study. American Journal of Otolaryngology - Head and Neck Medicine and Surgery. Volume 35, Issue 3 , Pages 329-331, May 2014

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Laryngospasm in a Child

Washington Post published a story July 23, 2012 regarding a child who suffered from laryngospasm attack that was erroneously diagnosed as asthma.

Laryngospasm is when the true vocal cords (TVC) come together rather than apart when breathing. Normally, only when talking do the vocal cords come together (or adduct) and vibrate to create a voice. When breathing, the vocal cords separate (or abduct) to allow air to pass between the vocal cords and into the lungs. Watch video.

What the story portrayed is not uncommon and patients who suffer from laryngospasm may go for years without the correct diagnosis.

The voice therapy that was recommended is also appropriate to help him cope when an attack occurs.

However, that's also the point where I start to disagree with the article.

It is all fine and dandy to learn breathing coping strategies, but that only deals with WHEN an attack occurs. What about what causes an attack to happen in the first place? Would it not be better to prevent an attack from happening at all and thereby coping strategies don't even need to be initiated?

As such, I do feel it important to start an aggressive workup to evaluate all the known triggers that may initiate a laryngospasm attack. Such triggers include allergy, post-nasal drainage, and reflux.

As long as the trigger is not addressed, a patient can continue to suffer recurrent attacks.

Once the triggers are found and fixed... the laryngospasm attacks can be potentially "cured."

Watch the video below depicting larygnospasm as well as less severe forms of the same (vocal cord dysfunction or paradoxical vocal cords).

Source:
Long-ago asthma diagnosis didn’t explain boy’s difficulty breathing. Washington Post 7/23/12

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Dirty Air Filters and Allergies - Don't Forget the Car!!!

Most people with bad allergies know to change their home's air filter at least quarterly with at least a 1000 microparticle performance rating (mpr). Such filters will remove pollen, dust, and other airborne particles that may exacerbate allergies as well as keep the vent system within a home clean.

BUT... allergic patients should also not forget to change their car's air filter as well regularly, especially given the car is moving around outside and people often have the air conditioning or heat turned on blowing into the face. And guess what... there are many different quality car air filters.

As such, do recommend that whenever you have your car for maintenance, request the mechanic to show you your car's air filter.

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To Ear Plug or Not to Ear Plug

Seems like a fairly simple question... but oh what controversy it stirs up when regarding a patient with ear tubes who wants to go swimming.

There are two schools of thought...

1) Based on evidence and research, no need to wear ear plugs... ever.

The argument... Well, here's the research:

• A meta-analysis of swimming and water precautions.
• Water precautions and tympanostomy tubes: a randomized, controlled trial.
• A meta-analysis of swimming and water precautions.
• The effect of water exposure after tympanostomy tube insertion. 

 2) Based on personal experience, ear plugs should be worn.

The argument:

When there's a tube present through the eardrum, any water that gets into the ear canal can potentially go through the tube and into the middle ear space and cause an infection (otitis media). The middle ear space should remain sterile, but if the water is contaminated with germs, this sterile space becomes violated.

Remember, germs found in swimming pools, lakes, rivers, and oceans can be quite funky to say the least. Think of all the birds and animals that go potty in such bodies of water (let alone humans). Read more about poop in swimming pools.

Furthermore, there is a type of ear infection called Swimmer's Ear (otitis externa) which is an infection of the skin lining the ear canal. If swimming can cause Swimmer's Ear, than by golly, it certainly can cause middle ear infections as well.

Also, if swimming can cause life-threatening brain eating amoebic infections (amoeba travels into the nose and up into the brain), than by golly, such water getting into the ear can certainly cause ear infections.

Though research does not necessarily bear this argument out, many ENTs have noted from personal experience that it is not uncommon that a patient with ear tubes presents with a draining ear infection within a few days of swimming.

Given water precautions take minimal effort and costs little ($10 ear plugs or swim cap or ear bands... see below), it seems worth it to play it on safe side.

Conclusion?

What do I typically recommend? Ear plugs when swimming, but not necessary when taking a bath (given tap water is theoretically clean).

Many will disagree depending on who you ask, but that's my personal opinion.

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Noise Hyper-Sensitivity in Kids

Although we mainly see kids for hearing loss due to fluid in the ears, chronic ear infections, or eustachian tube dysfunction, every so often, a child will show up with the exact opposite problem.

The child hears just fine, but suffers from noise hypersensitivity, also known as auditory hypersensitivity. Such children are overwhelmed from everyday noises whether doorbells, sirens, key clanking, etc; typically high-pitched sounds. The hands will go over the ears in an attempt to dampen the sound and may even become tearful.

This phenomenon is not uncommon in kids with developmental delays, autism, central auditory processing disorders (CAPD), Down's syndrome, etc. But "normal" kids may suffer from this condition as well.

Before going into treatment, one first needs to understand how sound is perceived first.

Human hearing is a complex listening device composed of not just the ability to "hear" the sound, but also to "comprehend" the sound. Disorders like CAPD is analogous to dyslexia where the patient can "hear" sounds perfectly normally, but has trouble understanding what they hear.

As a child develops, the auditory neural pathways in the brain that govern the comprehension of sounds are either reinforced or dampened down with time. For example, auditory neural pathways that allow for speech comprehension are reinforced whereas neural pathways perceiving background noises and other random sounds are dampened with time.

In auditory hypersensitivity, for whatever reason, the auditory neural pathways governing the perception of certain miscellaneous noise like sirens or doorbell are reinforced causing the perception of the sound to be more significant and tremendous than it should be. In a normal child without sensitivity, such pathways are suppressed.

To use an analogy, consider the auditory neural pathway like the road system in the United States. Over time, certain roads like the interstate highway is "reinforced" leading to more drivers using such streets to get from point A to point B far more quickly than if they used local roads. Problems occur if for some reason, cars avoid the highways and local roads are taken preferentially leading to traffic jams and irate drivers.

Auditory hypersensitivity is kind of like that... local roads being "reinforced" when it should be suppressed.

So what can be done to treat this frustrating condition?

In essence, therapy is geared towards reinforcing good auditory neural pathways and suppressing the bad ones that lead to noise hypersensitivity.

Such therapy programs include listening to special music and ear training exercises. One such program is "The Listening Program".

But one thing is clear... keeping someone with noise sensitivity in silence is the worst thing that can be done. It just reinforces the bad pathways!

Of course, there are other causes of noise sensitivity:

1) Migraines (children may not exhibit the classic head pain, but they still can suffer from noise sensitivity)
2) Cochlear hydrops (if associated with hearing loss, tinnitus, sound distortion)

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Actress Kristin Chenoweth Suffers from Meniere's Disease

Kristin Chenoweth is an accomplished actress both on TV and live on Broadway having performed in Wicked as Glinda as well as appearances in TV shows Glee and Pushing Daisies.

She also suffers from Meniere's Disease which was diagnosed in 2007.

As such, she is prone to dizzy attacks which may have contributed to well-known falls during performances over the years.

• 2003: Fell off the stage during rehearsals for Wicked
• 2006: Fell off the stage during Broadway revival of The Apple Tree
• 2011: Fell down the stairs during injuring her back on the set of Glee.

And those are just the falls we know about.

Meniere's disease is a disorder of the inner ear which leads to spinning dizzy attacks without any specific trigger. The dizzy spinning typically lasts several hours and is often preceded by tinnitus, aural pressure, and a hearing decrease on just the affected ear.

Fluctuating hearing loss is not uncommon as well.

Diagnosis is not straightforward and is usually obtained by history alone, but supporting tests include ENG (electronystagmography), VEMP (vestibular evoked myogenic potentials), ECoG (electrocochleography), ABR (auditory brainstem response), MRI scan, etc.

Once diagnosis of Meniere's disease is made, treatment occurs in stages:

Stage 1: Eliminate all salt (less than 1000mg of sodium per day), caffeine (no coffee, tea, decaffeinated, sodas, chocolate, etc), and alcohol from the diet.

Stage 2: If stage 1 does not help, addition of a diuretic pill like maxzide.

Stage 3: Invasive procedures which include endolymphatic shunt operation or vestibulectomy using intratympanic gentamyin injection into the ear or surgical lysis.

Flare-ups are treated symptomatically with phenergan and if needed, steroids whether oral or injection into the ear.

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What is Asymmetric Nerve Hearing Loss

Given my last blog article regarding an ENT who got sued for not doing an MRI after audiogram showing an asymmetric hearing loss, the question that should be on everybody's mind is what IS asymmetric nerve hearing loss on a hearing test?

I am sad to report that there is no clear consensus on what is asymmetric nerve hearing loss.

First of all, at its most basic definition, asymmetric nerve hearing loss is when hearing is worse in one ear when compared with the opposite ear due to nerve damage.

Technically, hearing should decrease equally on both sides over time, but when one side gets worse faster than the other, it can cause concern because:

1) A tumor can be pressing against the nerve causing it to slowly fail faster than the other ear's nerve which is not compressed.
2) There is a loud noise history with asymmetric exposure to the ears. One example is hunting with a rifle where the left ear would repetitively get noise-induced damage from the gunshot in a right-handed shooter.
3) Bad luck

The conflict is at what point is an asymmetry considered significant enough to warrant a workup which may include an MRI scan of the head and/or auditory brainstem response (ABR)? Also, for a given patient history, a physician/patient may elect to recheck hearing bi-annually to monitor for asymmetric progression rather than pursue workup immediately (further studies being pursued only if asymmetry progresses over time).

Is asymmetry defined as 1 decibel difference between ears? Is it 50 decibel difference?

Even if the decibel difference is agreed upon, than over what frequencies? All of them or just a few of the frequencies?

So for the purposes of a "medically" significant asymmetric nerve hearing loss, the definition must define not only HOW big the difference in hearing loss is present between ears but also at what frequencies.

In one paper, it is 15 decibels at just 3000 Hz.

In another paper, it is 20 decibels at any two adjoining frequencies (or 15 decibels at two adjoining frequencies between 2000 and 8000 Hz).

Get this... even when criteria is defined, one study found substantial disagreement among five expert judges on what hearing tests they considered showed asymmetry.

Even insurance companies are jumping into the fray in what they considered significant enough to warrant covering the MRI scan. At one point when I ordered an MRI scan of the head for what I thought was a significant asymmetry found in one patient's hearing test, the insurance company denied the test citing "that there needed to be other neurological deficits PLUS the asymmetry seen on hearing test before MRI scan would be authorized".

I personally pursue further workup using the 20 decibel difference at two adjoining frequencies OR 30 decibel at one frequency.

Assuming medically significant asymmetric hearing loss has been defined and is present...

What are the chances of something bad going on (i.e., tumor) when an MRI scan of the head is ordered for asymmetry found on hearing test?

Less than 10% (depending on study, can be as low as 1-4%).

Given such a low positive yield on testing, why even pursue a MRI scan?

Because of defensive medicine to avoid being named in a lawsuit if the affected patient just happens to be within that 10% found to have an acoustic neuroma.

Indeed, in one study, 40% of ENTs stated medico-legal concerns factored into their decision to get an MRI scan of the head.

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ENT Sued for Malpractice for Hearing Loss Due to Acoustic Neuroma

A patient has sued an ENT for failing to workup an asymmetric sensorineural hearing loss (nerve hearing loss greater in one ear compared to the opposite ear) that allegedly deviated from standard of care that ultimately led to permanent hearing damage and facial paralysis.

Since January 2008, the plaintiff saw the defendant ENT who performed 3 audiograms that revealed an asymmetric sensorineural hearing loss. In 2010, the plaintiff suffered a sudden sensorineural hearing loss at which time an MRI scan of the head was performed revealing a "large" acoustic neuroma (benign tumor of the hearing nerve).

Resection of this tumor resulted in a visible facial droop, permanent hearing loss, and cognitive deficits due to partial removal of brain tissue.

According to plaintiff, had the ENT performed MRI scan when asymmetric sensorineural hearing loss was first detected (presumably back in 2008), he never would have suffered from these defects.

Read about the case here.

Normally, if and when asymmetric sensorineural hearing loss is first detected, some type of workup is typically performed (auditory brainstem response and/or MRI scan of the head) unless there are extenuating factors present in the history. Such extenuating factors include old age and/or significant loud noise history that may lead to asymmetric hearing loss such as shooting (which often causes left greater than right nerve damaged hearing loss in right-handed shooters).

Apparently THREE audiograms were performed over time. If there was progressive worsening of the asymmetric sensorineural hearing loss, than MRI should have been performed and/or at the very least an auditory brainstem response testing (ABR). IF the audiograms showed stable asymmetry over time, it can be argued that absolutely no further workup is needed.

The key question in this case is had the defendant ENT obtained an MRI in 2008 when asymmetric sensorineural hearing loss was first detected, the acoustic neuroma would have been discovered earlier thereby preventing the permanent hearing loss he later suffered in 2010 along with facial paralysis and cognitive defects that occurred after surgical resection.

A couple problems with this line of reasoning from a purely medical perspective:

1) Acoustic neuromas grow at a rate of 1mm per year on average. As such, if the acoustic neuroma was large in 2010... it most certainly was large in 2008 being only 2mm smaller.
2) As such, surgical resection of the "large" acoustic neuroma had it been performed in 2008 probably would have resulted in the same outcome of permanent hearing loss, facial paralysis, and cognitive defects.

Hypothetically, had the MRI been performed back in 2008 revealing the large tumor, the options that would have been presented to the defendant patient would be:

1) Surgery
2) Radiation
3) Observe

Given it is established that the acoustic neuroma was large even in 2008, any type of intervention whether surgery or radiation, most certainly would put at risk the facial nerve which runs alongside the acoustic neuroma. Permanent facial paralysis and hearing loss most certainly is not an uncommon outcome after intervention.

One could even argue that in all likelihood, ALL the defendants current complaints would have occurred 2 years more quickly had the MRI scan of the head and subsequent intervention been performed.

Observation would have only lead to the current sequence of events.

As such, did malpractice occur?

Given the same outcome would probably have occurred, the defendant physician may argue that malpractice did not occur.

Should the defendant ENT have ordered the MRI scan of the head back in 2008 when an audiogram he obtained showed the asymmetric sensorineural hearing loss?

Probably though this might be debatable depending on patient's prior noise history and exact audiogram findings. Most definitely if the audiograms revealed a progressive worsening of the asymmetry over time. Most likely not if the audiograms remained the same over time.

Would knowing there was an acoustic neuroma present in 2008 have changed the patient's ultimate outcome?

Probably not given the large size.

Source:
Couple sues physician for medical malpractice. The West Virginia Record 7/10/12

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Stem Cells Restore Toddler's Congenital Hearing Loss

In a potentially revolutionary treatment, a two years old toddler born deaf has had her hearing restored after receiving stem cells from her banked umbilical cord blood. (Reported in ABC News)

Madeline Connor at age 1 year old was completely deaf in the right ear and had severe hearing loss on the left. Normally hearing aids or cochlear implant would have been the only options.

However, in January 2012 at the age of 2 years old, Madeline underwent a "simple" experiment whereby stem cells were infused into her damaged inner ear. The stem cells were derived from umbilical cord blood that was banked at the time of her delivery at the Memorial Hermann-Texas Medical Center.

Over the next 6 months, there has been dramatic improvement in her hearing. She is also now talking for the first time.

Madeline also is not the only child who has undergone this revolutionary stem cell treatment. Apparently, there are ten other children who are being followed after undergoing similar stem cell infusion derived from banked cord blood.

It must be stressed that though Madeline's progress is quite amazing, it is still too early to say if this is a "bona fide" treatment for congenital hearing loss.

• Will the improvement continue and more importantly, last over years to decades?
• Will it work for other children?
• What is the expected hearing improvement with stem cell infusion?
• Will it treat ALL forms of nerve-damaged hearing loss?
• Does it have to be stem cells derived from cord blood or are stem cells derived from other sources possible (i.e., skin)?
• Can adults with non-congential hearing loss also benefit?

I eagerly await the outcome of this FDA approved trial which hopefully will be published at some point in the near future.

I also eagerly await the protocol used to obtain and infuse the stem cells. I suspect the infusion of stem cells is similar to that done when steroids are infused into the ear for sudden hearing loss as shown in this video below. However, this is just a guess of mine.

Source:

Cord Blood Stem Cells Restore Toddler's Hearing. ABC News 7/11/12

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Singer Florence Welch Cancels Concerts Due to Vocal Injury

CBS news reported that Florence Welch, the lead singer for British band Florence + The Time Machine, had to cancel two upcoming concerts due to a vocal injury.

Florence Welch (@flo_tweet) herself provided most of the details in a series of tweets today:

July 11, 2012 @ 11:15AM : hello everyone, thankyou so much for all your messages of support, yes its true..it finally happened, I've lost my voice..:(

July 11, 2012 @ 11:18AM : I've sustained a vocal injury and been told i cannot sing for a week.., seriously i felt something snap, it was very frightening.

July 11, 2012 @ 11:20AM : unfortunately this means i will not be able to perform at Benicassim and Optimus alive festival this weekend..i am so so sorry..

Florence used the words "felt something snap" which is pretty classic for a vocal hemorrhage. For those who are Adele fans, something similar happened to her as well in November which mandated a prolonged period of voice rest (months) and even resulted in vocal cord surgery. (read more)

I am guessing that Florence had a blood vessel on her vocal cords that was causing minimal vocal impact. But with the "snap," the blood vessel likely ruptured causing instant vocal decompensation whereby the vocal pitch suddenly becomes much deeper and if bad enough, even complete voice loss as it appears to have happened to Florence.

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

However, when a blood vessel is present in the vocal cords, they may look something like this which is what Florence's vocal cords prior to the "snap" might have looked like:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. If it is small, the changes may be non-existent. If it is more pronounced, the vocal instability may be noticeable and for a singer, it may make the voice very unpredictable.

When the blood vessel becomes engorged and traumatized (singing forcefully, screaming, coughing), it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle (typically right before period).

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully which increases chance of vocal cord hemorrhage. Rupture (even in the middle of a performance) results in hemorrhage into the vocal lining itself causing a sudden and complete loss of voice (see picture to right). There may even be mild pain associated with this occurrence. This is the "snap" sensation Florence felt.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly. If significant hemorrhage is present, the vocal cord may not even be able to vibrate causing vocal loss.

How is this treated?

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

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

In Florence's case where she was told to be on strict voice rest for only one week, I suspect no polyp is present. Just hemorrhage.

If polyp is present, surgical intervention may be required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

Source:
Florence Welch told not to perform "to avoid permanent damage" to voice.  CBS News 7/11/12

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Katie Couric Gets a Hearing Test

On July 10, 2012, Katie Couric reported on a personal story during which she obtained a hearing test.

In a modern society like the United States, there are many sources for hearing loss with our alarms, lawn-mowers, and loud music.

As the article correctly pointed out, damage due to loud noises is due to two factors: loudness and duration.

The louder something is, the shorter time of exposure before hearing damage can occur. The quieter something is, the longer a person can listen before suffering noise-induced hearing loss.

Otherwise, hearing aids may be in your future... even if you are in your 20s or 30s!

Source:
Am I Going Deaf? Yahoo News 7/10/12

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Phone App That Measures How Loudly You Listen to Your Music!

There are plenty of sound meters in the market for iPhone and Android smartphones that tell a user how  loud the surrounding noise is. Many of these apps are free.

However, rather than recording the loudness of the surrounding environment, there is now a new phone app called Safe and Sound (only for Android phones) that measures the decibel level of the sound emitted from headphones and gives the user a clear indication of how loud their music really is. Furthermore, it also records the user's listening history and alerts them when they are close to their daily recommended dose of noise exposure.

It is free as well!

Listening to loud music has become an increasing concern as hearing loss is being seen at earlier and earlier ages with increasing need for hearing aids. Complaints of tinnitus is also present.

Download the app here.

Developer website.

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Hearing Loss Reversed by Teeth

When a patient is totally deaf in just one ear (normal hearing on the other side), there are only a few options to help.

• BAHA - Bone Anchored Hearing Aid
• CROS Hearing Aid - Stands for Contralateral Routing Of Signals.

With BAHA, it does require surgery given the hearing aid is literally mounted on a post that is directly drilled into the skull on the deaf ear side. Total cost about $10,000.

With CROS, two hearing aids are required; one on the deaf hear which picks up sound, and another on the good ear where the sound is transmitted to. Total cost about $2,500.

Well, for many folks, having surgery is not palatable and wearing two hearing aids when one ear is perfectly good is also not acceptable.

There's now a third option called SoundBite (cost about $6,800).

With SoundBite, a hearing aid is placed in the deaf ear to pick up sound which is than wirelessly transmitted to a mini-retainer like device placed around the back molars. This special retainer vibrates the teeth which in turn vibrates the skull which sends sound waves to the good ear allowing a patient to hear.

And preliminary results show that patients like it the best among the three options.

However, nothing is all good...

The disadvantage with the SoundBite is battery life. The ear piece battery only lasts about 12-15 hours and the teeth retainer piece about 8 hours. Also, the teeth retainer needs to be fitted by a dentist.

Also, not everybody is a candidate for SoundBite. In order to quality, a patient must have:

1) Good teeth and gums
2) Deaf in only one side with normal hearing on the other. A comprehensive hearing test is required obviously.

Source:

Using Teeth to Help Restore Hearing in One Ear. WSJ 7/10/12

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Foley Catheter to Stop Nosebleed???

A foley catheter, as shown above, is normally used to drain urine from the bladder, but it can also be used to stop severe nosebleeds... albeit under dire circumstances and when there is no other suitable alternative.

Normally, for a severe nosebleed, the nose can be packed with a tampon like packing material. The packing material I like best is a rapid rhino which is illustrated below.

Nasal packing like the rapid rhino exerts pressure within the nose to the point whereby the bleeding stops (like putting direct pressure on a leg wound to stop bleeding).

However, if there's no nasal packing around and the person is having a severe life-threatening nosebleed which almost always is due to a posterior bleeding site, and all you have is a foley catheter...

Use the foley catheter!

Insert the foley through the nose on the side that is bleeding just like an naso-gastric tube...

Once inserted so the catheter can be seen in the back of the mouth, inflate balloon with saline. After inflating the foley balloon, pull the foley catheter back out as if to take the foley catheter out. However, given the foley balloon is inflated, it will snug up in the back of the nose such that it can't be taken out.

Pull on the foley catheter with enough pressure to equal the amount of pressure desired to stop the nosebleed. Once at the correct tension, clamp the foley at the nasal entrance to prevent it from falling back into the nose. Packing with gauze in the front of the nose can also be performed to prevent bleeding coming out the front.

Of course, this is a TEMPORARY measure and should be replaced as soon as possible with appropriate nasal packing material.

But, it certainly works when in a bind.

Here's a video showing how cauterization can stop nosebleeds.

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The Problem with Patient Based Portals and Mobile Healthcare Today

I was recently asked by a large New York City based consulting firm regarding my thoughts about mobile healthcare and where I see things headed.

I gave them my two cents, but thought to share with my readers.

As any patient who has been through the healthcare mill knows, there is a profound lack of communication among private offices, hospitals, and health systems.

Let's start with a true story...

I recently saw a patient in the hospital who was admitted through the emergency room with severe sinusitis who had been on multiple different antibiotics without relief and even had surgery 1 week ago after which she was hospitalized for a few days for unclear reasons. She also had multiple drug allergies. Problem is, she didn't know much of what was done to her, what her allergies were, and most importantly, received all her care in a different hospital system. It was also the weekend. 

I couldn't really start treatment on this patient until I knew what was done as I didn't want to waste healthcare dollars on treatments already tried and failed as well as repeat CT scans that were already done as well. In terms of life and death, I couldn't really start any medications until I knew exactly what her drug allergies were. 

I called the other health system's medical records... closed for the weekend. 

I called the ENT on-call at the other health system who did not know anything regarding the patient. 

Ultimately, I was able to get the information I required by a back-end route... The patient knew cultures were obtained during surgery. I also had a friend in my hospital microbiology department. I contacted my friend who fortunately knew the microbiologist at the other health system who than looked up the information we needed and faxed them over to me.

If I did not have any personal contacts, I would not have been able to do anything until Monday.

Would a patient portal have helped me out here? Perhaps...

Would mobile healthcare have helped me? Doubtful if a non-functional patient portal system was in place.

The Problem With Patient Portals

It's all fine and dandy if a patient sees ALL their physicians within the same health system like Kaiser Permanente or Duke Medical Center. Mobile health makes perfect sense. Patient portal can access all a patient's records.

Problem is when you get beyond a large health system and where the majority of healthcare occurs which is in community settings.

For example in my community, there is no single large health system.

There are private practices and the hospital. We all use different electronic medical records. The electronic medical records (EMR) do not communicate with each other.

As such, if a patient portal is used, we ALL would have to use different patient portals which can only access information from that one practice and none of the others.

So for a given family, they may see the pediatrician that uses EMR #1. Father see primary care doctor using EMR#2. Mother sees OB/GYN that uses EMR#3. Mother also sprained ankle so also sees an orthopedic surgeon who uses EMR#4. One of the kids also sees ENT for recurrent ear infections who uses EMR#5.

Each of these EMRs do not communicate with each other. As such, even if all of the practices uses a patient portal, they all would require the parents to remember each practices'  different portal web addresses which each require different userids and passwords. Though I'm sure there will be some people who will do exactly that, most will not or won't remember the web information.

As it is right now, I have a hard enough time remembering my current collection of userids and passwords for my bank, Amazon.com, gmail, insurance, etc.

Not sure I will use a patient web portal which I may even think of accessing no more than once or twice a year if I'm basically healthy.

The Problem with Mobile Healthcare

How in the world will mobile healthcare work anywhere except in big medical centers if electronic medical records are fragmented out in the community like it is now? After all, mobile healthcare is basically being able to access medical records quickly and easily from a smartphone rather than a desktop computer.

But if you can't even achieve that task with a desktop computer, how can a smartphone???

It's like trying to build a house with a weak foundation.

In order for patient portals as well as mobile healthcare to REALLY work, communication needs to exist between different electronic medical records regardless of the vendor.

The Solution

For patient portals and mobile healthcare to really work and be used, we first need to treat electronic medical records like the computers they reside on. There currently are many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components... USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the "internet" that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems... but no... they don't communicate at all... which is why paper reports still exist... which are than scanned into the EMR.

Rather than the government dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

Once inter-operability and communication standards exist for EMR systems, only THAN will mobile healthcare and patient portals be the disruptive concept that is being prematurely attributed to these systems right now.

The golden goose being a patient (or physician) will only needing to access ONE patient portal that can access medical records wherever they may reside.

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Creative Ways to Wear a Scarf for Patients with a Trach or Ugly Neck Scar

[Watch the video below!!!]

Given I operate on the neck not uncommonly... a common fear for a patient is how the incision will look afterwards. For a simple neck mass excision, the incision almost always heals just fine to the point nobody will notice the scar.

However, this concern is multiplied a hundred-fold when a patient undergoes a tracheostomy (hole in neck) for severe obstructive sleep apnea or for some other airway reason. It could even be a laryngectomy where the entire voicebox is removed for cancer reasons. 

Who wants everybody to know that there's a hole in the neck... especially for a woman??? Even if there's no hole, sometimes the scar IS noticeable, especially after thyroidectomy, and therefore undesirable.

Scarring from an incision can potentially be addressed with dermatologic procedures, but if no surgery is desired and honestly, what really can be done with a hole defect in the neck... it really boils down to a scarf of some kind to obstruct the neck from causal view.

I mistakenly thought there's only 2 ways to wear a scarf around the neck.

The video below shows 25 ways to wear a scarf! Even if a patient or an individual decides NOT to wear a scarf ever... you should STILL watch the video. The video editing is AMAZING!!!

The actress in the video is Wendy Nguyen who is a prolific fashion blogger who my wife pointed out to me one day.

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How to Save Time Doing Healthcare Social Media: A Primer for Physicians

Followers, friends, and colleagues of mine often think that I spend HOURS doing social media everyday; reading, writing, and posting to all the various social media outlets I participate in including Blog (the one you are reading), Twitter, Facebook, YouTube, Google+, and LinkedIn.

Nothing can be further from the truth.

Beyond writing blog posts which does take time... I probably spend about 30 minutes daily reading and sharing. My reading lists typically is from customized Twitter lists I have created following users I find particularly interesting and helpful for my purposes to gain ideas to write about as well as share information that I feel may be of interest to my own followers, mainly on Facebook and Twitter.

Subscribing to RSS feeds can also be used, but I find customized twitter lists easier.

And I automate nearly everything when it comes to sharing to save time.

Here are my workhorse applications I use to save me time: Hootsuite, IFTTT, and bufferapp.

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Hootsuite

Rather than using Twitter whose interface I find clunky and inefficient, I use Hootsuite which combines all my customized Twitter lists as well as my other social media accounts all onto one concise, clean, and efficient web interface. They also have an iPhone and iPad app.

Any tweets or shared links I encounter, I can easily post to any other social media account all automatically from within Hootsuite so I don't waste time going to each individual websites for posting purposes.

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IFTTT

I also extensively use a service from  IFTTT (IF This, Than That) which allows for easy-to-create macros that automatically creates a customized action whenever I do some action. For example, I created a macro (known as recipe in IFTTT) whereby whenever I post something on twitter, IFTTT will automatically repost on LinkedIn... instantly and invisibly. You can create as many macros (recipes) as you want. Automatic responses can occur to over 47 social media accounts (Blog, LinkedIn, Facebook, YouTube, instapaper, email, tumblr, yammer, etc)

So theoretically, you can post once on twitter... and IFTTT will automatically repost the same information on all the other social media services instantly.

Of course, IFTTT can do more than just repost, but that's what I mainly use it for.

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bufferapp

Lastly, I use bufferapp. This nifty website will send out tweets at designated times that is user-specified. All the user has to do is "fill" the bufferapp bucket with the information you want tweeted.

So monthly, I will fill the bucket with up to 30 tweets I want sent out twice per day during business hours when tweets typically are noticed.

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New Webpage on Non-Acid Reflux

Given the frequency of patients I have seen over the years suffering from non-acid reflux causing symptoms of:

• Chronic cough
• Chronic throat-clearing
• Phlegmy throat
• Lump in throat sensation (globus)

I have decided to write a formal webpage to this condition.

Check it out here!

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Hearing Aid Styles and Colors - There Are Many!

It is not uncommon that a patient with hearing loss interested in hearing aids mistakenly believe there's only TWO hearing aid styles.

The kind that goes in the ear and the kind that goes behind the ear.

Although that is true, there are more different variations of both types that catches many people by surprise.

Image taken from NIH

There also seems to be a generational gap in what style is preferred by patients.

"Older" folks in their 60's or older prefer the styles that go in the ear, mostly because of the stigma associated with hearing loss and use of a hearing aid that reinforces and reminds them of their age. Also, because they remember the large skin-toned BTE that used to be the only option.

The "younger" generation typically prefer the min-BTE that go behind the ear. It probably helps that so many people use wireless bluetooth earpieces almost like a status symbol.

Beyond where hearing aids go, they now come in different colors and patterns for further personalization! Skin-tone is no longer the only color option.

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Lithium Disc Battery Danger for Kids (and Hot Dogs)

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which were due to disc batteries (20 millimeter lithium cells).

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

When swallowed, it can burn through the esophageal/intestinal lining causing a perforation which can lead to death if not promptly treated (or even in spite of it if too much time passes before treatment).

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

For illustrative purposes, lets see what happens to a hot dog when a lithium disc battery is placed inside it. This example was created by Dr. Stephen Marcus who is the director of the New Jersey Poison Information Center and published in the Pediatrics Blog here. You can also do this at home... give it a try (make a slit in the hot dog and push a lithium button battery into it... than watch).

Just 3 hours later, this is what you would see...

Keep disc batteries away from kids!!!

Please!!!

References:
A lithium battery in a hot dog is no picnic. Pediatrics Blog 7/2/2012

Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009. PEDIATRICS Vol. 129 No. 6 June 1, 2012 pp. 1111-1117

Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010 PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

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US Gymnast Maroney Suffers Nasal Fracture

World vault champion McKayla Maroney on the US gymnastics team suffered a nasal fracture during pre-meet training when she over-rotated at the end of a tumbling run and fell hard earlier this month. She also suffered a concussion. A visit to the ER revealed her injuries. Apparently no surgical intervention was pursued.

This case illustrates that most nasal and even facial fractures do NOT require surgical repair.

The key elements that lead towards a decision for facial and/or nasal fracture surgery are the following (not all-inclusive, but general pointers):

- Any functional deficit including inability to open and close the jaw.
- Change in your occlusion (the way your teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity due to nasal/facial fracture (bruising and swelling does not count).
- Nasal obstruction not due to swelling.

The two main specialties able to assess whether surgery is required or not is ENT and Plastic Surgery as well as some oral surgeons.

Source:
Maroney suffers concussion, nasal fracture. ESPN 6/10/12

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Guns n' Roses Rocker Duff McKagan Underwent Sinus Surgery

Duff McKagan, the bassist of Guns n' Roses, apparently underwent sinus surgery back in December 2010.

According to media reports, his sinus cavities developed significant scar tissue due to years of cocaine abuse.

Sinus surgery due to scar tissue is a relatively rare indication for surgery, but required if they block sinus cavities leading to recurrent sinus infections.

Cocaine abuse more typically causes other sino-nasal abnormalities especially septal perforation.

Exactly what type of sinus surgery Duff McKagan underwent is unclear, but for sinus scar tissue, balloon sinuplasty is typically the route taken and can be performed in the office.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

However, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections whether scar tissue is present or not, a workup is typically required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

Traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Source:
Duff McKagan explains sinus surgery. SFGate 12/17/10

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