Bruce Jenner of the Kardashians with Hearing Loss Brain Tumor Scare

Image by jla0379 from Wikipedia

This past weekend, fans of the TV show Keeping Up with the Kardashians found out that Bruce Jenner had what most likely was an asymmetric nerve hearing loss in his high frequencies when he had a hearing test done that lead to a brain tumor scare.

What this means is that his ability to hear was much worse in one ear compared with the other... and it was due to nerve damage rather than earwax or fluid in the ears.

Whenever there is this type of nerve hearing discrepancy between the right and left ears, there is concern for the possibility of a benign brain growth called an acoustic neuroma. As this tumor gets larger, it compresses the hearing nerve causing progressive hearing loss on just one side.

Whenever a significant difference in nerve hearing is found on a hearing test, an MRI scan of the internal auditory canal is performed to look for this or other related tumor. Statistically, there is only a 5-10% risk of an acoustic neuroma with the presence of an asymmetric nerve hearing loss.

Fortunately for Bruce Jenner, no tumor was found and hearing aid placement was pursued.

Now, is it absolutely necessary that an MRI be performed? No, though it is the BEST test to further evaluate.

Alternatively, one can perform serial hearing tests every 6-12 months to monitor for any progressive hearing loss... and if present, than pursue an MRI scan.

One can also get a specialized test called an auditory brainstem response (ABR) which measures how quickly a sound gets transmitted to the brain. If a tumor is present, the signal is delayed whereas if no tumor is compressing the hearing nerve, the signal reaches the brain at a normal speed.

Of course, if the ABR comes back abnormal, than an MRI scan would be recommended as the next step.

Read more about asymmetric hearing loss.

Source:
‘KUWTK’ Recap: Bruce Jenner Might Have A Brain Tumor. Charter 6/24/13

BRUCE JENNER FEARS BRAIN TUMOR IN HEARING LOSS WOES—WATCH THE NEW KARDASHIANS CLIP. E Online 6/20/13.

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Pro Golfer with History of Leukemia and ENT Emergencies

The New York Times published a story about pro golfer Laura Kueny who was diagnosed with acute lymphocytic leukemia at 3 years of age and the harrowing experiences she had to go through to beat the cancer.

It certainly brought back memories when I was a resident at Duke University and was filled with dread whenever I got consulted to evaluate a sick child with leukemia undergoing treatment.

It is breathtaking just how sick such children are... what in a normal child is not considered an ENT emergency like strep throat, tonsillitis, sinusitis, and ear infections, are now considered an emergency. Such common childhood infections can literally kill a child undergoing chemotherapy and/or bone marrow transplant. With cancer treatment, these kids have no immune system and significantly reduced ability to clot due to platelet loss.

Being poked and prodded is a given... but there's also the ENT endoscopies and surgeries that often need to be performed to either save a life or to just figure out what germ is causing an infection so the appropriate powerful antibiotic can be given.

Making a hole in the eardrum as well as nasal endoscopies are routinely performed in order to culture the pus present.

Tonsillectomy surgery can be a particularly harrowing experience for an ENT surgeon as it can be literally life-saving and life-ending all at the same time. A bad tonsillitis can overwhelm what little immune system these children have in spite of antibiotics and emergency tonsillectomy may need to be performed to help the child recover from a potentially lethal infection... BUT... performing this type of surgery when platelet counts may be non-existent can also result in life-threatening blood loss. In the end, the child remains intubated after surgery while getting IV platelet infusions, and the entire oral cavity packed with gauze to provide direct pressure to manually stop bleeding for a few days. Once the gauze packing is removed and no bleeding is seen, extubation can proceed.

Sinus surgery for persistent sinusitis can also result in a nosebleed that just will not stop bleeding thereby requiring prolonged nasal packing.

And is it worth it in the end?

Yes... for what used to be a death sentence has now become one of the more curable cancers.

Source:
Golfer Leaves Hospital as a Survivor, Returns as a Winner. New York Times 6/22/13

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Possible Blood Test for Oral Cancer Caused by HPV?

There might be a blood test which can possibly predict individuals who may develop oral cancer caused by HPV years before it happens. HPV, an abbreviation for human papilloma virus, encompasses over 100 different strains among which only a few can cause problems in humans. Specifically, HPV 16 can lead to cervical cancer in woman and oral cancer in both genders.

HPV triggered oral cancer is also the most common cause of oral cancer now exceeding even smoking and drinking alcohol.

Unlike HPV that causes cervical cancer which can be screened for by pap smears in women, there's currently no good screening test to look for HPV that might cause oral cancer.

However, that's not to say that researchers aren't busy looking for just such a test...

In June 2013, researchers published a possible blood test that might predict those individuals at risk for developing HPV oral cancer.

By analyzing blood samples taken from 638 patients with head and neck cancers, they discovered that antibodies against HPV16 E6 was present in pre-diagnostic samples for 34.8% of patients with oropharyngeal cancer and 0.6% of controls (healthy patients without cancer). Furthermore, HPV16 E6 was NOT associated with other cancer sites. The increased risk of oropharyngeal cancer among HPV16 E6 seropositive participants was independent of time between blood collection and diagnosis and was observed more than 10 years before diagnosis.

Now I should state that HPV16 E6, which is actually a gene found in the virus, only accounted for 34.8% of patients. It bears repeating... it was positive only 34.8% of the time. In other words, this test predicted oral cancer only one out of every 3 patients who actually developed cancer.

As such, it is not a very specific test... ideally, you want a number as close to 100% as possible, otherwise patients who test negative to this blood test may falsely think they are not at risk.

Now, the other problem is what if a patient DOES test positive to HPV16 E6?

Does that mean such patients need to undergo routine fiberoptic endoscopy screening examinations every few months or years? Are biopsies required or not if visual examination appears normal? If biopsies are required, how often and from where? After all, oral cancer encompasses the tongue, tonsil, pharynx, larynx, supraglottis, palate, buccal mucosa, etc, etc, etc. That's a lot of biopsies...

Coincident with the development of a good blood test is the need for research to develop a protocol of what to do with the results of such test information.

Reference:
Evaluation of Human Papillomavirus Antibodies and Risk of Subsequent Head and Neck Cancer. Journal of Clinical Oncology. Published online before print June 17, 2013, doi: 10.1200/JCO.2012.47.2738

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Def Leppard's Guitarist Vivian Campbell's Chronic Cough Due to Lung Cancer

Image from Wikipedia

A chronic cough that's been going on for months to years is an extremely tough problem to figure out due to the many possible triggers including reflux, reactive airway disease, post-nasal drip, allergies, etc.

For Def Leppard's guitarist Vivian Campbell, his chronic cough was ultimately found to be due to Hodgkin's Lymphoma in his chest around his windpipe. In his own word's that he posted on the band's Facebook page (June 10, 2013 post):

“I feel fortunate that my cancer sent me an alarm call in the form of ‘the cough that wouldn’t quit’. Otherwise, how would I have known? After several months of trying every inhaler known to man, my doctor finally had me X-rayed. A further CAT scan revealed that enlarged lymph nodes were doing wrestling manoeuvres on my windpipe – hence the cough. What was causing the enlarged lymph nodes, however, was yet to be determined, so I underwent a surgical biopsy on March 11th, the first day of Leppard rehearsals for our Viva Las Vegas shows. Obviously, I didn’t make it to rehearsal that day, but it’s okay; I know the songs by now…"

Fortunately, compared to other types of lung cancer, Hodgkin's Lymphoma is more indolent leading to vague symptoms like a chronic cough that goes on for months if not years. It is also highly curable.

Just goes to show you that for patients suffering from chronic cough, more needs to be done than just a chest x-ray, breathing tests, and trying out different inhalers.

Sometimes, a CT scan of the chest and even bronchoscopy may need to be performed to fully evaluate pulmonary etiologies for a chronic cough.

And if nothing is found wrong with the lungs... further testing to check out other disease processes that may lead to a chronic cough is required and may include barium swallow, allergy testing, methacholine testing, 24 hour impedance testing, etc, etc, etc.


Media Report:
Def Leppard's Vivian Campbell battling Hodgkin's. USAToday 6/10/13

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OSA is a Risk for Sudden Cardiac Death

Mayo Clinic researchers have determined that not only does OSA (obstructive sleep apnea) lead to increased risk of stroke, cardiac arrest, hypertension, vascular disease, etc but it can also increase the risk of sudden cardiac death, usually due to a fatal cardiac arrhythmia. This conclusion was reached after tracking thousands of men and women with sleep apnea for up to 15 years of whom 142 had sudden cardiac deaths or arrests who were resuscitated.

These sudden cardiac arrests occurred mainly at night, 60 years of age or older, with AHI scores of 20 or greater, and having low blood levels of oxygen. When oxygen saturation was 78% or less, the risk of sudden cardiac arrest increased by 80%. Normal oxygen saturation is 95-100%.

Unfortunately, the study failed to address whether those who used a CPAP machine (continuous positive airway pressure) or underwent surgical intervention to correct the OSA had a reduced risk of sudden cardiac death.

Such surgical intervention to treat OSA include UPPP and base of tongue reduction. Sedated endoscopy may be required to determine where the obstruction occurs anatomically before deciding on a surgical course of action.

Source:
Sleep Apnea May Boost Risk of Sudden Cardiac Death. WebMD 6/11/13

Reference:
Obstructive Sleep Apnea and the Risk of Sudden Cardiac Death: A Longitudinal Study of 10,701 Adults. J Am Coll Cardiol. 2013;():. doi:10.1016/j.jacc.2013.04.080

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Google Search Now Provides Nutritional Information

It is not uncommon for me to recommend a patient to avoid certain dietary things like salt and caffeine, especially when dealing with tinnitus or Meniere's disease among other problems.

The next few questions I often get is "What can I eat than?" What foods contain low salt? etc etc.

Though I can refer a patient to a dietitian who knows the answer to many of these questions off the top of the head, Google may now be the next step to take in the future.

As of June 10, 2013, Google now provides fast and accurate information regarding nutritional information on all sorts of foods. With time, the already large database of foods will increase.

For example...

As it relates to decreasing salt intake, I often recommend somebody with Meniere's or tinnitus to ingest no more than 1000mg of sodium per day.

Given I'm Asian, I happen to use a lot of soy sauce. If I'm curious as to how much sodium is in soy sauce, just google search "How much sodium is in soy sauce?" and you will get the following answer:

Note that you can also specify what type of soy sauce as well as quantity to get a more specific answer.

Cool!

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Taking Too Much Vitamins May Even Cause Cancer

Image by David Richfield from Wikipedia

Too much of anything can be harmful... even vitamins which people seem to consider benign regardless of how much is taken. In fact, taking regular large doses of vitamins  (greater than 150% of what is recommended per day) actually INCREASES the risk of cancer.

To be clear, vitamins and supplements are great, but only when taking the recommended daily amount in a normal, healthy individual. Supplements may be necessary only if there's a deficiency, but not when you are a healthy individual.

The New York Times wrote a nice expose regarding this issue along with why the FDA doesn't say anything about it (vitamin lobbyists passed a law in 1976 prohibiting the FDA from saying anything).

So, let's take a look at the studies mentioned in the NYT documenting the adverse affects of too much vitamins:

The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1994 Apr 14;330(15):1029-35.

"Unexpectedly, we observed a higher incidence of lung cancer among the men who received beta carotene than among those who did not (change in incidence, 18 percent; 95 percent confidence interval, 3 to 36 percent)... more deaths from hemorrhagic stroke were observed among the men who received this supplement than among those who did not. Total mortality was 8 percent higher (95 percent confidence interval, 1 to 16 percent) among the participants who received beta carotene than among those who did not, primarily because there were more deaths from lung cancer and ischemic heart disease."

Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med. 1996 May 2;334(18):1150-5.

"After an average of four years of supplementation, the combination of beta carotene and vitamin A had no benefit and may have had an adverse effect on the incidence of lung cancer and on the risk of death from lung cancer, cardiovascular disease."

Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005 Jan 4;142(1):37-46. Epub 2004 Nov 10.

A dose-response analysis showed a statistically significant relationship between vitamin E dosage and all-cause mortality, with increased risk of dosages greater than 150 IU/d.

Antioxidant supplements for preventing gastrointestinal cancers. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004183.

We could not find evidence that antioxidant supplements prevent gastrointestinal cancers. On the contrary, they seem to increase overall mortality.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2012 Mar 14;3:CD007176. doi: 10.1002/14651858.CD007176.pub2.

We found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. Antioxidant supplements need to be considered as medicinal products and should undergo sufficient evaluation before marketing.

There are many more studies that show the adverse affects of taking mega-vitamins as well as additional studies that show that taking mega-vitamins makes absolutely no difference. Of course, with any medical issue, there are also studies that support the consumption of mega-vitamins, but the studies are not as rigorous nor as conclusive.

What to do?

I would suggest taking a regular multi-vitamin daily which contains enough vitamins to supplement any deficiencies that may occur from insufficient dietary intake... Otherwise, additional vitamin supplementation is not necessary unless a known deficiency is present.

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What are the Most Common Severe Drug-Induced Anaphylaxis?

Image by James Heilman, MD from Wikipedia

Interesting paper came out listing the most common severe drug-induced anaphylaxis. From a database of 333 patients who suffered from anaphylaxis,

• Anaphylactic shock (76.6%)
• Severe systemic reactions (10.5%)
• Acute laryngeal edema (9%)
• Severe bronchospasm (2.1%)
• Fatal in 6 cases (1.8%)

There were 270 cases (81.1%) of ambulatory anaphylaxis. Sixty-three cases (18.9%) occurred during anesthesia.

84 drugs were identified as being responsible for these cases of anaphylaxis.

• Antibiotics (49.6%)
• Muscle relaxants, latex and anesthetics (15%)
• NSAIDS (10.2%)
• Tylenol (3.9%)
• Iodinated or magnetic resonance imaging contrast media (4.2%)
• Allergy shots and vaccines (3.9%)
• Other drugs (13%)

Among antibiotics, amoxicillin (97 cases), other penicillins (four cases), cephalosporins (41 cases), quinolones (15 cases), and pristinamycin (seven cases) were the most common.

Reference:
Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy. 2013 Jun 6. doi: 10.1111/all.12168. [Epub ahead of print]

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At Home Allergy Testing

Recently, a new at-home allergy test can be found on store shelves throughout the United States as well as Amazon.com. It is called "MyAllergyTest" produced by ImmuneTech Corporation and it is FDA approved. The way it works is that you place a few drops of blood into the collection kit which is than mailed to a lab in a pre-paid, pre-addressed envelope.

Results are than obtained via internet or by certified mail in about one week.

What's tested? Only ten things (IgE only):

• Timothy Grass
• Bermuda Grass
• Mountain Cedar
• Short Ragweed
• Alternaria Mold
• Cat Dander
• Mite pternoyssinus
• Egg White
• Wheat
• Milk

As such, if testing comes back normal, it does not mean you do not have allergies... It just means that you do not have allergies to these 10 things only... You could be allergic to other non-tested substances.

A report is produced listing what you are allergic to and how badly:

How accurate is the testing? Apparently, it is comparable to Pharmacia CAP system (specific IgE FEIA).

In terms of actual numbers, the test has a sensitivity 88%, specificity 94%, and accuracy 91%.



Source:
FDA.gov

Company Website

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Sinus Headache [video]

I could describe it... but I think it's better if you just watch the video...

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Dangerous Tongue Patch Procedure for Weight Loss

Image from Wikipedia

There is a clinic in Beverly Hills who has been offering a risky "tongue patch" procedure in order to achieve weight loss of about 30 pounds in a single month. Although this clinic is currently the only one providing this "service" in the United States, it has been performed in Venezuela for quite some time.

In essence, a mesh made of marlex typically used for hernia repair is surgically sutured to the back area of the tongue and left in place for up to one month. While in place, this postage-stamp sized patch causes extreme discomfort if not pain whenever eating leading to a decrease in food ingestion and therefore weight loss. This non-FDA approved procedure is paired with a 800 calorie liquid diet.

In a normal swallow, the back of the tongue is required to help propel food down into the throat. With a patch in place, this step of the swallow becomes disrupted. Watch video to see how swallowing works here.

Does the concept work? In theory yes via starvation (hurts too much to swallow)...

Are there problems with it?

Absolutely and may even be considered highly unethical.

This procedure is associated with substantial risk including difficulty talking (you do need a tongue that moves well to enunciate words), infection, swelling, tissue overgrowth, and potential to dislodge leading to possible airway obstruction.

Why would somebody even consider this procedure? Well, if diet and exercise just doesn't work and financially, a desperate patient can't afford gastric lap band or bypass surgery... that's why some patients have pursued it.

Source:
Tongue Patch Surgery: Risky Weight Loss Procedure Draws Criticism. Yahoo News 6/5/13

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New Movie Trailer for Fauquier ENT YouTube

It has been an amazing experience with how successful our videos have been on YouTube. We now have 60+ different videos of ENT procedures that has been viewed over 247 million times since 2007. We also now have over 12,300 subscribers to our video channel.

To celebrate, a movie trailer of sorts has been created to introduce new viewers to the sort of videos they will see and will continue to see from us.

Check it out! And... if you haven't yet subscribed to our video channel, please do so!

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Former Bills QB Jim Kelly Diagnosed with Jaw Cancer

Image from Wikipedia

Former QB for the Buffalo Bills, Jim Kelly, announced that he has a squamous cell carcinoma of his upper jawbone.

He had been experiencing jaw pain since Dec 2012. When the pain failed to resolve with antibiotics, follow-up testing which probably included a CT scan revealed a cystic mass of the maxillary bone. Removal of this nickel-sized cyst in March 2013 revealed cancer.

Additional testing reported by Jim Kelly showed that the cancer has not spread elsewhere. Such testing may have included bloodwork and a PET/CT scan.

This Friday, a complete cancer resection operation will be performed. Given what information was provided, he will likely have his maxillary bone removed along with a rim of soft tissue until no pathological evidence for cancer is present. A limited neck dissection which entails removal of all the lymph nodes in the neck may also be performed.

Of course, after removal of his upper jawbone, there will be a big hole present. As such, he will likely also undergo simultaneous reconstruction to replace what was removed. Bone, muscle, and soft tissue will likely be obtained from either the leg or arm to reconstruct Mr. Kelly's jawbone.

It is also not unusual to have a feeding tube placed for some time to allow healing before oral intake is allowed.

This operation takes a LONG time... typically anywhere from 4-12+ hours depending on what is found during the operation.

Depending on final pathology which may take up to one week for results, Mr. Kelly may need to undergo further cancer treatment with radiation therapy with or without chemotherapy.

I wish him the best of luck!

Source:
Former Bills QB Kelly battling cancer of the jaw. Boston.com 6/3/13

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Can HPV be Caught by Kissing Someone with HPV Throat Cancer?

HPV transmitted by oral sex is the leading cause of oral and throat cancer now. And for spouses/partners of patients diagnosed with HPV throat cancer, the main concern is whether it is "contagious".

After all, if HPV is transmittable by oral sex, than it would seem that kissing can also transfer HPV to the partner as well.

Well, a small Johns Hopkins study suggests that intimately kissing someone who has HPV oropharyngeal cancer does NOT lead to a new HPV infection in the mouth or throat in the partner. Among 93 partners of 164 patients, prevalence of HPV infection in the throat was no higher than would have been expected. Specifically, about 1.2% had HPV which is equivalent to what one would find in couples without history of HPV throat cancer (1.3%). There were only six male partners, none of whom had oral infection with HPV.

Please keep in mind that this study is far from definitive and further study is required before one can say with absolute certainty that kissing and other intimate activities are totally safe. After all, oral sex leading to HPV infection of the mouth is a relatively recent discovery. Who is to say that with enough time and study, even kissing may eventually be found to do the same???

The study was originally presented at the 2013 annual meeting of the American Society for Clinical Oncology and published in April 2014.

Reference:
Oral Human Papillomavirus (HPV) Infection in HPV-Positive Patients With Oropharyngeal Cancer and Their Partners. Journal of Clinical Oncology. April 28, 2014, doi: 10.1200/JCO.2014.55.1341

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Why Is a Nosejob Sometimes Necessary to Resolve Nasal Obstruction?

A very common complaint for a patient to see an ENT surgeon is to resolve nasal obstruction. The most common surgeries to resolve nasal obstruction include septoplasty, adenoidectomy, and turbinate reduction. All of theses procedure are performed within the nasal cavity and does not affect appearance.

However, sometimes in order to resolve nasal obstruction, the appearance of the nose MUST change especially if the nostril openings are very narrow. By looking at these example pictures of the nostril openings, it's pretty obvious that breathing would be an issue. So even though a nosejob is typically performed for cosmetic reasons, it may also be recommended for medical reasons should nasal breathing be inadequate.

For both these patients, the nasal columella is crooked to one side resulting in one nostril opening being larger than the other which causes nasal obstruction on the more narrow side.

Correction of this crooked nasal columella into a straight and midline appearance would result in improved nasal breathing as well as a change in appearance.

Sometimes the nasal columella may be straight, but the nostril openings are both too narrow leading to nasal obstruction. Correction would require enlarging the nasal opening by use of alar batten and spreader grafts which would result in not only improved nasal breathing, but also a wider nasal appearance overall.

The explanation for why the nasal appearance does not change especially after septoplasty which requires cartilage and bones removal is actually quite simple. The analogy would be a house where the appearance on the outside would not change even though you may knock down a wall between two rooms inside the home.

SO... Here is a side view of the septum. The blue arrow is pointing to the nostril opening and the red arrow is pointing to the lip.

In this picture below, the septum has been removed.

As you can see, the outside appearance of the nose remains unchanged as the rim of the nose is kept intact as shown by the red arrows here:

So that in a nutshell is the explanation for why deviated septum surgery does not change the outside nasal appearance.

Read more about the septoplasty surgery here.

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Medical Translator Commercial...

I'm sure many patients would like a medical translator like this one shown in this humorous commercial. In case you haven't seen it yet...

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