Infographic on Obstructive Sleep Apnea (OSA)

Check out this great infographic by Aviisha Medical Institute (generated from information by PubMed.gov, Medscape, and BioMed Central) on the numerous adverse consequences that can arise from the onset of Obstructive Sleep Apnea (OSA). [Thanks to @hobsonent who brought it to my attention.]

Here's another one regarding how important sleep is:

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The Art of Facial Paralysis

Professional photographer Sage Sohier spent 3 years in a Boston ENT clinic photographing patients suffering from facial paralysis along with family members.

These intimate portrayals document the personal struggles patients with facial paralysis go through that is shared with family. Patients shown include children suffering from this malady.

Her collection of photographs include people with mild to complete degrees of facial paralysis, a condition that usually occurs on just one side of the face and can result from Bell’s palsy, cancer, stroke, accident, surgery, and congenital nerve damage. Sohier documented patients as they progressed through treatment capturing their progress over time, witnessing hope and excitement as they regained the ability to smile, speak, and eat.

Her collective photos resulted in a book About Face as well as a showing of her photographs to be displayed at the New York City Foley Gallery on April 17.

Learn more about facial paralysis here.

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Stroke vs Non-Stroke Facial Paralysis

Image by Patrick Lynch from Wikipedia

A recent blog post about a ER doctor who was found negligent for not pursuing a stroke workup for an isolated facial paralysis did bring up an interesting medical phenomenon about what differentiates a facial paralysis due to stroke vs facial paralysis due to facial nerve inflammation.

To begin, the facial nerve innervates the entire half of the face. The nerve itself exits from the skull behind the ear and sends finger-like branches to all the muscles of the face (nerve is yellow).

So if something happens to the nerve, the entire face including forehead, around the eye, cheek, and lip would become paralyzed.

HOWEVER, if a stroke occurs that knocks out the part of the brain that governs facial movement on just one side, the patient will have facial paralysis only on the lower half of the face. The forehead on both sides will still move just fine!

Why is that?

At the brain level, the facial nerve branch that governs forehead movement is innervated by BOTH sides of the brain. However, the facial nerve branches for the remainder (lower part) of the face is innervated by only ONE side of the brain.

As such, if complete facial paralysis including forehead is present, it is NOT due to a stroke or any other brain problem. This condition is called Bell's Palsy.

If the forehead moves fine, but the rest of the face is paralyzed on one side, than it may be due to a stroke or some other brain-level problem. Of course, with a stroke, one would see not only facial paralysis with forehead sparing, but also paralysis involving other parts of the body (which makes it obvious).

Image by Patrick Lynch from Wikipedia

Take a look at the picture to the left illustrating the facial nerve branches. Nerve branches in solid yellow or orange come from either the right or left side of the brain. Nerve branches in yellow/orange hashes come from both sides of the brain.

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Surgeries on a Weekend Have More Complications

The New York Times published an interesting story regarding how patients with ulcerative colitis suffered significantly more surgical complications when performed on a weekend compared to a weekday. Just how much worse?

The cited research reported that the most common post-operative complication was post-operative infections (Weekend 30% vs. Weekday 20%). However, there was also an increased risk of need for repeat laparotomy, mechanical wound complications, and pulmonary complications. Of note, there was no difference in disease severity between weekend and weekday groups.

Oddly, this increase in complications did not occur with Crohn's disease patients.

Although these findings can not and should not generalize to other surgical procedures, the following logistical issues ARE present when decision for urgent surgery is made after hours or on weekends.

The following issues are probably what prompts this type of research to occur in the first place.

During such off-periods, there are no surgical support staff present in the hospital. They need to be called in from home. As such, there may be a slightly higher time delay before surgery begins. Furthermore, the surgical tech that assists the surgeon may be unfamiliar with the surgery as well as instruments used leading to a surgical procedure that may be "inefficiently" performed.

For example, if I need to take a child back to the OR who is suffering from excessive bleeding after a tonsillectomy, the surgical technician who may be assisting me may be an orthopedic technician unfamiliar with ENT instruments as well as unfamiliar with how the procedure is performed.

Although one may like to select who assists in the surgery, unfortunately, the patient nor the surgeon gets to choose who their surgical support staff is. It is whoever happens to be on-call when the need for urgent surgery arises. You get who you get...

However, during the weekday, the surgical support staff helping with the surgery is the team that does that particular surgery all the time... the "A" team so to speak.

The other factor is the surgeon himself. During the weekday, the patient will most likely have surgery performed by "their" surgeon who knows and is already familiar with the patient.

After-hours or on the weekend, the patient may or may not get the surgeon who knows the patient personally. It would be whoever the on-call surgeon is.

So now you know...

Now to be fair, there have been studies that both support as well as refute the assertion that weekend surgeries/admissions place patients at elevated risk of complications.

Source:
Weekends Worse for Surgery. New York Times. 3/22/13

Reference:
Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease. AP&T Article first published online: 4 MAR 2013. DOI: 10.1111/apt.12272

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ER Doc Found Negligent in Bell's Palsy Case

This case is not quite what you might think...

Here's the background... The Wisconsin State Supreme Court  found an ER physician negligent for failing to offer a carotid ultrasound for a patient who presented with an isolated facial paralysis (patient did not exhibit paralysis anywhere else in the body) and upheld a $2 million jury award to the patient in 2008. Not only that, the Wisconsin Medical Board reprimanded the ER physician and fined her $300. [link]

Hmmmm... After all, it is not considered routine nor standard of care to obtain a carotid ultrasound for an isolated facial paralysis known as Bell's palsy. I should also mention that the ER physician was NOT found negligent in the diagnosis of Bell's palsy.

Well, here's the other part of the story... The patient did have a CT scan of the brain in the ER which was normal. A diagnosis of Bell's palsy was appropriately made by the ER physician and the patient sent home. Eleven days later, the patient suffered a stroke with irreversible damage. A stroke workup at that time revealed a carotid artery with 95% obstruction.

For those uninitiated, paralysis due to a blocked carotid artery would cause lack of blood flow to one entire half of the brain resulting in not only facial paralysis, but also paralysis of half the body too. Furthermore, a stroke causing facial paralysis would have forehead sparing (more on this).

The court's feeling was that the patient should have been offered a carotid ultrasound at the time of the initial ER visit for Bell's palsy... in essence, the court was stating a stroke workup should have been offered/done for a Bell's Palsy. I should also mention that most ER's do not have carotid ultrasound capabilities outside of business hours.

To reiterate, a carotid ultrasound is NOT a test that a physician would or should normally order for a Bell's Palsy workup. By the court stating a carotid ultrasound should have been performed, it has turned a medical condition of Bell's palsy which is not a stroke concern into a diagnosis of possible stroke.

Does that now mean that whenever a patient presents with a Bell's palsy, a stroke protocol should also be pursued which would include:

1) Stroke rapid response by the ER
2) Hospital admission
3) Stroke workup which would include:
  • Carotid ultrasound
  • MRI Head
  • Cardiac workup for arrhythmias (atrial fibrillation which can cause embolic stroke)
  • Pulmonary and vascular workup for deep venous thrombosis (can also cause embolic stroke)
etc, etc, etc

Medically speaking, Bell's palsy is NOT a stroke nor a concern for possible stroke nor increased risk of stroke. Bell's palsy is an isolated inflammation of the facial nerve that has nothing to do with the brain.

ER physicians have a hard enough job as it is now, but to be responsible for pursuing workups for totally unrelated diagnosis separate from the main presenting concern should be cause for concern.

Perhaps there is more to this case that was absent from what has been reported in the media...

Source:
State board reprimands doctor who was found negligent by high court. Wisconsin State Journal 3/21/13

Health Sense: How much should doctor tell you? Wisconsin State Journal 7/9/12

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Mal de Debarquement Syndrome - Rare Cause of Dizziness

The BBC recently printed a story describing a rare condition called mal de debarquement which causes dizziness, typically after a boat cruise, though can occur with airplane flights and even a long drive in a car with switchbacks (going up/down a mountain).

Two signs that a patient has mal de debarquement are if they feel a rocking sensation for weeks or months starting AFTER a cruise and two, if they're much better when in motion like vigorous exercise, but feel much worse when staying still.

Read the story here.

Unfortunately, no great treatment for this condition beyond displacement type exercises (walking, running, bicycling... but NOT on a treadmill or stationary bike).

This condition was also in an article by the Washington Post in 2010.

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Some Facts About Q-Tips and Ears

In this week's episode of "Girls" (Season 2; Episode 9 "Girls Gets Dark"), Hannah grappling with OCD, inserted a Q-tip deep into her ear canal and "heard air hiss out the hole" due to perforating her eardrum.

Although this scene came out of a TV show, this scenario is not uncommon and results in many ENT office visits every month for not only eardrum perforations, but bleeding due to trauma to the ear canal skin.

Some facts about Q-tips as it relates to the ear...

It should never be used to clean earwax within the ear canal. In fact, on Unilever's website (the maker of Q-tips), the company explicitly states that Q-tips should only be used to "gently around the outer ear, without entering the ear canal." [link]

In fact, the word "ear" appears less than a dozen times on the entire Q-tip website.

Apparently, Q-tips are meant for many other uses beyond ears which play only a very small role in the world of Q-tips.

• Cleaning tiny spaces in ventilator grates
• Applying polishes to silverware
• Dust picture frames
• Clean keyboards and the computer screen
• Applying wood stain
• Clean tracks and grooves of medicine cabinets
• Clean small compartments of washing machines
etc, etc, etc

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Dr. Chang Quoted in the Wall Street Journal

The Wall Street Journal on 3/15/13 published a story on how voice therapy and vocal surgery can dramatically improve a person's vocal quality... seemingly taking years away from how you sound.

In this story, Dr. Chang was quoted a few times and even included a patient he has treated successfully with voice surgery to restore his voice.

In regards to how aging can create muscle atrophy and bowing resulting in:

"It creates a breathy, raspy voice," says Christopher Y. Chang, an otolaryngologist at Fauquier Ear, Nose & Throat Consultants in Warrenton, Va.

Later in the WSJ article, surgical intervention is discussed and introduced Mr. James Driver, a Warrenton, VA jewelry repair storeowner who Dr. Chang treated:

"In the procedure, called injection augmentation of the vocal folds, a doctor threads an endoscope through the patient's nose or mouth into the throat, then injects a tiny amount of collagen, fat, hyaluronic acid or a gel filler into the vocal cords to plump them up. The substances usually last three to six months. If the procedure works, a doctor may recommend inserting silicon or Gore-Tex implants to fatten the cords permanently.

In 2011, James Driver was felled by an episode of temporary paralysis that left one of his vocal cords frozen. The 57-year-old owner of a Virginia jewelry-repair business worked with a therapist and did throat exercises on his own, but he could only manage a whisper. "You had to be right next to him with your ear to his mouth" to hear him, says his wife, Erin.

The couple sought out Dr. Chang, who recommended an injection. The day after the procedure, Mr. Driver was speaking at near regular volume. A year later, he's still going strong, though he hears his own voice as being slightly raspier than it used to be. "It made a huge difference," Mrs. Driver says."

 Read the full article here.

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Diagnose Cancer with Flash of a Light!

Traditionally, cancer is diagnosed by a surgical biopsy with pathology results taking days later. Supportive evidence for a cancer is also determined based on visualizing the lesion as well as radiological studies (CT, MRI, Ultrasound, etc).

However, there is a very exciting breakthrough technology that may be able to make a cancer determination under 1 second with only a flash of a light... meaning no biopsy with associated pain and scar to go along with it.

Called Verisante Aura, a probe emits a light that non-invasively analyzes a lesion by scanning 21 different cancer biomarkers at the cellular level using Raman spectroscopy.

Raman spectroscopy (RS) is a technology that involves shining a laser onto a material and interpreting the reflected light to learn more about its biochemical composition.  Healthy cells have a different reflected light "fingerprint" compared with diseased cells. Although this technology won the Nobel Prize in 1930, such RS units used to be huge and complicated machinery to operate. Fortunately, only recently has RS units been miniaturized and made robust enough to be idiot-proof to operate by Canadian researchers.

How accurate is it?

It has up to 99% accuracy leading to potential reduction in unnecessary biopsies by 50 to 100 per cent [link]. Given each scan is under 1 second, a complete body scan can also be accomplished in a single office visit. However, in order to obtain sensitivities between 95% and 99%, the specificities did range between 15% and 54% which is comparable to clinical examination and other optical-based methods.

The one caveat is that the probe needs to be able to shine a light directly on the suspicious lesion... meaning it is applicable only for lesions found on the skin and body cavities (mouth, colon, esophagus, etc)... not lesions under the skin (like a thyroid nodule). The lesion also needs to be larger than 3.5mm in size.

With such instant diagnostic accuracy, it would not only revolutionize in the diagnosis of cancer, but also in treatment! The big question mark for any surgeon is "did you get all the cancer out"? Well, with this probe, one could just scan the wound bed after excising the cancer and see if there's any residual cancer left behind that needs to be removed further. In essence, every surgeon can now perform a Mohs-like resection instantly and without need for pathology assistance with frozen sections.

Verisante Aura is currently approved for use in Canada, Europe, and Australia... but not yet available in the USA pending FDA approval.

Source:
Simply Amazing! Instantly Diagnose Melanoma with the Flash of a Light. Forbes 3/14/13

Reference:
Real-time Raman spectroscopy for in vivo skin cancer diagnosis. Cancer Res. 2012 May 15;72(10):2491-500. doi: 10.1158/0008-5472.CAN-11-4061. Epub 2012 Mar 20.

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Kim Kardashian Gets Allergy Testing

Celebrity Kim Kardashian of Keeping up with the Kardashians reality TV show underwent allergy testing with Dr. Mirmelli. Allergy testing was accomplished via skin prick (our office performs allergy testing by blood draw instead called immunocap).

She apparently was allergic to her pet cat...

Kim apparently decided to let her pet cat Mercy go... a decision in contrast to what most cat-allergic people do.

Watch the video.

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Book on Hoarseness

My fellowship mentor, Dr. James Thomas, taught me much of all I know about the voicebox both when it works and when it doesn't leading to hoarseness.

Much of his knowledge is imparted in a book he wrote which is now available for purchase on Amazon.com. Although healthcare professionals interested in the voice will find the book very helpful, it is written in such a way that any layperson without a medical background can also find it understandable and helpful.

Check it out here!

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Hearing and Understanding ONE Voice Among Many Sounds

Have you ever wondered how is it that a normal hearing human being can hear and understand one person talking in an environment where there are many other people talking just as loudly be it a restaurant, conference, county fair, etc?

How is it that you can hear and understand one particular person over another, even if they are both talking equally loud?

Researchers are just beginning to understand how a human does it... Before explaining, lets use an analogy.

In the past, I used the analogy of an old antenna based radio to explain how human hearing works... A given antenna radio has a volume knob that one can adjust up or down (as would occur with a hearing aid) as well as antenna reception which allows one to get a clear signal vs one full of static.

The ear is like the volume knob and the brain is the antenna... As such, if the reception is bad and there's a lot of background static, a person will have a hard time understanding what is being said on the radio... regardless of whether the volume knob is turned up all the way or not.

Similarly, if the brain is not filtering out the background noise to isolate the sound or person you want to hear and understand, you will have a hard time understanding what is being said.

While the ear indiscriminately hears everything, I've always just stated "the brain" acts to filter out the background noise you don't want to hear, but nobody really understood how, until recently...

Researchers in New York determined that there are different regions of the brain that perform this sound filtration that is completely separate from the auditory cortex (part of the brain that "hears" sounds transmitted from the ear).

Furthermore, the brain areas responding only to the selected voice constantly fine-tunes the reception to allow further improvement in comprehension over time... just like fiddling with an antenna to get as clear a signal on a radio station.

If the brain is not able to properly focus and filter the sound, the individual will have a hard time understanding conversation in a noisy environment, regardless of whether the person has normal hearing or not (for example, in patients with ADHD).

Of course, if hearing loss is also present along with an unfocused brain, it just makes it that much harder (for example, in the elderly who not only have hearing loss, but also decrease in brain function as well).

On the opposite extreme are people who make their living focusing on a specific sound among many sounds and have much greater ease in understanding people talking in a noisy environment. Take professional musicians in an orchestra who excel at hearing a single instrument during a Beethoven orchestral performance.

Source:
Hear That? In A Din Of Voices, Our Brains Can Tune Into One. NPR 3/6/13

Reference:
Mechanisms Underlying Selective Neuronal Tracking of Attended Speech at a “Cocktail Party”. Neuron, Volume 77, Issue 5, 980-991, 6 March 2013

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The Facial Triangle of Danger (Even Death)

Image by SpooSpa from Wikipedia

If you draw a line between the eyebrow to the corners of the lip, a triangle is created which delimits a region esoterically known as the "danger triangle".

Why is this region considered dangerous?

It's because infections within this region can lead to infections of the brain (rarely). Why? The blood supply within this triangular area communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a rip-roaring pimple of the upper lip, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

The cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain and potentially can even lead to death if not treated promptly and aggressively.

Of course, tiny infections like a small pimple or a small laceration due to biting a lip is not going to cause problems.

However, rapidly progressive major infections of the skin with abscess formation do need to be treated cautiously.  Typically, such patients are hospitalized on IV antibiotics until definite and significant improvement can be seen at which time patients can be discharged home on oral antibiotics.

At which point a "minor" infection becomes "major" requiring hospitalization is a judgement call.

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Do Surgeons Swear When Operating?

Surgeons, whether deserved or not, have a reputation of being mean-spirited and foul-mouthed as a group overall. It does not help that TV shows and movies perpetuate this reputation.

Well, a study was actually carried out to see if surgeons are truly foul-mouthed or not and published their findings in the British Medical Journal in 1999.

Using a grading system based on how bad the swearing is, researchers secretly tallied how often surgeons used profanity in the operating room.

The observation was carried out over 100 operations totaling 80 hours and 30 minutes of operating time.

What they found was that orthopedic surgeons were found to be the most foul-mouthed with an overall score of 41 (zero being no swearing at all).

ENT surgeons had the best score of 2 when one surgeon exclaimed "bugger" during one case.

Here's the chart...

Taken from BMJ

Reference:
Surgeons swear when operating: fact or myth? BMJ 1999; 319 doi: http://dx.doi.org/10.1136/bmj.319.7225.1611 (Published 18 December 1999)

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The Problem with Universal Healthcare

I usually hit the delete key whenever I get a chain email... But this particular one caught my eye enough for me to read the whole thing. This story is probably impossible to prove or disprove (I tried to find the name of this professor), but the overall message was quite intriguing... enough so to share given its applicability to universal healthcare.

My healthcare commentary is provided after the end of the story below (to preface, I believe in a compromise of sorts... I guess I'm a centrist)...

An economics professor at a local college made a statement that he had never failed a single student before, but had recently failed an entire class. That class had insisted that Obama's socialism worked and that no one would be poor and no one would be rich, a great equalizer.

The professor then said, "OK, we will have an experiment in this class on Obama's plan".. All grades will be averaged and everyone will receive the same grade so no one will fail and no one will receive an A.... (substituting grades for dollars - something closer to home and more readily understood by all).

After the first test, the grades were averaged and everyone got a B. The students who studied hard were upset and the students who studied little were happy. As the second test rolled around, the students who studied little had studied even less and the ones who studied hard decided they wanted a free ride too so they studied little.

The second test average was a D! No one was happy.

When the 3rd test rolled around, the average was an F.

As the tests proceeded, the scores never increased as bickering, blame and name-calling all resulted in hard feelings and no one would study for the benefit of anyone else.

To their great surprise, ALL FAILED and the professor told them that socialism would also ultimately fail because when the reward is great, the effort to succeed is great, but when government takes all the reward away, no one will try or want to succeed. Could not be any simpler than that. (Please pass this on) These are possibly the 5 best sentences you'll ever read and all applicable to this experiment:

1. You cannot legislate the poor into prosperity by legislating the wealthy out of prosperity.
2. What one person receives without working for, another person must work for without receiving.

3. The government cannot give to anybody anything that the government does not first take from somebody else.

4. You cannot multiply wealth by dividing it!

5. When half of the people get the idea that they do not have to work because the other half is going to take care of them, and when the other half gets the idea that it does no good to work because somebody else is going to get what they work for, that is the beginning of the end of any nation.

Healthcare is complex, but for simplicity's sake, universal healthcare is a type of socialism/communism... Medical care costs a LOT of money... It's not fundamentally free.  As such, if everybody universally can get free healthcare coverage, somebody has to pay... which typically means those who are wealthier ends up paying for those who can't afford it.

This also means that universal healthcare cannot provide "expensive" treatment for everybody... whether it be cancer treatment, the latest robotic throat surgery, or the newest type of test.

Rather, in order to pay for healthcare given to those who otherwise would not have any, healthcare coverage at the top end is decreased which includes the latest and greatest types of medical treatment.

As such, the "wealthy" will not only grow resentful for paying into this universal healthcare, but also because they would not be able to obtain the greatest medical care due to lack of coverage in such a system.

So, the wealthy will flee this system in some way... but with the exit of the wealthy, there will be less money in the system to pay for universal healthcare which would lead to an overall decrease in coverage for everybody else still in the system.

In some ways, we already do have a form of universal healthcare for those who can't afford it in the form of Medicaid and Medicare. Those who work (the "wealthy") pay taxes to fund these programs for those who do not work or are too poor to afford healthcare.

These programs DO provide good BASIC healthcare services. But these programs also do NOT pay for the latest and greatest in medical treatment either... Such treatment even extends to the doctors you are able to see. Some physicians no longer accept Medicare or Medicaid insurance as reimbursement for services are too low.

When looking into the origin of this story (which appears to have surfaced in 2009), I encountered another similar story:

A young woman was about to finish her first year of college. Like so many others her age, she considered herself to be a very liberal Democrat, and among other liberal ideals, was very much in favor of higher taxes to support more government programs, in other words, redistribution of wealth.

She was deeply ashamed that her father was a rather staunch Republican, a feeling she openly expressed. Based on the lectures that she had participated in, and the occasional chat with a professor, she felt that her father had for years harbored an evil, selfish desire to keep what he thought should be his.

One day she was challenging her father on his opposition to higher taxes on the rich and the need for more government programs. The self-professed objectivity proclaimed by her professors had to be the truth and she indicated so to her father. He responded by asking how she was doing in school.

Taken aback, she answered rather haughtily that she had a 4.0 GPA, and let him know that it was tough to maintain, insisting that she was taking a very difficult course load and was constantly studying, which left her no time to go out and party like other people she knew. She didn't even have time for a boyfriend, and didn't really have many college friends because she spent all her time studying.

Her father listened and then asked, 'How is your friend Audrey doing?' She replied, 'Audrey is barely getting by. All she takes are easy classes, she never studies, and she barely has a 2.0 GPA. She is so popular on campus; college for her is a blast. She's always invited to all the parties and lots of times she doesn't even show up for classes because she's too hung over.'

Her wise father asked his daughter, 'Why don't you go to the Dean's office and ask him to deduct 1.0 off your GPA and give it to your friend who only has a 2.0. That way you will both have a 3.0 GPA and certainly that would be a fair and equal distribution of GPA.'

The daughter, visibly shocked by her father's suggestion, angrily fired back, 'That's a crazy idea, how would that be fair! I've worked really hard for my grades! I've invested a lot of time, and a lot of hard work! Audrey has done next to nothing toward her degree. She played while I worked my tail off!'

The father slowly smiled, winked and said gently, 'Welcome to the conservative's philosophy.'

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