Death From a Severe Nosebleed

Image by RIs from Wikipedia

Attila the Hun was one of the most feared enemies of the Roman Empire. Ruler of the Huns from the year 434 until his death in 452, his empire stretched from Ural River to the Rhine River and from the Danube River to the Baltic Sea.

Although there are numerous theories as to how he died, the conventional account is that he died from a severe nosebleed on his wedding night.

Some may scoff that only people in historical times die from nosebleeds... but it unfortunately still even happens in the present.

Yes... a life-threatening nosebleed can be fatal whether a historical figure like Attila or a modern day individual. And I am talking in people who are otherwise completely healthy (no hemophilia, ITP, Osler-Weber-Rendu, etc).

Indeed, a Seattle lawyer died from a nosebleed in 2008.

Two British individuals died from a nosebleed in 2008 and in 2011.

And those are just the ones that are reported in the media.

It is estimated that in 1999, 4 out of 2.4 million deaths in the United States was due to a nosebleed [link].

Fatal nosebleeds in a normal healthy individual are almost always due to an arterial bleed, notably the sphenopalatine artery located in the back of the nose. Other less common fatal nosebleeds may be attributable to the ethmoid arteries located in the top of the nasal cavity.

Treatment of such life-threathening nosebleeds depends on the situation, but may include:

• Nasal packing
• Embolization
• Surgical

Cautery as shown in the video below is rarely successful.

Sources:
Man died after suffering two-hour nose bleed. Mirror News 11/24/11

Man Dies From Severe Nosebleed. ABC News 12/2/11

Woman sues hospital after her husband dies of nosebleed. KOMONews 5/4/13

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Vocal Cord Tear Silences R&B Singer Frank Ocean

Image by Fred von Lohmann from Wikipedia

On July 25, 2013, R&B singer Frank Ocean was forced to cancel his entire Australian concert tour due to a small vocal cord tear.

After singing his opening night with a sore throat during which he reportedly sounded "noticeably off-key," he seeked medical attention and was informed of the unfortunate condition of his vocal cord. Listening to his voice on this YouTube video recorded during this fateful concert, his voice actually does not sound as bad as I would expect with a vocal cord tear. However, at time point 1:20, there was an obvious pitch break.

If a vocal cord tear was truly present, it must have been extremely small and not along the free edge because even with a small vocal cord tear located along the vibrating margin, the vocal quality would have been noticeably degraded throughout the vocal range. Why?


In order for the vocal cords to produce a clear voice, the vocal cords must come together and vibrate evenly. This vibration occurs on the vocal cord mucosa. ANYTHING that disrupts this mucosal vibration would result in a raspy voice including small bumps like a nodule or polyp, but also a vocal cord tear. Watch video of normal vocal cords in motion.

Small bumps typically cause problems in the voice only in the high range at quiet volumes because often the bump can vibrate along with the mucosa (just like a buoy on the ocean). As long as the vibration is unaffected, the voice comes out. As a bump gets bigger, a greater portion of the vocal range becomes affected.

A tear, however, depending on where it is located could affect the entire vocal range due to vibratory disruption as it moves to and around the tear (the tear acts like an anchored pillar in the ocean).

The only way to correct a tear is MANDATORY strict voice rest for several weeks. Further using the voice when injured like this may only "rip" the tear larger potentially causing a greater risk of scar formation and a permanent hoarse voice.

Strict voice rest means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the vocal cord tear preventing proper healing. I would 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.

Here's an example picture of a vocal cord tear on both vocal cords in a patient suffering from viral laryngitis who did not quit using her voice for a prolonged period of time.

WHY would a vocal cord tear appear in the first place? Usually from excessively traumatic vocal abuse (ie, strong cough, scream, yell, etc).

Source:
Frank Ocean Suffers Tear to Vocal Cord, Scraps Australian Mini-Tour. Billboard Biz 7/26/13

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Popular Nasal Decongestants Associated with Birth Defects

Researchers have discovered that there is a very small, but significant association between birth defects and use of nasal decongestants in the first trimester of pregnancy. Unfortunately, decongestants (ie sudafed, afrin, etc) are also one of the most popular medications purchased over-the-counter to treat symptoms of nasal congestion, runny nose, and allergies.

In particular, three strong associations were found:

• Phenylephrine and endocardial cushion defects
• Phenylpropanolamine and ear defects
• Phenylpropanolamine and pyloric stenosis

Although these associations were related to ORAL decongestant use and first trimester intake, it was also found that intra-nasal decongestant use during the first trimester was associated with pyloric stenosis and tracheo-esophageal fistula.

Taken in summary, it is perhaps ideal that women in their first trimester of pregnancy avoid decongestant use due to a possible association between birth defects and medication usage. This association accounts for a VERY small percentage increase in birth defects and as such more study is needed.

For example, the baseline prevalence of endocardial cushion defect is 0.34 per 1,000 live births. Phenylephrine exposure increases this risk 8-fold resulting in 2.7 per 1,000 live births. That's an overall increased risk of only 0.27%.

Keep in mind that all these over-the-counter products contain a decongestant ingredient:

• Afrin
• Sudafed
• Tylenol Cold Multi-Symptom Nighttime
• Alka-Seltzer Plus Cold
• Delsym Night Time Multi-Symptom
• Tylenol Cold Multi-Symptom Severe
• Tylenol Cold & Flu Severe
• Vicks Dayquil Cold & Flu Relief
• Benadryl Allergy Plus Sinus Headache
• Theraflu Warming Relief Nighttime Severe Cold & Cough
• Vicks Nyquil Sinus
• Acutrim
• Dexatrim
• Afrin
• Zicam
etc, etc, etc

So what is a pregnant woman to do if her nose gets all stuffed up and wants to avoid decongestant medications to eliminate any possible risk of birth defects? Click here for some suggestions.

Source:
Use of Decongestants During Pregnancy and the Risk of Birth Defects. Am. J. Epidemiol. (2013) doi: 10.1093/aje/kws427

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Swimming Pools, Poop, and Ear Infections

So here's an interesting statistic... The average person has 0.14 grams of feces on their rear end. If a person does not shower prior to swimming, that 0.14 grams of stool gets washed off into the swimming pool. Kids tend to have a bit more stool on their rear end (up to 10 grams). [statistic taken from CDC as reported by NBC News]

That means if 100 individuals enter the swimming pool in any given day without showering beforehand, anywhere from 14 grams to 1 kilogram of stool enter the swimming pool water (0.03 - 2.2 pounds).

Although sunlight, chlorine, and filtration helps clean the water, it takes time (and is why a swimming pool is shut down the rest of the day when an obvious code brown occurs).

The stool issue is worse in lakes and oceans where you can add animals using such bodies of water as a toilet.

It may be one reason among many why swimming leads to increased risk of ear infections. Otitis externa (aka swimmer's ear) if the infection involves the ear canal skin or otitis media when an ear tube or a hole in the eardrum is present. It's also one reason why some ENTs recommend wearing ear plugs.

Now that's all very interesting... but perhaps the biggest question is HOW in the world did the CDC determine how many grams of residual stool on average is present on people's rear ends (kids and adults)??? Anyone know the answer to this? I would love to know the reference... I imagine that perhaps a bunch of GI docs who were performing colonoscopies scraped as much residual feces around people's bungholio prior to the colonoscopy and some poor technician had the unenviable task of weighing the scraped material.

Source:
No. 1 swimming pool problem? It's number two!. NBC News 5/16/13

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Vaccine to Prevent Throat Cancer

Spread through oral sex, it is well established that human papilloma virus (HPV) types 16 and 18 cause the vast majority of throat cancer especially in men... even more than smoking and drinking alcohol. What was not known, but suspected, was whether in BOTH men and women the HPV vaccine Cervarix (made by GSK) or Gardasil (made by Merck) would help prevent throat cancer as effectively as cervical cancer for which it is FDA approved for.

At least for the vaccine Cervarix, a randomized, control, double-blinded, prospective study has shown that it highly protects individuals from HPV 16 and 18 infection in the mouth/throat. The vaccine efficacy was calculated to be 93.3%. The big assumption being that reduced oral HPV 16/18 would lead to a decreased risk of throat cancer.

It is for these reasons that BOTH boys and girls are encouraged to get the HPV vaccine. We are talking about protecting our sons and daughters from getting throat and cervical CANCER later in life.

To be clear, more study is needed to really PROVE that such vaccines prevent throat cancer. For full disclosure, the weaknesses of this current study are as follows:

• It was performed only in women (the study would need to be replicated in males)
• The study lasted only 4 years... the question is whether life-long protection is present or will booster shots be needed?
• Does Gardasil also work for oral HPV 16/18?
• Does reduced HPV 16/18 presence in spit actually translate to decreased risk of throat cancer
• It is suspected that vaginal secretions carry a higher HPV viral load than the penis leading to a higher risk of throat cancer in men performing oral sex on infected women. As such, the other questions that need to be answered is whether such vaccines will:
     • Prevent a vaccinated woman from giving HPV to the man as well as
     • Prevent an infected woman to actually infect a vaccinated man?
     • Or, does BOTH partners need to be vaccinated to prevent HPV throat cancer?

It is truly an exciting time when vaccines can be given to prevent not only infections like mumps or shingles, but also cancer!

As a reminder, the HPV vaccines ONLY work when given to children before they become sexually active. It is too late to give the HPV vaccine for sexually active adults (ie, it won't work).

Source:
HPV Vaccine Found to Help With Cancers of Throat. NYT 7/18/13

Reference:
Reduced Prevalence of Oral Human Papillomavirus (HPV) 4 Years after Bivalent HPV Vaccination in a Randomized Clinical Trial in Costa Rica. PLOS One

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Maggots in the Ear After Trip to Peru

Image from Wikipedia

Adventurous international travelers have to worry about malaria and safe drinking water, but for one 27 years old British woman, she also had to contend with a maggot infestation in the ear after a trip to Peru.

It was not quite the 57 maggots found in one Illinois woman, but apparently this traveler recalled walking thru a fly swarm in Peru and that one fly did briefly enter her ear canal. However, it was enough for the fly (New World Screwworm fly) to lay its eggs causing maggots to hatch and slowly eat away her ear canal causing severe pain and scratching sounds within her head.

Surgery was required to remove the maggots. Less aggressive attempts to remove would only cause the maggots to burrow even deeper into her ear/head. Potential damage from the maggots include permanent hearing loss for obvious reasons, but also facial paralysis and taste changes given the facial nerve and chorda tympani (taste nerve) pass through the ear as well.

Fortunately, all maggots were successfully removed without any permanent damage.

Source:

British Woman Discovers Flesh-Eating Maggots Inside Her Ear. Medical Daily 7/16/13.

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We Now Offer Rapid Saliva Test to Look for Laryngopharyngeal Reflux

When you compare a spit test to the current way of how throat level reflux (LPR) is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

And we are one of the very few offices in the United States that offer this spit test. Even major laboratory companies like Labcorp and Quest do not offer this test yet.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

The steps to the test are as follows:

   

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is RDbiomed (in Europe) using their Peptest kit.

This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. Due to a special arrangement our office has with RDBiomed, the Peptest kit can be obtained in our office at a discounted price of $125 (compared to normal price of $175). Price includes the kit, test supplies, and courier shipping service.

Please note that this testing is ONLY offered to current patients of ours.

However, if you are not a current patient of ours, you can order this test yourself online as an individual without a visit to our office. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

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Treatment for Vocal Tremor

Vocal tremor is characterized by a rhythmic undulating vocal quality whenever talking, much akin to vibrato that can not be turned off. In the past, it was felt that use of botulinum toxin type A (botox) to treat vocal tremor was not possible nor realistic given the multiple muscle groups involved. This is in contrast to dystonias of the voice (i.e., spasmodic dysphonia) where only one muscle group is involved and is readily and easily treated with botox injections to the affected vocal cord muscle.

However over the past few years, several research papers have been produced that show that botox CAN alleviate (though not eliminate) vocal tremor both objectively and subjectively, though more than one site may need to be injected in order to produce vocal tremor relief. Such muscle sites include thyroarytenoid muscle, ventricularis muscle, lateral cricoarytenoid muscle, interarytenoid muscle, cricothyroid muscle, and strap muscles.

All these muscle sites are easily accessible either via, endoscopic guidance and/or EMG guidance alone. Indeed, physicians who already perform botox injections for spasmodic dysphonia should also be able to inject all the other muscle groups just as easily. [watch video]

Typically, "horizontal" vocal tremor is treated with thyroarytenoid, ventricularis, interarytenoid, and/or lateral cricoarytenoid muscle botox injections.

"Vertical" vocal tremor is treated with strap muscle botox injections.

Dosages are similar to that given to treat spasmodic dysphonia.

SO... for patients suffering from vocal tremor who do not respond well to oral medications (propranolol, primidone), consider botox injections!

Be aware that botox injections to treat vocal tremor may not be covered by insurance.

References:
A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope. 2013 Apr 1. doi: 10.1002/lary.24073. [Epub ahead of print]

Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep;61(9):1416-20.

Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope. 2000 Aug;110(8):1366-74.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 2004 May;113(5):349-55.

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Singer Carnie Phillips Suffered from Bell's Palsy

Image by InSapphoWeTrust from Wikipedia

In March 2013, singer Carnie Phillips (of the Wilson Phillips) revealed that she suffered from a sudden left facial paralysis due to a condition known as Bell's Palsy.

Through a series of tweets, it was apparent that it came fast and started improving within a week.

Thought to be due to a viral infection of the facial nerve, it is commonly treated with prednisone with or without an anti-viral antibiotic (ie, valtrex). For most patients, full recovery occurs, but in some, normal facial movement is never regained.

For more info on facial paralysis, click here.

Source:
Carnie Wilson of Wilson Phillips reveals she has Bell's palsy. LA Times 3/19/13

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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What Reflux Meds are Best in Infants and Children?

Once a decision is made to start medications beyond the conservative ways of dealing with reflux, the most common reflux medications used to treat adults are also used to treat reflux in infants and children. They are the same exact medications, albeit at lower dosages.

Although the effectiveness of such drugs are clear in adults suffering from acid reflux, it is less so in children. As is true with so much of medicine, there's no clear answer to the question of what the best reflux med is for infants and children. According to one review of literature, the answer is decidedly mixed and variable depending on what outcome was looked at (subjective symptom improvement or objective test findings).

In fact, symptom improvement (or lack of) did not always correlate with objective test findings (24 hour testing, barium swallow, EGD, etc) of reflux improvement and vice-versa. The most common finding was reduction in reflux based on tests, but no significant improvement in symptoms. Such findings does bring into question whether the diagnosis of reflux was even accurate.

In any case, when looking at SYMPTOMS in infants (less than 12 years of age) use of proton pump inhibitors was decidedly not favorable (one study in support and 4 against). In children (over 1 year of age), proton pump inhibitors were found to be equally effective to alginates and ranitidine.

When looking at OBJECTIVE test findings, proton pump inhibitors were found to be equally effective in both infants and children compared with placebo, alginates, or ranitidine. For reducing histologic aberrations, proton pump inhibitors showed no difference compared with ranitidine or alginates.

Conclusion
If GERD symptom control is the main goal, proton pump inhibitors should not be used in infants. In older children, these medications are helpful but potentially no better than alginates and zantac which have better side effect profiles. As is true with most studies, more study is needed.

Reference:
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. doi: 10.1542/peds.2010-2719. Epub 2011 Apr 4.

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Medications that (Might) Help Tinnitus?

The blunt answer is that there is no drug or supplement that has been consistently found to help with tinnitus (ringing of the ears).

Here's a partial table showing all the research that has been done either proving or disproving effectiveness to treat tinnitus (info collected from this review paper).

For a more comprehensive list going over 17 drugs, click here.

Drug	Research That Supports	Research That Disputes	Conclusion
Benzodiazepines (alprazolam, diazepam, clonazepam)	#1, #2, #3, #4	#1, #2, #3	Caution due to addiction and may worsen tinnitus if stopped.
Antidepressants (nortriptyline, amitriptyline, trimipramine, sertraline, paroxetine)	#1, #2, #3, #4, #5	#1, #2, #3, #4, #5, #6	TCA may benefit only in patients with depression symptoms
Anticonvulsants (carbamazepine, gabapentin, vigabatrin, tiagabine)	#1, #2, #3, #4, #5, #6, #7, #8, #9	#1, #2, #3, #4, #5, #6, #7	Mixed results
Antiglutamatergics (caroverine, memantine, acamprosate)	#1, #2, #3, #4	#1, #2, #3, #4	No conclusion.
(Anti)Dopaminergics (sulpiride, piribedil)	#1, #2, #3	#1	Studies are weak.
Ginkgo Biloba	#1, #2	#1, #2, #3	Not effective.
Melatonin	#1, #2, #3	#1	Potentially helpful.

For more meds, click here.

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What Caused Beethoven's Hearing Loss?

Image from Wikipedia

When Beethoven composed his 9th Symphony, it was an amazing accomplishment especially when considering he did so totally deaf.

It has been a medical mystery as to what caused his slowly progressive hearing loss to the point of deafness, but a recent publication suggests it was due to chronic low-level lead exposure consumed from wine tainted with lead.

FACT: High levels of lead were found deep in the bone suggesting chronic lead exposure over a long period of time.

FACT: Beethoven's physicians noted that he had alcohol dependence (profound liver damage was found on autopsy).

FACT: It is not unusual that wine in that time period was tainted with lead.

More significantly, the paper disputed the more common thought that his lead poisoning was due to taking excessive doses of lead-based medications administered by his doctor: lead was found deep in the bone indicating lead exposure over a long period of time and absence of physical exam signs/symptoms (ie, wrist drop) indicative of acute lead poisoning (lead consumed over a short period of time).

The paper also did rule out other causes of hearing loss including otosclerosis, autoimmune hearing loss, autoimmune inflammatory conditions, mercury poisoning, and syphilis.

Reference:
Lead and the deafness of Ludwig van Beethoven. Laryngoscope. 2013 May 17. doi: 10.1002/lary.24120. [Epub ahead of print]

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Does Drinking Alkaline Water Help With Reflux?

Image by WJ Pilsak from Wikipedia

Treatment in some reflux-sufferers may require addressing not just the acid in reflux, but also the pepsin. In one tantalizing research paper, alkaline water (pH 8.8) was found to instantly and permanently inactivate pepsin in vitro (ie, in a test tube). Pepsin is a stomach enzyme that can cause inflammation and mucosal damage when in the throat area. This peptic enzyme can be deposited outside the stomach due to laryngopharyngeal reflux (LPR) and can cause symptoms of globus, burning, hoarseness, chronic cough, chronic throat clearing, etc.

With pepsin triggered symptoms, treatment to resolve can become exceedingly frustrating given standard treatment with zantac, prilosec, and other "reflux" medications do not work as well. Furthermore, human pepsin remains stable at pH 7.4 and can be repetitively reactivated by acid from any source (ie, orange juice).

BUT... keep in mind that test tube results in this research may not necessarily translate to actual improvement in humans. However, drinking a small amount of alkaline water a few times a day (just enough to coat the throat) can't hurt.

Keep in mind that most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability.

I should also mention that drinking alkaline water will not do much to help acid reflux as the alkaline water will only briefly neutralize any acid and is ineffective for long-duration acid suppression. For those suffering from acid reflux, stick with the traditional reflux medications which work extremely well.

Reference:
Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngol. 2012 Jul;121(7):431-4.

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Can Melatonin Stop Ringing in the Ears (Tinnitus)?

In a rigorous study, researchers have found that taking melatonin 3mg nightly for 1 month did significantly help with patients suffering from chronic tinnitus (ringing in the ears).

Of course, the caveats are that melatonin significantly helped in patients with these specific characteristics:

• Male
• No history of depression
• Tinnitus has been present for a long time
• History of loud noise exposure
• Tinnitus is severe and on both sides

Given melatonin is a relatively benign supplement that can be purchased over-the-counter, it can't hurt to give it a try!

BTW... what did I mean by rigorous study above? It means that it was a prospective, randomized, double-blind, crossover clinical trial. That's pretty much as good a study as one reasonably achieve!

Reference:
Melatonin: can it stop the ringing? Ann Otol Rhinol Laryngol. 2011 Jul;120(7):433-40.

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Video of How Nasal Cauterization for Nosebleeds Is Performed (Silver Nitrate and Electric)

I made a nosebleed video a few years ago that was roundly criticized for being poorly made. The biggest complaint was the loud background music. As such, I have made a new video that I feel addresses many of the shortcomings levied on the original video. I also added additional footage of what different types of nosebleeds look like as well as adding bipolar cauterization as another method of cautery other than silver nitrate.

Check the new (upgraded) video!

For more info about nosebleeds, click here.

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Men's Ability to Taste Linked to Fertility?

Image by צביה from Wikipedia

Researchers found that two proteins that govern the ability to taste sweet and savory profoundly influenced sperm development.

This surprising connection between taste and male fertility occurred when the gene encoding the taste receptor proteins TAS1R3 (part of savory taste receptor) and GNAT3 (converts oral taste signal to a nerve signal) were modified in mice allowing for selective knockout with the drug clofibrate.

When these genetically modified mice were given clofibrate leaving the mice without any functional TAS1R3 and GNAT3, the males became sterile due to profoundly reduced sperm counts and malformations.

When clofibrate administration was stopped in these mice, fertility immediately came back.

Of note, clofibrate is a common drug prescribed to treat high cholesterol.

And it does potentially suggest that such cholesterol drugs may adversely influence human male fertility... as well as potentially lead to a safe and effective non-hormonal male contraceptive.

Reference:
Genetic loss or pharmacological blockade of testes-expressed taste genes causes male sterility. Published online before print July 1, 2013, doi: 10.1073/pnas.1302827110 PNAS July 1, 2013

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New Video on Tongue Tie Release Procedure

Tongue tie is a common problem whereby a flap of tissue anchors the tongue tip to the bottom of the mouth. With tongue tie, it is impossible for a patient to stick the tongue straight out (licking an ice cream is impossible) and may potentially lead to problems with feeding in a newborn baby, speech articulation in a young school-age child, and french kissing in teenagers and older.

Due to the frequency at which tongue tie release is performed and the questions parents often have about how this procedure is exactly performed, a video has been created to show the steps on a newborn baby. With the gracious permission of one mom... check out this video.

Tongue tie may not be the only problem that may cause breast-feeding difficulty in an infant. Upper lip tie and posterior tongue tie may also be present.

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