Why Do Biopsy Results Take So Long? [video]

One of the most common questions I get after a surgical procedure is how long it takes before biopsy results are back... especially when a mass was removed and there is a cancer concern.

Does it take a few hours? 24 hours? Days?

Disappointingly, it can take up to 7 days if not longer.

You want to know why?

Well, rather than explaining, watch a 6-minute video that explains the numerous steps that goes into providing a diagnosis after a mass is removed... in this particular case, a neck mass though the same steps apply to any mass removed from anywhere else in the body.

Special thanks to Robin Earl who spent hours hanging out in the pathology lab video-taping all the relevant video clips as well as Fauquier Health System for allowing this video to be made!

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I Am Taking a Reflux Medication & My Symptoms are Not Improving!

On an almost daily basis, I get an email from somebody with the same exact question or near-variation:

"Dear Dr. Chang,  

I have been taking a [insert reflux medication] for [insert number] weeks and I see no improvement in my [insert symptom]. What should I do?"

The reflux medication typically mentioned include nexium, dexilant, prilosec, prevacid, protonix, or some other proton pump inhibitor.

The most common symptoms typically mentioned include:

• Globus

• Phlegmy throat

• Throat clearing

• Cough

What Should You Do?

Well, assuming you never have taken a reflux medication in the past, proton pump inhibitors work extremely well in suppressing acid; even at low dosages.

As such, if you indeed have been taking a proton pump inhibitor for at least 3 weeks and see no improvement in symptoms, one must consider the possibility that acid reflux may not be the problem.

I rarely if ever just increase the dosage of a reflux medication in somebody who previously was never on one. Increasing the medication dosage MIGHT be considered only if somebody has already been on reflux medication for some time baseline.

So if acid reflux is not the problem, what may be causing above-mentioned symptoms?

There could be an anatomic problem...

• Zenker's diverticulum

• Cricopharyngeal spasms/hypertrophy

• Esophageal dysmotility

• Esophageal web or stricture

etc

Essentially, there's something wrong with your swallowing tube such that things back up into the throat causing symptoms. Think of it like a clogged sink... the pipe (esophagus) has a physical issue that causes water to backup into the sink (throat).

Workup to evaluate these possibilities include trans-nasal endoscopy, EGD, barium swallow, and/or manometry.

It could still be a reflux problem...

Just maybe, it's NOT acid reflux however, but mucus or non-acid reflux. Standard reflux medications do not work for non-acid reflux. The best way to evaluate this possibility is to undergo a 24 hour multichannel pH and impedance testing. Of note, BRAVO or pH monitoring alone is NOT good enough. Impedance must be measured as well as having sensors near the throat level.

In the meantime, one could also try avoiding eating anything that contains dairy, egg, and wheat (flour). These foods are considered highly mucogenic (most people can relate to the fact that when drinking too much milk, the mouth and throat can get phlegmy).

Is it allergy?

Post-nasal drainage can sometimes lead to throat symptoms. If you do have some sino-nasal allergies, try taking a steroid nasal spray and an anti-histamine nasal spray. Oral medications typically do not work as well.

There's also a condition known a eosinophilic esophagitis that can cause throat symptoms. The only way to diagnose this condition is an upper endoscopy (EGD) with biopsies of the esophageal lining.

Summary

Now this article just scratches the surface in FULLY addressing an individual patient's throat symptoms. After all, not everybody is exactly the same. For a more in-depth evaluation and individualized treatment of YOUR throat issues, please make an appointment with your ENT.

Here are some related articles that may be helpful:

• Globus

• Phlegmy throat

• Throat clearing

• Cough

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Reflux Medication Addiction

When a patient suffers from reflux, there is an astounding array of very effective medications to induce acid suppression for symptom relief.

Chief among the reflux medications are the proton pump inhibitors that include medications like prilosec, nexium, protonix, prevacid, dexilant, etc.

When such medications are taken by a patient, especially one who does not normally take proton pump inhibitors, effective acid suppression occurs. It works EXTREMELY well; even at low doses.

However, such medications should not be taken any longer than necessary and should be prescribed along with lifestyle changes to minimize persistence and/or recurrence.

Why?

In some ways, a patient suffering from reflux may become "addicted" to the reflux medication for continued symptom relief.

In other words, the reflux medication can induce the stomach to produce even more acid leading to the need for continued medical therapy... or increase dosages for continued symptom relief. Stopping the medication can cause even worse reflux... which leads the patient to resume the medication.

This "addiction"can occur in as little as 8 weeks in up to 40% of normal, healthy individuals. [link]

What happens?

The way proton pump inhibitors work is by blocking protein channels known as proton pumps in stomach cells (B) from producing acid (C).

The stomach cells realizing their proton pumps are being blocked, start revving up production of even MORE proton pump channels to fix its acid shortage which would in turn increase acid production and potentially lead to symptoms.

Sounds like a vicious cycle... because it is.

Although this "addiction" which is really an acid rebound phenomenon, is typically associated with proton pump inhibitors, it can also happen with H2-blockers (zantac, pepcid, etc), though not as severe.

Should you experience acid rebound after stopping a reflux medication, the unusually vigorous acid production and associated symptoms (the "withdrawal") go away if you can stand to wait it out. Since it takes time for the stomach to re-adjust, this wait can be significant:

• After stopping an H2-blocker, rebound symptoms usually start within two days and usually subside within 10 days.
• After stopping a proton pump inhibitor, rebound symptoms usually start after a week and continue for up to two months.

One can also slowly "taper" down the dosage of reflux medication and address any acid symptoms with an antacid.

Now, in certain circumstances, it is imperative that reflux medications be taken for months if not longer because the benefits outweigh the risks (gastric ulcer, Barrett's esophagus, vocal cord granuloma, etc). There is a specific reason for long-term treatment.

But if treatment is solely due to symptom relief alone, such medications should not be used daily indefinitely.

Talk to your doctor if you have concerns.


References:
Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137:80-87. Epub 2009 Apr 10.

Rebound hypersecretion after omeprazole and its relation to on-treatment acid suppression and Helicobacter pylori status. Gastroenterology. 1999;116:239-247.

Systematic review: rebound acid hypersecretion after therapy with proton pump inhibitors. Aliment Pharmacol Ther. 2007;25:39-46.

Results of an intervention in an academic Internal Medicine Clinic to continue, step-down, or discontinue proton pump inhibitor therapy related to a Tennessee Medicaid formulary change. J Manag Care Pharm. 2009;15:344-350.

Safety of the long-term use of proton pump inhibitors. World J Gastroenterol. 2010;16:2323-2330.

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How Much Tongue Can Be Removed Without Affecting Function?

Unfortunately, whether through trauma or cancer concerns, parts of the tongue may be removed. When a part of the tongue is removed, the principal concern patients have is whether speech and swallow will be affected.

The answer to this question depends on 3 main factors.

• What orientation is the tongue removed?

• How much is removed?

• Will nerve function be preserved? The nerve is what makes the tongue move (specifically cranial nerve 12 called the hypoglossal nerve)

Regardless of how much or little of the tongue gets removed, if nerve function is lost, speech and swallow will be affected. As such, when tongue resection is performed, extreme care is taken to preserve nerve function and not to accidentally cut the hypoglossal nerve unless absolutely necessary (the nerve is invaded by cancer). As an FYI, this nerve is about 1.75cm off to the side of the tongue's midline.

When tongue removal is performed on the SIDE of the tongue, up to 1/3 of it can be removed without significant speech or swallow deficits ASSUMING nerve function remains intact and tongue tip is left alone. If more than 1/3 is removed, some degree of reconstruction will be required involving taking skin and muscle from the forearm to fill the space lost to the tongue resection (procedure is called radial forearm free flap).

If the tongue tip is removed, far less can be lost before it will start to affect speech. Why? Because the tongue tip is used to help articulate words. How much can be removed before it starts to affect speech depends on the tongue length and shape. Swallow is typically unaffected.

Typically tongue tip removal occurs through trauma when it may get bitten off during a seizure or bitten off by another individual as occurred to this man whose tongue tip was bitten off by his girlfriend when he tried to kiss her. [link]

Side of the tongue removal usually occurs through surgical excision due to cancer concerns.

Sleep Apnea

As an aside, there is another type of tongue removal procedure used to address obstructive sleep apnea where the central back part of the tongue is removed. This procedure is performed when the tongue is large and causes obstruction while a person is sleeping. If properly performed, no speech or swallow deficits will occur.

Read more about this procedure here.

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Split Tongue (aka Forking the Tongue, Snake Tongue, etc)

Photo Source Here

Splitting the tongue into two halves is a relatively rare type of body modification, though it is becoming more common. Tongue trauma can also result in such tongue bifurcation as well.

There are 3 described basic methods of creating a split tongue. scalpel (cold steel), cautery (electric or laser), and tie-off. Scalpel and cautery methods are performed by a surgeon, but the tie-off method can be performed by anybody.

The tie-off method was developed by 19 year old Dustin Allor in which he took fishing line tied through an existing tongue piercing and looped it over the tongue tip.  Over time, the fishing line is sequentially cinched tightly through the tongue tissue. This slow process (days to months) allows the tongue to heal as it is being split negating the need for stitches or cauterization due to nominal bleeding.

A split tongue can also be reversed, though more painful than creating it.

More can be read about split tongue on Wikipedia.

Needless to say, this procedure is NOT covered by insurance... but reversing it potentially can be covered by insurance.

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What to Do and Care After Vocal Cord Surgery

When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.

The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.

When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.


As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.

I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.

Strict Voice Rest! 

This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.

The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Strict voice rest typically lasts for 1-2 weeks after surgery.

No Coughing or Throat-Clearing

Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.

Take Reflux Medications

Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.

Voice Therapy

Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!

The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.

Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!

Restricted Voice Rest

Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.

Restricted voice rest is a fairly broad phrase, but essentially means to:

• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)

This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!

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Can You Spot the Gorilla in the CT Scan?

I am not going to go into too much detail regarding a recent news article regarding how 83% of radiologists (physicians who specialize is looking at radiology pictures) failed to see a gorilla on a CT scan of the chest... you can read more of the details here.

But, the question is can YOU find the gorilla in the CT Scan that was portrayed?

Still can't see it?

Look below...

Keep going...










Keep going...








Keep going...





I'll point to it...

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How Much Radiation Exposure Occurs with a CT Scan? X-ray? Sunlight?

A common concern now is how much radiation exposure occurs with common radiological testing such as x-rays and CT scans, especially given the small increased risk of cancer with accumulated exposure over years.

Of note, ultrasounds and MRI scans do not emit radiation. MRI scans use magnets while ultrasounds use sound waves in order to obtain imaging information.

So, here's a chart comparing such tests with common environmental radiation exposure such as sunlight. Information taken from www.X-RayRisk.com:

Radiation	Amount
Sunlight (high-altitude city)	6 mSv per year
Sunlight (sea-level city)	3.1 mSv per year
Frequent Flyer	1 - 6.7 mSv
Single Airflight coast-to-coast	0.01 - 0.03 mSv
Smoke 20 cigarettes per day	53 mSv
CT Chest	7 mSv
CT Head	2 mSv
Nuclear Stress Test (Technicium)	9.4 mSv
Nuclear Stress Test (Thallium)	40.7 mSv
Barium Swallow	5 mSv
Mammogram	0.4 mSv
Chest X-ray	0.1 mSv
Dental X-ray (Bitewing)	0.02 mSv

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Does Acupuncture Help With Allergies?

Image from Acupuncture For All

According to one study, it does... Performed by researchers in China and Korea, they divided 238 patients suffering from allergies into 3 groups: active acupuncture, sham acupuncture, and no treatment.

They found that acupuncture, even if it was sham, did help significantly with nasal allergies. However, only active acupuncture helped with not just nasal allergies but also allergy symptoms beyond the nose!

Of course, when considering all the other research performed on this subject, the results are a bit more mixed with some reporting no improvement with acupuncture.

For those interested in avoiding medications and allergy shots, it may be something to consider trying. It can't hurt and it can potentially even help.

References:
A multicenter, randomized, controlled trial testing the effects of acupuncture on allergic rhinitis. European Journal of Allergy and Clinical Immunology. Volume 68, Issue 3, pages 365–374, March 2013

Acupuncture for allergic rhinitis: a systematic review. Annals of Allergy, Asthma & Immunology Volume 102, Issue 4 , Pages 269-279, April 2009

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17 Year Old Girl Dies After Tonsillectomy

Patients sometimes focus too much on the intricacies and risks of the surgery itself and not realize that subsequent care AFTER surgery may be just as important and risk-laden.

Media reported yesterday about the tragic death of a 17 year old girl after tonsillectomy.

Apparently in March 2012, the Pennsylvania teenager underwent a routine tonsillectomy without any problems. While in recovery after surgery (PACU), she was given fentanyl, a powerful narcotic to help with pain, but also has a known side effect of slowing the breathing down.

"Over the next 25 minutes, her respiratory condition rapidly worsened and went unnoticed by nurses, who failed to perform required assessments and were not warned by the equipment monitoring Mariah's vital signs because it was not set properly and was muted. Sadly, as a result of these oversights and others, Mariah sustained significant brain damage due to oxygen deprivation and died 15 days later." [link]

It is also implied that in order to give the patient privacy, curtains were drawn such that her distress was also not visually seen by nurses.

Clearly, multiple lapses occurred leading to this tragic death.

Those alarms are there for a reason!!! Why mute them? Patients (and even staff) do complain of the annoying beeps and noises such machines make and out of exasperation, they can be muted due to the many false-alarms, but as this case illustrates, those very alarms could have saved her life.

Once a patient is identified with respiratory distress, narcan could have been given that would have reversed fentanyl's sedating (as well as pain-killing) effects. At worst, the patient could have been re-intubated.

This case also highlights that in certain situations, patient safety trumps patient privacy.

In PACU (a common open room where patients go after surgery), there is absolutely no patient privacy. Everyone can see everything. That way, if there's any problems, nurses can immediately see if a patient is in distress. That's also one reason among others why family is not allowed in the PACU (due to lack of privacy for other patients).

Abington Surgical Center where the surgery was performed has imposed a series of policy changes to ensure another death like this may never happen again. According to media, these policy changes include:

• each patient who has received IV narcotics (which is pretty much all patients who have surgery) in the PACU must be assigned one-on-one nurse care
• patient monitoring equipment may no longer be muted
• curtains restricting the view of the patient can no longer be drawn
• there must be a dedicated charge nurse to oversee nurse staffing and patient flow in the unit.

Except for the first point, I agree with all these policy changes which really shouldn't be a policy change per se... It should have been always there.

However, the one-on-one nursing care certainly can't hurt, but is probably unnecessary and potentially a waste of nursing resources. I should point out that IV narcotics are given ALL THE TIME in the hospital whether in PACU, the hospital floor, ER, and ICU, but one-on-one nursing care is not usually present in any of these locations. Rather, the intensity of nursing care should depend on the acuity of the surgery as well as the medical needs of the patient. A blanket policy change that applies indiscriminately is needlessly wasteful.


Source:
17-Year-Old Girl's Tragic Death After Routine Tonsillectomy Leads to Post-Operative Care Changes. SacBee.com 2/5/13

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How Much Caffeine is Present in Coffee? Decaff? Chocolate?

© Radu Razvan Gheorghe | Dreamstime Stock Photos

There are quite a few ENT problems that can potentially be due to caffeine intake. Even death has been attributed to high caffeine intake in young adults who drink a lot of energy drinks like Red Bull.

In any case, caffeine can contribute to (some proven, some suspected, some debatable):

• Tinnitus
• Meniere's Disease
• Migraine Headaches
• Headaches
• Dizziness
• Reflux
• Lump in Throat Sensation (Globus)
• Chronic throat clearing
• Dry throat
• Phlegmy throat

Alcohol and salt are other big as well as under-recognized items that may cause similar ENT issues.

As such, caffeine abstinence is one of the first things to be tried with some of these conditions. What many people may not realize is how prevalent caffeine is even in some food items not normally considered to contain caffeine. Such unrecognized items include tea, chocolate, and even decaffeinated coffee (it has been de-caffeinated, but not to the point of being caffeine free).

Here is an infographic showing relative caffeine amounts in a variety of beverages taken from C&EN:

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Negative Ear Pressure Causing Inability to Pop a Clogged Ear

Have you ever closed the lid on an air-tight container containing a left-over hot meal and stuck it in the refrigerator? And than when you try to open the lid the next day once that hot meal cools down, it is REALLY hard to open the lid because of the accumulated negative pressure? In essence, the negative pressure has "locked" the lid down.

Well, something similar can also potentially happen inside the ear with eustachian tube dysfunction, especially with negative pressure (rather than positive pressure).

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva (watch video below). Once medical treatment has failed, ear tube placement has been the step of last resort.

The question some patients have is WHY does it become so hard to get an ear to pop open with eustachian tube dysfunction...

It may be that the mucosal lining of the eustachian tube has swelled to the point that there is no opening present.

There may also be a physical obstruction blocking the eustachian tube due to large adenoids, nasal polyps, or some other nasal mass.

However, a lesser known phenomenon is due to the negative pressure itself creating a suction effect on the lining of the eustachian tube analagous to the stuck container lid mentioned in the first paragraph. The middle ear negative pressure itself may be literally "sucking" the lining of the eustachian tube closed. If the negative pressure is great enough, it may be very hard to get it open.

When this happens, the eustachian tube becomes "locked".

One can "mimic" this effect even in a healthy individual (not that anybody would want to try). When a swimmer dives deep into the water, some ear pain will start to develop due to the negative pressure building up in the middle ear. If the swimmer does not ear pop and continues to go deeper into the water, at around 3.9 feet, it may start to get very difficult to get the ear to pop open even with effort. At around 5 feet of water depth, it will become impossible to pop the ear open. Normally, swimmers and SCUBA divers continuously ear pop when diving at depth to prevent any ear discomfort.

As such, in situations where negative ear pressure is present and medications fail to resolve the ear clogging, a hole can be surgically made in the eardrum WITHOUT tube placement which will often resolve the symptoms fairly quickly. The hole "releases" the negative pressure to allow the eustachian tube to function normally. The analogy would be that once you release the negative pressure within an air-tight container, it becomes very easy to remove the lid thereafter.

The eardrum hole typically heals closed in a few weeks and the clogged ear sensation will often not come back. If it does, the myringotomy (surgically creating a eardrum hole) can be repeated and if necessary, a tube can be placed to prevent the body from healing the hole closed anytime soon.



Some things that have helped some people to pop their ears:

 

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Just How Contagious is the Flu (and Other Viral Infections)?

Everybody knows the flu and other viral infections are contagious, but did you wonder just how contagious???

Well, here are some facts gleaned from a few studies:

• In just 4 hours, one sick worker can contaminate 50% of surfaces in a typical office
• After 8 hours, one sick worker can contaminate 70%+ of surfaces
• Non-sick workers have a 40-90% chance of getting infected after spending one day with a sick worker
• A sneeze or cough can hurl virus 6 feet away from the mouth
• A sick person literally "emanates" virus up to 6 feet away... even if they are NOT sneezing or coughing.
• Some sick individuals are super-carriers spreading the virus around them 32 times more than others

The good news is that viruses can not survive on surfaces for long... They usually die off within a day (type of surface, temperature, and humidity affecting duration).

Source:
Flu Virus Can Travel Up to 6 Feet, Infect Up to 90 Percent of People Just from Contaminated Surfaces. Medical Daily News 2/1/13

References:
Exposure to Influenza Virus Aerosols During Routine Patient Care. J Infect Dis. 2013 Jan 30. [Epub ahead of print]

InfluenzaVirus: Here, There, Especially Air? J Infect Dis. (2013) doi: 10.1093/infdis/jis774

Germs Spread Fast at Work, Study Finds. AHSC 1/30/13

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Uvula Piercing

It happens, but thankfully rare...

Ear piercing I will do, but truly uvula piercing is not something I would recommend given a whole host of problems it may cause including:

• Gagging
• Snoring
• Airway obstruction
• Uvular stretching
• Uvular bisection
• Accidental inhalation if it comes loose
• Uvular swelling
etc. etc. etc.

Indeed, most people would rather get their uvula removed rather than "enhancing" it!

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Speech Impediment to Great Singing on American Idol

During January 2013 auditions of Season 12 of American Idol, there was Lazaro Arbos who has a terrible stutter when he talks, but sings beautifully. A week later, we encountered Micah Johnson who also suffers from a speech impediment, but rather than a stutter, it was due to "nerve damage" sustained during a tonsillectomy. (Watch videos below)

With stuttering, the problem mainly lies at the brain level. The brain coordinates how a person uses all of their throat muscles to create speech. Talking and language is mainly a LEFT-brain activity (or more precisely, the dominant hemisphere). Singing is mainly a RIGHT-brain activity and as such, uses different pathways than talking. It's also the same reason why patients who have suffered from a stroke may not be able to talk at all, but can sing their words out.

Now, in the case for Micah Johnson, it is reported that his speech impediment was due to "nerve damage" from tonsil removal surgery. As such, his speech impediment is NOT at the brain level (also known as central), but peripheral. Peripheral nerve injury is much more difficult to correct and requires extensive practice (speech therapy) in order to create brand new pathways at the brain level to help it "adapt" and compensate for the loss of function from the nerve injury. The analogy would be walking with a limp to compensate for a leg injury.

However, in Micah's case, it is a bit difficult to explain why he talks with an impediment, but sings wonderfully. It is not a matter of activating previously established brain pathways as what happens with stuttering.

With a tonsillectomy, there is a mouth gag placed to move the tongue out of the way. Typically, this surgery takes about 15 minutes to perform on average. Per Micah, his tonsillectomy took 90 minutes or almost 6 times longer than normal.

I hypothesize that the mouth gag over that time duration slowly crushed the nerve innervating the tongue (cranial nerve 12) causing it to not move as well leading to his speech difficulties. This complication is EXTREMELY rare and if it occurs, almost always temporary. This situation is analogous to a "dead" arm when sleeping on it for too long... but recovering normal function after a few minutes.

Unfortunately in Micah's case, it seems to never have recovered fully.

The puzzling issue for me is how is it that he is able to sing, but not talk well? Peripheral nerve injuries would affect ANY activity involving the affected muscle. For example, if the nerve to a leg muscle is cut, that muscle will not work well whether running or walking. The ability to sing, but not talk well due to a peripheral nerve injury is akin to stating that one can only limp when walking, but can run fantastic.

Anyone have any ideas what may be going on with Micah's amazing singing?

Just as an FYI, another rare complication of tonsillectomy that may lead to speech problems is velopharyngeal insufficiency leading to a hyper-nasal sounding speech. In this situation, there is no nerve damage present. Rather, it is an anatomic problem whereby the soft palate does not 'lift" completely to close off the nasal passage from the mouth. This problem can be surgically fixed.

In any case, best of luck to both men!

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