Why Can't Some Contact Dermatitis Be Diagnosed by Blood Test, EVER?

I often see patients for allergies who desire allergy testing due to mysterious hive-like rash on the skin, and given many are fearful of needles, they opt for a blood test like RAST or immunoCAP to diagnose what they are allergic to. Some would even argue that skin prick testing would not be diagnostic.

Though such blood tests have become remarkably accurate (skin prick is still the most accurate way to diagnose what a person is allergic to), there are profound and significant limitations.

In order to understand why, first a little biology lesson.

In "classic" allergy (Type 1 hypersensitivity), there are antibodies called IgE floating around in the blood. When such antibodies come into contact with what a person is allergic to, it causes mast cells to explode releasing bioactive chemicals that triggers the classic signs of allergy including runny nose, sneezing, and hives.

The timing of exposure to reaction is very short... within minutes.

In this scenario, the allergy blood testing is appropriate... because such testing measures the amount of IgE antibodies floating around in the blood.

Unfortunately, not all contact dermatitis is due to this biologic response.

There is another type of allergic reaction that can cause skin manifestations that is NOT mediated by IgE antibodies at all!

Known as Type 4 Hypersensitivity, special cells called macrophages initiate the "allergic" reaction when it detects an allergic substance.

This type of reaction occurs hours to days AFTER exposure.

Obtaining a blood test for allergies will NOT diagnose this type of allergic reaction because the test measures the level of IgE which is not involved in this type of reaction!

The ONLY way to test for Type 4 Hypersensitivity is skin patch testing, typically performed by dermatologists.

Patch testing is performed on skin where the dermatitis is not apparent (typically upper back). The allergens are mixed with a non-allergic material (base) to a suitable concentration which is then placed in direct contact with the skin within small aluminium discs. Adhesive tape is used to fix them in place. The patches are left in place for 48 hours. The patches should not be exposed to sunlight or other sources of ultraviolet (UV) light. After 48 hours the patches are removed and an initial reading is taken one hour later. The final reading is taken a further 48 hours later. Additional readings beyond 48 hours increase the chance of a positive test patch by 34 per cent. The patient should refrain from washing until the last reading is taken.

Some chemicals produce an allergic reaction only when exposed to light (usually ultraviolet type A). If this scenario is suspected, patch testing is performed, one while exposed to UVA light and the other hidden in darkness. A positive light-reaction is made if the patch exposed to UVA light causes a skin reaction whereas the one hidden in darkness looks fine.

What are some common chemicals/substances that cause Type 4 skin reactions?

• Balsam of Peru: an aromatic mixture made from resins and essential oils. It is found in the haemorrhoid preparation Anusol, some perfumes and certain spices. 
• Caine mix: local anaesthetics found in preparations for sore throats, sunburn remedies, haemorrhoid preparations, Wasp-eze. Used by dentists and doctors for minor surgical procedures. 
• Carba mix: rubber 'accelerators' (chemicals used to speed up the polymerisation process in the manufacture of rubber). It is found in rubber gloves, shoes, bandages and elastic. Of those allergice to carba, 85 per cent are also allergic to thiuram. 
• Chlorocresol: a substituted phenol preservative that kills bacteria. It is widely used in medications and some cosmetics. It cross-reacts with Dettol, which you should also avoid if you have a chlorocresol allergy. 
• Chromate: a metal used for plating other metals to prevent rusting and in the manufacture of stainless steel. It is also found in cement and tanned leather. 
• Cobalt: found in jewellery, dental implants, artificial joints, jet engines. Most patients are also allergic to nickel, and some are also allergic to chromate. 
• Colophony: present in adhesives, plasters, paper, printing inks, medicated creams, glue tackifiers (stamps, labels), and cosmetics. 
• Epoxy resin: plastics, used mainly as adhesives in the industrial setting but also by DIY enthusiasts. Found in two-component glues, such as Araldite. 
• Formaldehyde: preservative frequently used in household products and in industry. Often found in cosmetics and shampoo. 
• Fragrance mix: used in patch testing, this collection of eight individual fragrances detects about 75 per cent of patients allergic to perfume. If you have perfume allergy, you will not be allergic to all fragrances, but you cannot tell from the label which fragranced cosmetics are safe. Avoid all cosmetics listing 'parfum' as an ingredient on the label. Also found in air fresheners, washing powders and candles. 
• Lanolin: produced by sheep to protect the fleece from the results of weathering. It is widely used in cosmetics, medical creams and bandages. 
• Latex: most commonly found in gloves used by healthcare professionals.
• Mercapto mix/thiazoles: a rubber accelerator found in rubber shoes, insoles, gloves and elastic. It is also a component of balloons and bandages. 
• MBT (mercaptobenzothiazole): another rubber accelerator. Neomycin: an antibiotic commonly used in ear and eye drops and creams to treat infected skin problems. Cross-reacts with other antibiotics. 
• Nickel: 10 per cent of women and at least 1 per cent of men are affected by nickel allergy. Nickel is released from metals such as alloys or electroplated items. Found in jewellery, keys, coins, zips and buckles, pacemakers and batteries. 
• Parabens: preservatives found in cosmetics and topical medical products to inhibit the growth of fungi and prevent slow deterioration. They are commonly used in cosmetics, household products, glue, shoe polish, shampoos and conditioners, sunscreens and medical creams. 
• PPD (paraphenylenediamine): a permanent hair dye that is very frequently used in hair salons and at home. Dyed hair cannot cause an allergy but the dye may do during application. Also found in skin paints, such as 'henna' tattoos, and occasionally in fur and leather dyes. Primin: a substance produced by the plant Primula obconica, a common houseplant. 
• PTBPF resin (para-tertiary-butylphenol-formaldehyde): a synthetic polymer used as an adhesive. It is often combined with leather or rubber to make shoes, handbags, watchstraps, hats and belts. 
• Thiuram (tetramethylthiuram disulphide or TMTD): another rubber accelerator that is also found in pesticides. People who are carba allergic often react to thiuram. Patients who react to the drug disulfiram (Antabuse), used for alcohol dependence, may also be allergic to thiuram. 
• Toluene sulphonamide formaldehyde resin (TSF resin): the commonest polymer in nail polish and a frequent allergen.

Given a patient often has no idea why, how, when a hive reaction occurs, it is important to obtain a good history to see if a reaction is immediate or delayed as it may influence what type of allergy testing may be required.

BUT, the key thing for people to remember is that allergy blood testing and skin prick testing can NOT diagnose all allergies due to intrinsic factors.

Skin patch testing may be the ONLY test to determine what that mysterious hive reaction is due to.

AND, now you know why!

For physicians, skin patch testing supplies can be purchased at www.dormer.com. However, your local dermatologist should be able to perform such patch testing (our office does not).

In our area, Dr. Moshell at Georgetown is the expert in this field.

Phone: 301-951-2400
5530 Wisconsin Ave, Suite 730
Chevy Chase, MD 20815

Another dermatologist in Northern Virginia who performs patch testing is:

Kurt Maggio, MD
7512 Gardner Park Dr
Gainesville, VA 20155
Phone: 703-753-9860

Robert Gurney, MD
11315 Sunset Hills Rd
Reston, VA 20190
Phone: 703-437-7744

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There are FOUR Distinct Types of Allergic Reactions

When people think of allergic reactions, they incorrectly believe there is only one kind... the kind that makes a person's nose run or the rash that appears after eating a food one is allergic to.

Sounds simple, but sadly it is WAY more complex than that.

There are actually 4 distinct types of allergic reactions that occur. All images courtesy of University of Georgia unless otherwise specified.

Type 1
This is the classic type of allergic reaction everyone is familiar with. Generally, it is activated by IgE antibodies in the blood in conjunction with mast cells. This is the type of allergy that is typically tested for by skin prick as well as blood testing (RAST or immunoCAP).

The reaction goes something like this: The allergen (stuff you are allergic to; green starfish in image below) binds IgE (stuff measured in allergy blood tests; Y shape in image) found on mast cells (the cell responsible for allergies). When that happens, the mast cell explodes releasing chemicals that cause all the classic symptoms of allergy.

Type 2
This is the allergic reaction that occurs if you get the wrong blood type during a blood transfusion. Rather than IgE, this reaction is mediated by IgG and does not involve mast cells.

The reaction goes something like this: Antibodies (homing beacons; green Y in image) in the blood attach to certain cells (cells that have a red triangle) which than marks them for destruction. Destructive proteins (called complement) and killer soldier cells than "home in" on these tagged cells and destroy them (like laser-guided missiles).

Courtesy of University of Florida

Type 3
This reaction typically occurs in autoimmune diseases like rheumatoid arthritis but can occur with injections.

The reaction is due to clustering of IgG antibodies (Y shape in image below) and the "allergic" substance (green pellets). This clustering can ultimately create a mega-complex (called immune complex) which can than activate destructive proteins (complement as in Type 2) as well as clog up the small arteries causing surrounding tissue death and/or ischemia.

Type 4
This type of reaction is what mediates latex allergy and other forms of contact dermatitis. It also forms the basis for organ rejection after a transplant as well as the PPD reaction that occurs when testing for tuberculosis.

Rather than antibodies, special cells called macrophages actually directly cause the damage. These cells hunt and "eat" the offending protein or cell with the end result being a "reaction".

Summary
To summarize, take a look at this chart:

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Customized Cancer Treatment Using Technique Similar to C&S for Infections

Imagine being 24 years old and having undergone 350 surgeries to remove growths from the throat... and expecting to undergo even more in the future.

Well, this situation is not unheard of for patients who suffer from a condition called recurrent respiratory papillomatosis (RRP). Although it is not rare for intermittent and sporadic warty growths called papillomas to occur in the mouth and throat due to the HPV virus, RRP is a much more severe condition where such papillomas start appearing at birth and appears like popcorn over time. It is not a question of "IF", but of "WHEN" such growths will reappear after removal.

Surgical removal is performed as they appear and start causing problems (trouble breathing, hoarseness, etc).

But, for a patient who has undergone 350 surgeries for removal, something new and innovative had to be done.

For researchers at Georgetown, they managed to "grow" the papillomas in a petri dish and test a variety of chemotherapeutic agents on it to see what works the best... BEFORE giving it to the patient.

This scenario is analogous to doing a culture and sensitivity on an infection to figure out what antibiotic will work the best.

Though this technique was performed on papillomas, the same approach can potentially work on any cancerous growths.

Imagine having an aggressive form of lung cancer and rather than undergoing numerous trials of chemotherapy that may or may not work, a small sample of the cancer is instead grown in a petri dish where all the different types of chemotherapy drugs are tested on it. Treatment would utilize the drugs that worked best in the petri dish which theoretically would work best in the patient.

Indeed,

"What could be more personalized than taking this person's cell, growing it in culture, finding a drug to treat them and then treat them?" said Doug Melton, co-director of the Harvard Stem Cell Institute. [link]

Source:
Bizarre tumor case may lead to custom cancer care. USA Today 9/26/12

Reference:
Use of Reprogrammed Cells to Identify Therapy for Respiratory Papillomatosis. New England Journal of Medicine. 9/27/12

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Sheryl Crow Blames Brain Tumor on Cell Phone Use

On the inaugural episode of Katie Couric's new talk show Katie, Sheryl Crow described her history with a brain tumor called meningioma which was found in her right temporal lobe. This diagnosis was reported in a previous blog post.

Most interestingly, during the show, she blames the meningioma on excessive cell phone use years ago when she was on the phone for hours promoting her records using one of those archaic analog cell phones.

The relationship between cell phone use and brain tumors including benign tumors like meningioma has been discussed in prior blog posts.

Watch the interview here:

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After Surgery, Do Patients Have Out-of-Pocket Costs for Follow-Up Visits?

Assuming a patient has insurance, the answer is generally no for a certain period of time...

For a period of time after surgery, insurance specifies that a surgeon provides any and all routine post-operative care for "free" without any patient out-of-pocket charges.

This period after surgery is called "global period" and is based on the assumption that the insurance has already paid for not only the surgery, but all the post-operative care that goes along with the surgery.

BUT... there are certain situations where global period does not apply... such as if a problem arises that is separate from the surgery like seeing the surgeon for a sinus infection after having a skin wart removed.

The sinus infection is a separate problem from the skin wart removal procedure and out-of-pocket copays will apply.

Also, global period does not apply if you decide to see a different surgeon in a different office for any post-operative care. It only applies to the surgeon who actually performed the procedure.

The next question is how long the global period is for post-operative care?

For most surgical procedures, it is 90 days after which any subsequent care is NOT "free".

However, especially for ENT-type procedures, there are a significant number of procedures where the global period is substantially shorter... even zero days.

Here's a sampling of common ENT-type procedures and the global period number of days.

90 Days Global Period
Tonsillectomy +/- Adenoidectomy
Uvulopalatopharyngoplasty
Parotidectomy
Thyroidectomy
Septoplasty

10 Days Global Period
Ear Tube Placement
Coblation Turbinate Reduction
Closed Nasal Reduction for Nasal Fracture

0 Day Global Period
Sinus Surgery
Vocal Cord Surgery
Nosebleed Control

For procedures that have a short global period, depending on circumstances, the surgeon may elect to not charge if a patient is seen past the specified number of days.

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Healthcare Mobile Web Presence

It is pretty much a given that healthcare organizations, medical offices, and physicians maintain a web presence given how frequently consumers turn to the internet and google especially for health information.

Given that... I would like to point out that more and more of this web traffic occurs on a smartphone rather than a computer and in an effort to retain consumers who seek healthcare, it behooves that any web presence be also mobile friendly.

According to my own personal web statistics using google analytics (free), in the month of Sept 2012, more than half (59.7%) of all web visits occurred using a smartphone.

Compare this to 53% in July 2012 and 39% in January 2012.

In January 2011, it was a laughably small 12.5%.

Overall, mobile web browsing accounts for 20% of all web traffic in North America. Cisco in February 2012 predicted that:

"global mobile data traffic will increase 18x between 2011 and 2016... By the end of 2012, the number of mobile-connected devices will exceed the number of people on earth, and by 2016 there will be 1.4 mobile devices per capita. There will be over 10 billion mobile-connected devices in 2016, including machine-to-machine (M2M) modules-exceeding the world's population at that time (7.3 billion)."

Also, google's own internal research revealed that half of consumers will use a website less often if it does not work well with a smartphone even if they like a business. In essence, you WILL lose customers at the moments that matter without a website specifically made for mobile devices.

It is based on just such statistics that persuaded me to take the time and money to convert my practice website such that it is now mobile friendly earlier this month.

So what does it mean to have a mobile friendly web presence?

It means that a consumer does not have to enlarge or scroll around horizontally to view a single webpage. Information appears formatted specifically for the smaller smartphone screens automatically.

In the past, there was a call for healthcare to have a web presence. In the future, that may not be good enough... modern IT demands a web presence that is mobile-friendly. Indeed, if one made decisions purely based on statistics, the focus should be on "mobile presence" rather than "web presence".

Food for thought...

Sources:
Mobile-friendly sites turn visitors into customers. Google 9/25/12.

Google Research: No Mobile Site = Lost Customers. Forbes 9/25/12

Mobile is Not a Sideshow. Information Week 9/21/12

Cisco Visual Networking Index: Global Mobile Data Traffic Forecast Update, 2011–2016. Cisco 2/14/12

Mobile Devices Now Make Up About 20 Percent of U.S. Web Traffic. All Things D 5/25/12.

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How is Sinusitis Like Diarrhea, Germs and All?

A normal human body is composed of more "bacteria" cells than "human" cells. Indeed, the bacteria collectively living inside a normal healthy person would fill a half-gallon jug; numerically, there are probably 10 times more bacterial cells in the body than human cells.

Though the majority of these bacteria have no known effect on the human body (good or bad), some of these organisms perform tasks that participate in maintaining health and are deemed necessary members of the normal human flora.

When such "good" bacteria is wiped out through medical intervention (most commonly antibiotics), human diseases like clostridium difficile manifested by massive diarrhea occurs. Treatment (gross as it sounds) may include fecal bacteriotherapy which involves transplanting poop from a healthy individual into the patient.

So How is Diarrhea Related to Sinusitis?

Well, it seems when it comes to chronic sinus infections, the same phenomenon may be happening whereby chronic antibiotic usage leads to a situation where all the "good" bacteria has been killed off leading to a situation where "bad" bacteria constantly re-colonizes the sinus cavities causing mayhem.

"Good" bacteria needs to be present to prevent "bad" bacteria from reforming.

It is possible that simply giving more antibiotics may only reinforce the elimination of not only the bad bacteria, but also all the good ones leading to a chronic and repetitive state of sinusitis especially when biofilms develop.

But... is this true???

Apparently... it's possible!

Researchers have determined that there IS a relationship between sinus bacterial composition (microflora) and chronic sinusitis and that it differs from normal healthy sinuses.

The sinus microflora of chronic sinusitis patients exhibited significantly reduced bacterial diversity compared with that of healthy individuals. At least in the sinusitis population investigated, they found relative abundance of a single species, Corynebacterium tuberculostearicum. When mouse sinuses were populated with this bacteria, sinusitis occurred. Having a normal healthy microflora protected AGAINST this bacteria.

In healthy sinuses, Lactobacillus sakei was identified as a potentially protective species and defended against C. tuberculostearicum sinus infections, even when the sinus cavities were wiped of all bacteria.

This study demonstrated that sinus mucosal health may potentially be highly dependent on the sinus microflora and that "good" bacteria presence is necessary in maintaining healthy sinuses.

Now, I'm not advocating that we take poop from healthy people and fill the sinus cavities of chronic sinusitis patients... but it may influence a fundamental change in the way physicians treat patients suffering from sinus infections that just won't go away no matter what treatment has been pursued whether numerous antibiotics, saline flushes, sinus surgery, etc.

In such sinus cripples, perhaps saline flushes containing "healthy" bacteria would be beneficial??? Hopefully, it won't stink like poop, otherwise I think patient compliance may be an issue.

What about a gel containing good bacteria injected into the sinus cavities???

I should mention that taking probiotics would help the gut, but not the sinus cavities as I can't really see how the elements contained within the probiotic pill can get absorbed into the blood and land in the sinus cavities intact.

Pretty cool area of research which I'm looking forward to hopefully seeing more of in the near future!

Source:
Humans Carry More Bacterial Cells than Human Ones. Scientific American 10/30/07

Reference:
Sinus Microbiome Diversity Depletion and Corynebacterium tuberculostearicum Enrichment Mediates Rhinosinusitis. Sci Transl Med. 2012 Sep 12;4(151):151ra124.

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Dante's Hell of Prescriptions: When Treatment Causes More Ills

Here is a scenario which I unfortunately see all too often... a scenario how prescriptions are provided to a patient to address their ills which due to associated side effects causes even more problems which in turn is treated with even more prescriptions.

Take for example a patient who presents with a chief complaint of cough for over 12 months.

Suspicion for bronchitis is made and prescription for levaquin (antibiotic) and tussionex (a narcotic cough suppressant) is given to the patient.

Unfortunately, the patient suffers side effects from both medications and is given additional prescriptions to address these side effects which in turn is treated with even more medications which have other side effects.

One can see how such a downward spiral of prescription hell can increasingly snowball to the patient's ultimate disease ridden state of numerous physical complaints ALL due to side effects of medications... especially when one considers that the initial complaint of cough was due to the side effect of lisinopril which was originally prescribed to treat hypertension (which in itself has no symptoms).

It is at times like these where some sanity to the medication madness needs to occur and I tell such patients to STOP all medications... including the true culprit lisinopril.

And that's why ENT physicians always ask what medications a patient is taking... even if at first blush, a blood pressure medication seems to have no relevance to an ENT doctor.

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Why Did Hair Turn Green for Residents of a Certain Town?

In 2011, in a certain township called Anderslov in Sweden, formerly blonde residents' hair mysteriously started turning green.

Was it a biological problem? Was it a disease? Was it contagious?

Nope...

Actually, suspicion initially was towards the drinking water and in particular, the copper levels since copper is known to dye things green via a complex oxidation process.

When copper oxidizes, it forms minerals that are green (and/or blue) including:

brochantite (hydrated copper sulfate) Cu4SO4(OH)6
malachite (hydrated copper carbonate) Cu2CO3(OH)3
azurite (hydrated copper carbonate) Cu3(CO3)2(OH)2

This action is known as verdigris... it is also why if you look at the Statue of Liberty, she appears greenish:

It is also why cheap copper jewelry when worn against the skin will turn it green.

However, confounded researchers found normal levels of copper in the water going into the homes.

BUT... water tested first thing in the morning inside the homes was found to contain copper levels 5-10x normal.

What scientists discovered was that the ultimate culprit was a combination of living in a new home and hot showers.

During the night, sitting hot water reacted with copper from the pipes and water heater causing levels of copper and associated minerals in the water to build up. This problem was most severe in new homes where the pipes lacked special coating. So, when residents of affected new homes took a hot shower in the morning, the copper in the water turned their hair green.

In order to avoid green hair, cold water needed to be used to wash the hair... or move to an older home which contained pipes that didn't leach copper in hot water.

What is this special coating that prevents copper from causing green problems? It is a polymer that is applied during manufacturing and includes acrylic, epoxy, polyurethane, cellulose, silicone, or vinyl depending on the copper's ultimate use.

Of note, this research on green hair won the 2012 Ig Nobel Prize for chemistry.

Sources:
'Nerdy' Swede wins faux- Nobel for green-hair find. The Local 9/21/12

'New homes' turn Swedes' hair green. The Local 12/17/11

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Ear Pain Causes Based on Acupuncture Principles

When a patient complains of ear pain or pressure, I wonder if an acupuncturist sees a problem with the whole body rather than a problem just around the ear itself...

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How Does Silver Nitrate Cauterize?

Silver nitrate is a chemical compound commonly used by ENT surgeons to stop nosebleeds as well as obliterate granulation tissue (found around tracheostomy stomas as well as intra-orally).

Medical silver nitrate is typically purchased as matchstick applicators and is usually found in combination with potassium nitrate (75% silver nitrate and 25% potassium nitrate).

When this applicator is combined with water (moisture inside the nose or blood):

AgNO3 + HOH  -->  AgOH + HNO3

Nitric acid (HNO3) is produced along with an insoluble precipitate silver hydroxide (AgOH) which produces the characteristic brownish-white discoloration that can stain clothing as well as skin.

Nitric acid also known as aqua fortis and spirit of niter, is a highly corrosive strong mineral acid and is what initiates the biologic "cauterization" action. It is also what causes a patient to feel a burning sensation when applied.

Silver nitrate applicator sticks can be purchased on Amazon.com.

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Fauquier ENT Blog Redesigned

Over the past two weeks, Fauquier ENT blog has secretly undergone a major facelift which has finally gone public today...

I anticipate that there are a few errors here and there that will need to be addressed as I discover them over the next few weeks. So, please help me out and let me know if there's any errors you come across. I would be much appreciative.

The custom blog template redesign was done by an Indonesian company 30Dzign who I highly recommend for any customized blogger template work.

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Sinus Surgery Lawsuit Ruled Against ENT

A patient who had undergone endoscopic sinus surgery suffered detachment of the extraocular muscle resulting in double vision that required further surgical intervention.

A jury found against the ENT and ambulatory surgery center rewarding $2.5 million dollars to not only the patient, but also the wife "for loss of consortium".

Damage to the eye and vision is part of the normal consent process for endoscopic sinus surgery when considering the geographic proximity of the eye and sinus cavities.

Eye muscle injury as in this case is particularly relevant when surgery is performed on the ethmoid sinus cavity which is located between the eyes (purple in illustration). Risk of injury is even higher when powered instruments are used like a diego sinus shaver.

Although informed consent appears to have been present, the jury still found for the patient:

- $1.5 million to Mr. Dias for pain and suffering
- $0.5 million for loss of service
- $0.5 million to his wife for loss of consortium.

This case appears to suggest that informed consent does not really provide any legal protection. A bad outcome regardless of consent implies sufficient cause for lawsuit... and winning.

This case also suggests that any bad outcome can affect a patient's ability to have intimate relations with a spouse which is sufficient cause for lawsuit and winning.

I wonder if I now have to add to the informed consent (which may not afford me any legal protection) the possibility of "loss of consortium" with a spouse.

Source:
Patient Awarded $2.5 Million After Suffering Endoscopic Sinus Errors. Outpatient Surgery Magazine 9/5/12

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John Mayer Undergoes Second Vocal Cord Surgery

On August 27, 2012, media reported that grammy-award winning singer John Mayer underwent vocal cord surgery for a 2nd time in an attempt to permanently remove a recurrent vocal cord granuloma.

Fans know that in September 2011, 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 for the first time 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 had 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."

Well, it seems that whatever intervention pursued since March 2012 did not work completely given the repeat surgery.

Given this is his second surgery for the same problem, I suspect that not only was the granuloma removed, but perhaps steroid was injected into the wound bed to try and prevent the tissue growth that may lead to granuloma reformation as well as application of mitomycin C, a chemotherapy agent. Post-procedure treatment with PDL or KTP laser may also be pursued to ablate any proliferative blood vessels that my encourage granuloma formation. Botox may even have been injected to partially paralyze his ability to bring the vocal cords together to prevent phono-trauma to the site.

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).

That means strict voice rest.

Indeed, John Mayer stated (or wrote) after his most recent surgery:

"Silent for the next few months, no singing for probably six, but all signs point to this being the last step in getting to perform again."

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential with medications.

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:
Surgery silences singer John Mayer for a spell. CNN 9/1/12

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Yoga Pose to Treat Ear Pain or Pressure

So here's something I learned about yoga...

There is a yoga pose called Karnapidasana which can supposedly cure ear pain and pressure gradually over time. The term derives from "Karna" meaning ear and "Pida" which means pain, discomfort, or pressure.

So... who knows? Give it a try... if you can physically do it safely.

DISCLAIMER: Not recommended for those who are not flexible. Also, not something I personally recommend to treat ear pain and pressure.

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Find an ENT Doctor App

If you have an iPhone or Android, get the ENTLink App... You can search for an ENT by current location or by zip code. The search can be narrowed to a specific specialty area (laryngology, neuro-otology, rhinology, etc) as well.

Of course, you can search for the same information from the website.

Download the app for iPhone and Android.

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Yet Another Sinus Dilation Device - AerOS Sinus Dilation System

Sinus dilation has become all the rage in the past few years to treat chronic sinusitis, especially since CPT codes for this procedure has become available as of January 2012.

The first company was Acclarent who coined the balloon sinuplasty term.

Next was Entellus who produced their simpler system (XprESS and FinESS).

Now, there is SinuSys who has produced a new way to dilate the sinus opening without use of a balloon like Acclarent and Entellus. It is currently pending FDA approval, but is used in Europe.

This new system is called AerOs Sinus Dilation System and utilizes an osmotic self-expanding technology. A "simple" two-step insertion and removal of the device is required. Once inserted, the device gradually expands via low-pressure osmotic pressure in about 60 minutes. At that point, it can be removed.

The device itself is 5mm in size and exerts pressure of 2.5 ATM. The diameter is 3mm before dilation that ultimately expands to 5mm.

Compare this with Acclarent and Entellus balloon devices which are inflated to 12 ATM pressure and expands up to 7mm in size (depending on the model).

My personal concern with this device is the small size of 5mm... the surgeon will have to be super-precise for placement, otherwise, it'll fall out or do nothing.

Also, I question whether a 2mm dilation will actually make any difference. Prior studies have established that 4-5mm ostia size really is the minimal efficacious opening size. Larger is better, especially when the uncinate process is still intact as it would be in pure dilation cases. More study is required.

In any case, when (or if) this new device becomes available in the USA is unclear. It's all up to the FDA now.

Reference:
Feasibility of an osmotically driven, self-expanding device for sinus dilation to treat chronic sinusitis. Poster Presentation

Assessment of the short term patency of the maxillary sinus ostium following dilatation with an osmotic device in a sheep model. Jerome E. Hester, MD, David Edgren, BS, Andrea Koreck, MD, PhD, Jason Fox, BS, Janie Mandrusov, PhD, East Palo Alto, CA USA (Annual Meeting of American Rhinologic Society, September 2012, Poster# P-7).

Treatment of Maxillary Sinusitis Using the SinuSys AerOsTM Sinus Dilation System. White Paper 

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How to "Grow" Clean Air

The New York Times published a story regarding how common houseplants can purify the air of chemicals like benzene and formaldehyde.

This claim is based on NASA research performed in the 1980s when the agency was trying to figure out ways to keep the air quality as clean as possible within enclosed habitats (like a space station).

Of course, you can read the 27 page report... or read a mom-friendly book that summarizes the findings in an easy-to-understand language from Amazon.com.

"How to Grow Fresh Air" by Dr. BC Wolverton


The book reviews 50 common houseplants' ability to clean the air inside the home or office. Depending on the plant, chemicals that can be removed include benzene, formaldehyde, xylene, toulene, trichlorethylene, chloroform, ammonia, acetone, and alcohols. Such chemicals are emitted from electronics, drywall, adhesives, upholstery, carpet, paint, cosmetics, etc.

It is suspected that such chemicals may be the cause of "sick building syndrome" that induces symptoms of upper respiratory irritation, fatigue, headache, and congestion when afflicted individuals enter certain buildings.

My personal favorite plants are the fern and peace lilly, both which have a high rate of chemical vapor removal, easy to grow and maintain, and fairly resistant to insect infestation. Does the job and easy to care for.

BEWARE!!!

Now before running to the nearest greenhouse and buying numerous plants to keep inside the home, consider that though such plants remove chemicals from the air, the plants themselves may exacerbate allergies in sensitive individuals.

Why? Plants can increase dust (accumulated on the leaves) and mold allergens (in the soil).


Source:
Really? Some Plants Can Filter Airborne Chemicals. NYT 9/3/12

Reference:
Interior Landscape Plants Indoor Air Pollution Abatement. NASA 9/15/89

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Website Development Help

Given how extensive the practice website is (250+ webpages; 1300+ if including blog), I often get asked by patients and other offices how did I go about developing it.

First off, I am fortunate that I have some computer programming skills and have been creating websites since the 1990s. I have decent HTML knowledge with a dash of CSS understanding. I am clueless with  making new javascripts, but know how to use ones that have been already created.

As such this baseline knowledge of mine is sufficient to extensively look for answers to questions using google and if necessary, plagiarizing code that accomplishes a task I require.

However, I also bring in help when I need it. I have a few absolutely awesome and reliable computer programmers I tap when I need it including Chris Ferrell with PettyGroveFull (New York City) and Chris Mohler (Memphis, TN) who is a freelance programmer. 

They are both diligent, fair, trustworthy, and provide regular feedback (I have never even met them face-to-face).

Chris Ferrell re-designed my entire website incorporating HTML5 and CSS3 a few years ago.

Chris Mohler than optimized the website further and enabled mobile viewing more recently.

For other programming tasks that Ferrell and Mohler are unable to help with (programmers have their areas of specialty just like doctors!), I go to Elance which is an awesome website where one can post a job ("I need somebody to redesign my blog and move it to Wordpress") and various contractors looking for jobs can than bid on it.

Just like Amazon.com, contractors have star ratings from prior clients.

And given the work is digital, the you can tap anybody in the WORLD... so bids can come from not only North America, but India and Russia.

As such, prices can be quite competitive and much lower than what one would expect given contractors are competing against everybody else in the world!

Indeed, I currently have an ongoing project I granted to a programming group in Indonesia. So far, so good!

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Wrong Site Surgery Performed by ENT

In 2010, an ENT performed a tongue tie release on a 5 years old child who was supposed to undergo a tongue lesion biopsy (apparently 1cm in size over the central dorsal tongue). Tongue tie release was NOT consented for nor discussed with the parents who expected a tongue biopsy to be performed instead. In the investigative report performed by the Department of Public Health:

"When the surgeon was asked whether he examined the patient in the preop area prior to the surgery, he stated, "Usually, I don't examine anybody. I sometimes visit... In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to the surgery." [link]

According to the record, time-out WAS performed. Consent WAS in the chart for a tongue lesion biopsy. Records indicated that all mandated check-lists and time-outs were performed.

So what happened?

1) Surgeon Error: Let's face it... the surgeon made a mistake. Ultimately, it is his responsibility to ensure that the procedure goes smoothly which by definition means doing the correct procedure.

Seeing patients before surgery probably would have prevented this error. Not seeing the patient prior to surgery is not good practice.

Even if a surgeon employs a nurse practitioner or a physician assistant to see patients for him in the office or in the hospital, before any surgery, he personally should examine and discuss the upcoming surgery with all patients.

As an aside, at least once per week, I have patients calling who desire to schedule surgery without wanting to see me first for a consultation appointment. There are many reasons why I mandate that a patient MUST first be personally seen by me in the office PRIOR to any surgery scheduling. Preventing this scenario is one good reason why.

2) Nursing Error??? If the nurses knew what procedure was supposed to be done (according to the report, they did)... they should have spoken up! If they were too afraid to speak up, they should have contacted management to speak up for them... or ask the anesthesiologist to say something.

After all, patient welfare supersedes all else. Having wrong site surgery is the exact opposite.

However, to be fair in this particular situation, I do not believe the nurses knew what the surgeon was doing. Why???

The procedure was being done inside the mouth and a small child's mouth at that... honestly, nobody except the surgeon and possibly the anesthesiologist can really see what the surgeon is doing. The instruments used for tongue tie release is very similar to what would be used for tongue lesion biopsy.

3) Time-Out and Check-List Error: In a typical day, there are so many time-outs and check-lists being performed that it starts to get muted into background noise. It's just like the alarms and blinking lights that I imagine an instrument panel of a sophisticated machine would be for somebody who stares at it all day, everyday. You hear/see it... but than you don't hear/see it.

What people notice are sounds that are unusual for a given situation.

For example, cars make all sorts of noises when being turned on and moving somewhere. However, most people don't actually "hear" the sounds being produced by the car because of our lack of attention to it, because it is repetitive and continuous.

However, if one day, the engine starts knocking, that certainly gets a driver's attention and remembered.

Time-outs and check-lists suffer from inattention... even if performed.

They are a wonderful tool, but utterly undependable for long-term use.

So what would work given it must be done per regulations??? My suggestion would be to mix it up to prevent it from becoming "background" noise.

Have the time-out performed by different members of the surgical staff on every case rather than the same person. Ring a bell before doing time-out one time. On another time, have everyone dance a short jig before doing it. Whatever is done, do NOT make it repetitive which otherwise risks being inadvertently ignored.

The key is to make it different and notable each and every time in order to focus attention and prevent the task from becoming muted into the background.

Source:
CA Fines 14 Hospitals for Medical Errors. Health Leaders Media 8/31/12

Reference:
California Human and Health Resources Department of Public Health Report. 5/18/11

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