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Wednesday, 25 September 2013

Life-Saving Emergency Trach Performed in Restaurant

Posted on 10:02 by Unknown
On Sept 23, 2013, a physician performed a life-saving emergency tracheotomy in a restaurant on a patron who was choking on a piece of meat. [link]

While eating dinner at The Mark Restaurant in California, Dr. Royce Johnson, an infectious disease doctor affiliated with UCLA, performed this procedure on Pauline Larwood, a female supervisor and a community college trustee.

Dr. Johnson saved this woman's life using a pocket knife and the hollow cylinder of a pen after a Heimlich maneuver failed to work.

Interestingly, Dr. Thomas Frieden, director of the CDC, who was also present in the restaurant assisted in the care by monitoring Larwood’s pulse during the incident.

Also present in the restaurant witnessing the emergency procedure were:

• Francis Collins, MD (director of NIH)
• Farming and business moguls Lynda and Stewart Resnick
• Rep. Kevin McCarthy, R-Bakersfield
• Assemblywoman Shannon Grove, R-Bakersfield
• State senator Jean Fuller, R-Bakersfield

Although typically surgeons are the individuals trained to perform tracheotomies, bravo to Dr. Johnson who took the initiative in spite of the fact that he probably has never performed one.

I should also add that though media reports state that an emergency tracheostomy was performed, it is probably more likely that an emergency cricothyroidotomy was performed instead which is easier and less "bloody."

Source:
Dramatic dinner rescue involves knife, UCLA doctor and CDC chief. The Bakersfield Californian 9/24/13

CALIF. DOCTOR SAVES CHOKING DINER WITH KNIFE. The Associated Press 9/25/13


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Posted in california, choke, cric, doctor, emergency, hollow, knife, life, movie, neck, pen, pocket, restaurant, state, surgery, throat, trach, tube | No comments

What is the Best Antibiotic for Strep Throat?

Posted on 09:40 by Unknown

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69


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Posted in antibiotic, best, infection, medication, sore, strep, surgery, throat, tonsillectomy, tonsillitis, treatment | No comments

Sunday, 22 September 2013

Accurate Hearing Testing Using an iPhone

Posted on 03:08 by Unknown
There is an iPhone app called "EarTrumpet" that apparently can provide accurate hearing testing... almost as good as a professionally administered test (conventional audiometry) and certainly as good (if not better) than medical-quality automated testing machines (ie Otogram).

Created with the assistance of the ENT department at the University of California, Irvine...

According to one study, this iPhone application provided results as good as one administered by an audiologist:

• 96% of the threshold values when obtained in a sound booth
• 94% of the threshold values when testing was done in just a "quiet" room

When accuracy was defined as "within 10 dB of the corresponding threshold value obtained using conventional audiometry."

Given how accurately the iPhone application performs, it may potentially be a very helpful screening tool to evaluate patients with ear/hearing complaints. If the testing comes back normal hearing (between 0-20db at ALL frequencies), than the patient probably hears just fine.

However, if there's any hearing loss detected, it is advised to seek professional opinion because there  are weaknesses to this program and further testing WILL be necessary.

• It ONLY performs air conduction testing. Given the lack of bone conduction testing, pure nerve testing is not possible, especially when hearing loss is detected. For example, the iPhone application will not be able to test hearing loss due to earwax/fluid versus actual nerve hearing loss.
• Speech audiometry is not present. Only pure tone audiometry. Speech audiometry provides information regarding how well spoken words are understood... one can potentially "hear" a beep at a specific frequency just fine, but still mishear a spoken word which is composed of many different sound frequencies.
• As it pertains to this research study, while there was excellent agreement in masked threshold values between the iPhone app and conventional audiometry, the sample size was limited. Masking is especially important when significant asymmetric hearing loss is present.

There may also be potential bias with the research. The developer of the EarTrumpet iPhone app, Allen Foulad, is also the lead researcher of the paper. It would be worthwhile to have other independent labs reproduce and verify the findings.

However, I applaud Dr. Foulad for his work in this area as well as entrepreneurial spirit!

You can download his app here.

As a bonus, this iPhone application can also act as a personal sound amplifier. It can enhance environmental sounds via earphones attached to the iPhone.


Reference:
Automated Audiometry Using Apple iOS-Based Application Technology. Otolaryngol Head Neck Surg. 2013 Aug 20. [Epub ahead of print]
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Posted in accuracy, accurate, aids, app, audiogram, audiology, eartrumpet, good, hearing, iphone, loss, screening, smartphone, testing, works | No comments

Friday, 20 September 2013

Don't Like a Research Paper? Sue the Journal and Authors...

Posted on 08:58 by Unknown
What is a lawyer to do if medical research produces results that make it more difficult to win lawsuits? Why you sue the medical journal and the researchers who authored it.

And you ask the medical journal to retract it.

And than you ask for a court order forbidding the report to be entered as evidence in future litigation.

Sound like a joke?

Wish it was, except it happened... is happening...

A Boston lawyer has sued the American Journal of Obstetrics and Gynecology for a case report published in 2008 regarding an infant delivery in which a brachial plexus injury was sustained via natural forces of labor without any excessive traction provided by the physician.

More info can be found on the lawsuit here which was initially dismissed by a trial court, but is on appeal to the First Circuit.

Given I'm an ENT, I can't necessarily state whether this published medical report has merit or not, but typically if a study is without merit, one criticizes it by publishing additional research studies to either support or refute it.

If lawyers now start influencing what can be published or not, or indirectly influence researchers whether to publish "unpopular" results for fear of lawsuits, it will have a chilling effect on the advancement of science and medical research.

Hopefully, suing medical journals and researchers will not become a popular trend.


Sources:
Publish an article that undermines lawsuits? See you in court. Overlawyered 9/18/13

Maternal forces causing injury. United Brachial Plexus Network 5/16/11

Permanent brachial plexus injury following vaginal delivery without physician traction or shoulder dystocia. American Journal of Obstetrics & Gynecology. Volume 198, Issue 3 , Pages e7-e8, March 2008
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Posted in arm, author, baby, birth, court, erg, gynecology, infant, Journal, lawsuit, malpractice, medical, obstetrics, research, shoulder, sue | No comments

Saturday, 14 September 2013

Opera Music Improves Heart Transplant Survival

Posted on 06:00 by Unknown
Sara Maines of The MaineStudio
Not kidding... This research was actually published in the Journal of Cardiothoracic Surgery in 2012. I should add that the research was done in mice rather than humans and won the 2013 Ig Prize in Medicine.

To quote from the abstract:
"recipients of a B6 cardiac graft that were exposed to opera music and Mozart had significantly prolonged allograft [transplant] survival... whereas those exposed to a single sound frequency (100, 500, 1000, 5000, 10,000, or 20,000 Hz) or Enya did not... Our findings indicate that exposure to opera music, such as La traviata, could affect such aspects of the peripheral immune response as generation of regulatory CD4+CD25+ cells and up-regulation of anti-inflammatory cytokines, resulting in prolonged allograft [transplant] survival. "
Wonder if this research can apply to other surgical healing and survival...

Reference:
Auditory stimulation of opera music induced prolongation of murine cardiac allograft survival and maintained generation of regulatory CD4+CD25+ cells. Journal of Cardiothoracic Surgery 2012, 7:26 doi:10.1186/1749-8090-7-26
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Posted in heart, ig, medicine, mice, mozart, noise, opera, prize, singing, sound, survival, transplant | No comments

Friday, 13 September 2013

Don't Like the Research Conclusions? Here's How to Belittle it...

Posted on 04:58 by Unknown
Love this blog post published in the Washington Post by Dylan Matthews. Look at the flowchart below, but it's worth reading his WaPo article here.



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Posted in argue, conclusion, dispute, flowchart, like, not, research, washington post | No comments

Wednesday, 11 September 2013

Did a Case of Lemierre's Syndrome Influence Super Bowl XLVII?

Posted on 10:13 by Unknown
Image by Keith Allison from Wikipedia
Lemierre's syndrome is an exceedingly rare complication of tonsillitis characterized by an infected clot of the jugular vein leading to sepsis. It may also have potentially influenced Super Bowl XLVII due to an interesting quirk in history.

Back in 2008, a former Heisman Trophy winner from Ohio State University named Troy Smith was the quarterback for the Baltimore Ravens. Great things were expected of him as he was gearing up to start in the third preseason game of the 2008 season.

Unfortunately... you guessed it... he came down with Lemierre's Syndrome.

Which allowed for a rookie quarterback named Joe Flacco to step in.

Joe Flacco went on to lead the Baltimore Ravens to a Super Bowl win in 2012.

Troy Smith, in the meantime, has never quite recovered professionally since his bout of Lemierre's Syndrome.


Sources:
Troy Smith. Wikipedia

Joe Flacco. Wikipedia
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Posted in baltimore, bowl, flacco, football, infection, joe, lemierre, quarterback, ravens, smith, super, syndrome, tonsil, tonsillitis, troy | No comments

Monday, 9 September 2013

Law Firm Launches Website for Tinnitus Sufferers

Posted on 03:52 by Unknown

It would be a sad day indeed if a patient google searches a medical condition or symptom and the first page of results are all pointing to a law firm.

In perhaps the beginning towards this possibility, personal injury law firm, Mercury Legal Online, has launched a website dedicated to patients who suffer tinnitus and hearing loss sustained from time working in a job that contained a lot of loud noise without using hearing protection. Thanks to @earsurgeonuk who brought this to my attention.

The website even provides a compensation calculator, requirements to make a claim, and an infographic about tinnitus in general...


Source:
Law firm launches website dedicated to tinnitus sufferers. Digital Journal 9/8/13
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Posted in compensation, ears, law firm, ringing, tinnitus, Website | No comments

Sunday, 8 September 2013

Lawsuit Alleges Transcranial Magnetic Stimulation Paralyzed Patient's Face

Posted on 13:34 by Unknown
University of Iowa Hospitals and Clinics is being sued by a patient who underwent an experimental transcranial magnetic stimulation (TMS) therapy which allegedly caused a facial paralysis which was than negligently treated. The trial is scheduled for Oct 13, 2013. [link]

Briefly, the patient in 2008 underwent experimental TMS to treat constipation and incontinence. TMS is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain using pulses of electromagnetic induction through the scalp. Researchers were hoping to learn more about the nerve connections between the brain and the rectum and how biofeedback training may affect them.

Unfortunately, the patient contended that the treatment gave her a severe headache and by the next day, a facial paralysis. She went to the emergency room and was given an anti-viral antibiotic to take, but no steroids.

Her facial paralysis worsened and she ultimately underwent facial nerve decompression surgery 12 days later which helped with her taste loss, but not her facial paralysis.

The lawsuit contends that:
1) The patient was not informed of the risks of TMS as it relates to facial paralysis
2) Steroids should have been prescribed and the patient immediately referred for nerve decompression surgery

Does TMS carry a risk of facial paralysis?

I honestly do not know much about TMS, but I can certainly state that I've never heard of TMS causing or carrying a risk of facial paralysis. In fact, TMS is used to evaluate facial paralysis by being able to assess the integrity of the facial nerve as well as predict its potential for regeneration after injury [link].

Hypothetically, could TMS cause cranial nerve injury and swelling leading to facial paralysis??? I suppose so, but will defer to people more knowledgeable than I to answer this question.

The timing is certainly suspicious in this case with paralysis occurring within 24 hours of TMS.

But if it can, it certainly is worth a published case report.

Even more importantly, patients who are currently undergoing TMS to evaluate their facial paralysis now need to be warned of the risk that the TMS test itself may make their facial paralysis even worse!!!

What about steroids?

Although some may consider medical management of facial paralysis still controversial, I personally feel that steroids SHOULD have been immediately prescribed without any anti-virals.

The current preponderance of evidence is that anti-virals make absolutely no difference in the treatment of facial paralysis... even when the facial paralysis is due to a virus [link].  I personally do not prescribe anti-virals for patients with facial paralysis regardless of etiology.

What about steroids? Moderate quality evidence show that steroids were significantly more likely than anti-virals to produce complete recovery [link #1; link #2]. I always prescribe steroids to treat facial paralysis.

What about facial nerve decompression surgery?

Now surgical decompression of the facial nerve can be considered controversial. Decompression entails removing part of the skull, moving the brain to one side slightly, and removing all bone covering the facial nerve.

The theory being that if the facial nerve is swollen as it courses through the skull from the brain to the face, strangulation followed by nerve death occurs. To use an analogy, if a finger starts to swell from trauma, a ring being worn may prevent blood flow and eventually cause strangulation of the finger. Treatment to reestablish finger blood flow is to cut the ring off. Facial nerve decompression is akin to cutting a ring off to save a swollen finger.

Typically, surgical decompression of the facial nerve is pursued when facial paralysis occurs in the context of physical head trauma (ie, car accident). In the absence of preceding physical trauma, it would be the rare surgeon who would recommend surgical facial nerve decompression.

Obviously, the main question related to this lawsuit is whether nerve swelling occurred due to the TMS therapy necessitating surgical decompression. Presumably, an MRI scan was performed showing a highly inflamed and swollen facial nerve as well as significant nerve degeneration on ENoG testing. Supporting evidence (not mentioned in media reports) would be if profound hearing loss also occurred. Why? Because the facial nerve and hearing nerve both go through the same boney canal.

Malpractice?

TMS is not known to cause facial paralysis. As such, in a normal situation, this particular risk would not be expected to be included in the consent (as it has not been previously described). However, given this therapy was provided in the context of an experimental research protocol, the consent process is much more rigorous with much higher standards. With such higher standards, should risks never before seen be also included in the consent, especially if TMS has been performed many times for other purposes??? I don't know...

Certainly, my feeling as an ENT specialist is that steroids should have been given and not an anti-viral medication. Whether ENT specialist standards should apply to emergency room staff is harder to say.

Without more information, negligence as it pertains to delayed surgical facial nerve decompression is also hard to say.

Ultimately, we shall see what the court decides.


Source:
Lawsuit alleges Iowa doctors left patient's face paralyzed. Associated Press 8/13/13

References:
Transcranial magnetic therapy. Wikipedia

Electrical and transcranial magnetic stimulation of the facial nerve: diagnostic relevance in acute isolated facial nerve palsy. Eur Neurol. 2012;68(5):304-9. doi: 10.1159/000341624.

Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006851. doi: 10.1002/14651858.CD006851.pub2.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869. doi: 10.1002/14651858.CD001869.pub4.

Do either corticosteroids or antiviral agents reduce the risk of long-term facial paresis in patients with new-onset Bell's palsy? J Emerg Med. 2010 May;38(4):518-23. doi: 10.1016/j.jemermed.2009.08.016. Epub 2009 Oct 21.
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Posted in anti, antibiotic, decompression, facial, iowa, lawsuit, magnetic, malpractice, paralysis, research, stimulation, surgery, therapy, tms, transcranial, viral | No comments

Friday, 6 September 2013

Malpractice Lawsuit for Nerve Damage Sustained After Neck Cyst Excision

Posted on 17:58 by Unknown
Earlier this month, a malpractice lawsuit resulted in a $4 million dollar award to the patient plaintiff who suffered permanent nerve damage after a family practice physician excised a cyst from the neck. [link]

Briefly, the patient visited the family physician in July 2009 for a lump in his left neck. The family physician recommended that the mass be surgically excised which was subsequently performed by the same family physician (not a surgeon) in the office. After the procedure, the patient experienced a weakened left arm and shoulder and had difficulty picking things up with that arm or moving the arm more than 90 degrees. Subsequent evaluation by an orthopedic surgeon and neurosurgeon determined that the spinal accessary nerve was cut at the time of the neck mass excision.

So what probably happened?

The spinal accessory nerve (also known as cranial nerve XI), is a major nerve that comes off the spinal cord and supplies motor function to the shoulder and arm (red arrow below pointing to the nerve which is yellow).

Image Modified from Wikipedia
I suspect that in this case, the mass was located in the same area denoted by the red arrow above. Now assuming that media and court documents were correct that it was truly a cyst that was excised, the cyst must have laid right below the skin, but on top of the nerve.

Careless excision of the cyst would have resulted in this nerve being cut especially during dissection on the mass's deepest aspect, especially if the physician did not hug the mass during dissection. Using an analogy, good surgical technique is like peeling an orange without puncturing the yummy orange underneath. Poor surgical technique would be peeling the rind and taking bits of the edible orange as well... or leaving some nasty rind on the fleshy orange itself.

Often, novice surgeons take large cuts around a mass with the tip of the scissor or scalpel extending beyond visualization. Also, thick layers of tissues are cut rather than thin transparent amounts. Furthermore, when a mass is grasped and pulled, anatomic structures like a nerve can get pulled out of its usual location along with the mass which can lead to unintentional damage. 

As such, experienced surgeons know when to cut big (no important structures are around) and when to cut in tiny microscopic degrees (important nerves and blood vessels are around).

The neck has a large number of important blood vessels and nerves in a highly compacted area making surgery in this part of the body potentially fraught with peril. However, there are certain "safe" areas where no significant important nerves or blood vessels are found. Such a "safe" zone from a nerve perspective is right under the chin extending down over the voicebox. Of course, there are other important structures located in this area that could get damaged even if nerves aren't a concern.


Source:
Montco jury awards Hatboro man $4M for nerve damage. Phillyburbs 8/27/13
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Posted in arm, damage, doctor, family, lawsuit, malpractice, mass, neck, nerve, paralysis, Physician, shoulder, surgeon, weakness | No comments

Sunday, 1 September 2013

Teens (People) Who Listen to Music Loudly... A Possible Solution

Posted on 03:50 by Unknown
Now parents may not like this, but I do have a possible solution to getting teenagers to turn the music volume down so not to damage their hearing... Get them noise-cancelling headphones.

As an occasional audiophile myself, I understand that when listening to music with headphones, you invariably HAVE to turn the music volume up in order to hear everything clearly, especially when listening to music in noisy environments. Such environments include city sounds while walking, airplane buzz when flying, and car engine/road drone while driving.

Test this out yourself next time you drive a car. First, listen to the car radio with the engine turned off. Note the volume.

Now, see how well you hear the music from the car radio when driving on the highway.

It's the main reason why one may constantly fiddle with the volume knob while driving. It's also why people have to raise their voice in order to be heard in a loud restaurant.

For teens and other people who are audiophiles, the only solution is to turn the music volume up in order to hear the music clearly... which can damage their hearing over time.

So what to do? One can listen to music only when the environment is silent, but that's not going to happen for music-loving individuals who want to hear it all the time.

The other solution is to get a nice pair of noise-cancelling headphones.

A good pair of NC headphones significantly reduces if not eliminates the buzz, drone, white noise of the environment which is a very common cause of requiring a volume increase.

Now, not all NC headphones are created equal. Bose NC headphones are perhaps the best but are pricey at around $300.

However, cheaper brands do not noise-cancel at all or do so poorly even if they are labelled as noise-cancelling.

Generally speaking, Bose is by far the best followed by Panasonic, Sony, and AKG. You can read a Pogue's New York Times review of different noise-cancelling headphones here.

So... perhaps you can make a deal with your teen or adult loved one to turn the music volume down to protect their ears by getting them a Bose NC headphones which come in headphones and earbud models. Available for purchase on Amazon.


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Posted in bose, cancel, cancellation, damage, deaf, earbuds, headphones, hearing, loss, loud, music, noise, reason, solution, volume | No comments
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  • cdc
  • celebrity
  • celine dion
  • cell
  • cell phone
  • cells
  • cellscope
  • cellulitis
  • center
  • centreville
  • ceo
  • cerumen
  • cervarix
  • cervical
  • ces
  • chain
  • chairman
  • chance
  • chang
  • change
  • changing
  • channel
  • chapter
  • charge
  • charges
  • chart
  • chatterbox
  • cheap
  • cheaper
  • cheat sheet
  • cheating
  • check-list
  • cheek
  • cheekbone
  • cheerleading
  • chef
  • chemical
  • chemistry
  • chemo
  • chemotherapy
  • cheryl crow
  • chest
  • chewing
  • chicago
  • child
  • childhood
  • children
  • chin
  • china
  • chinese
  • chloe
  • choke
  • choking
  • cholesterol
  • chris
  • chronic
  • chronic cough
  • cicada
  • cigarette
  • circadian
  • class
  • clean
  • cleaning
  • cleanser
  • clear
  • clearing
  • cleft palate
  • clinic
  • clinical
  • clock
  • clockwork
  • clogged
  • clogged ears
  • clogged nose
  • clone
  • closure
  • cloud
  • club
  • cluster
  • cn1
  • coach
  • coat
  • coblation
  • cocaine
  • cochlea
  • cochlear
  • cocktail
  • code
  • codeine
  • codiene
  • coding
  • coffee
  • colace
  • cold
  • coleman
  • colitis
  • colon
  • colonoscopy
  • colored
  • comedy
  • comic
  • comment
  • commenting
  • commercial
  • common
  • compact
  • company
  • compensation
  • compete
  • complication
  • complications
  • composed
  • comprehension
  • computer
  • concert
  • conclusion
  • concussion
  • conducted
  • conduction
  • conferences
  • congenital
  • congestion
  • connect
  • connolly
  • consent
  • consequence
  • consortium
  • constant
  • consultant
  • contact
  • contagious
  • content
  • contestant
  • contributor
  • control
  • convicted
  • cook
  • cookbook
  • cooling
  • coombs
  • copay
  • copper
  • cord
  • core
  • correct
  • correction
  • Cost
  • cough
  • cough out
  • count
  • counter
  • counting
  • couple
  • court
  • cover
  • coverage
  • cpap
  • cpc
  • crackling
  • cranial
  • crazy
  • cribiform
  • cric
  • cricoid
  • crohn's
  • cros
  • cruise
  • crusting
  • crypt
  • cryptolysis
  • csf
  • css
  • ct
  • ct scan
  • cue
  • culture
  • curd
  • curdling
  • cure
  • custom
  • customized
  • cut
  • cutter
  • cycle
  • cyclical
  • cyp2d6
  • cyst
  • czech
  • da vinci
  • dad
  • daily
  • damage
  • dana
  • danger
  • dangerous
  • danny quirck
  • database
  • davinci
  • day
  • days
  • db
  • dc
  • de
  • deaf
  • deafness
  • dean
  • death
  • debarquement
  • debrox
  • decaff
  • decibel
  • decompression
  • decongestant
  • deductible
  • deep
  • deeper
  • def leppard
  • defects
  • defense
  • degree
  • dehydration
  • dental
  • dentist
  • department
  • dependent
  • depression
  • dermatitis
  • derrick
  • desensitization
  • design
  • development
  • deviated
  • deviated septum
  • deviation
  • device
  • dexilant
  • diabetes
  • diagnose
  • diagnosis
  • diaphragm
  • die
  • died
  • diet
  • dietitian
  • difference
  • difficulty
  • dificile
  • digestive
  • digital
  • dilation
  • dimensional
  • dimon
  • disability
  • disc
  • discectomy
  • discoloration
  • discriminate
  • discrimination
  • disease
  • dishwasher
  • disinfect
  • diskectomy
  • dislike
  • disorder
  • dispute
  • disqus
  • distance
  • distilled
  • distraction
  • diverticulostomy
  • diverticulum
  • diving
  • divorce
  • diy
  • dizziness
  • dizzy
  • DNA
  • do
  • doctor
  • doctors
  • documentation
  • does
  • does it work
  • does not take
  • doll
  • dose
  • double
  • douglas
  • download
  • downtime
  • dr
  • dr. gardner
  • dracula
  • drainage
  • drawing
  • drink
  • dripologist
  • drippy
  • droplet
  • drops
  • drug
  • drugs
  • drum
  • drves
  • dry
  • duff mckagan
  • duke
  • duration
  • dynamics
  • dysfunction
  • dysphagia
  • dysphonia
  • dystonia
  • e6
  • ear
  • ear candle
  • ear muffs
  • ear plug
  • ear plugs
  • ear tubes
  • earbuds
  • eardoc
  • eardrum
  • earlobe
  • earplug
  • earpopper
  • earprint
  • earring
  • ears
  • ears feel full
  • earthquake
  • eartrumpet
  • earvac
  • earwax
  • eat
  • echo
  • economics
  • ectasia
  • education
  • effect
  • effective
  • egd
  • egg
  • ehr
  • ejaculate
  • elance
  • elbow
  • electric
  • electrocautery
  • electrolarynx
  • electronic
  • electronic medical record
  • elizabeth
  • elvis
  • email
  • embarrassing
  • embedded
  • embolism
  • emergency
  • emg
  • emission
  • emma rosa
  • empty nose syndrome
  • emr
  • end
  • endo
  • endocarditis
  • endolymphatic
  • endoscope
  • endoscopic
  • endoscopy
  • enema
  • engine
  • enlargement
  • enriched
  • ent
  • entellus
  • entertainment
  • epi
  • epiglottis
  • epiglottitis
  • epinephrine
  • epipen
  • epistaxis
  • equipment
  • er
  • erg
  • error
  • errors
  • esd
  • esophageal
  • esophagoscopy
  • esophagus
  • ess
  • ETD
  • ethmoid
  • eustachian
  • eustachian tube
  • eustachian tube dysfunction
  • evaluation
  • evidence
  • evolution
  • exam
  • examination
  • excessive
  • excision
  • exercise
  • exertion
  • expert
  • expiration
  • expired
  • explanation
  • explosive
  • exposure
  • eye
  • eyeglass
  • f0
  • face
  • facebook
  • facial
  • facial paralysis
  • facility
  • fact
  • factors
  • fail
  • faint
  • fake
  • fall
  • family
  • fancy
  • fascia
  • fast food
  • fatal
  • father
  • fauquier
  • fauquier ent
  • fauquier hearing
  • fauquier hospital
  • fda
  • fecal
  • feces
  • fee
  • feed
  • feedblitz
  • feedburner
  • feeding
  • feeds
  • fees
  • female
  • ferrell
  • fertility
  • fess
  • fetus
  • fever
  • fevers
  • fiction
  • fight
  • film
  • filter
  • filtered
  • financial
  • find
  • fingerprint
  • fire
  • first
  • fit
  • fixation
  • fizz
  • flacco
  • flash
  • flat
  • flight
  • floor
  • florence welch
  • flowchart
  • flu
  • flublock
  • flucelvax
  • fluctuating
  • fluid
  • fluid in ears
  • flush
  • flushing
  • fly
  • foam
  • focus
  • foley
  • folliculitis
  • food
  • foods
  • football
  • forbes
  • forecast
  • forehead
  • foreign
  • forensic
  • forking
  • formaldehyde
  • formant
  • formation
  • fotoshop
  • foul
  • found
  • fox news
  • fracture
  • frank ocean
  • free
  • french
  • frequency
  • friend
  • friendly
  • front-page
  • full
  • fullness
  • function
  • fundoplication
  • funny
  • fusion
  • future
  • gallery
  • game
  • ganglion
  • gardasil
  • gary
  • gas
  • gastric bypass
  • gaviscon
  • gel
  • gender
  • Gene
  • generic
  • genetic
  • george
  • georgetown
  • gerd
  • germ
  • german
  • germs
  • gi
  • girl
  • girlfriend
  • girls
  • gland
  • glee
  • global period
  • globus
  • glottic
  • gloves
  • glue
  • glycol
  • gmail
  • gold
  • golfer
  • gone
  • good
  • google
  • google glass
  • gorilla
  • gpa
  • grade
  • graft
  • gram
  • grammy
  • grant
  • granulation
  • granuloma
  • graph
  • grass
  • grastek
  • grazax
  • green
  • grenade
  • gross
  • growth
  • guaiac
  • guardian
  • gun
  • gupta
  • guy
  • gwyneth
  • gymnast
  • gymnastics
  • gynecology
  • H1N1
  • h2
  • hacker
  • hair
  • hair cell
  • halitosis
  • hamburger
  • hannah
  • hapten
  • haptic
  • hard
  • harmful
  • harvard
  • hate
  • have
  • hayfever
  • hazard
  • hcl
  • head
  • headache
  • headlight
  • headphone
  • headphones
  • health
  • healthcare
  • healthsmart
  • healthy
  • hearing
  • hearing aid
  • hearing aids
  • hearing loss
  • heart
  • heart attack
  • heart disease
  • heartburn
  • heat
  • helium
  • hell
  • helm
  • helmet
  • help
  • hemangioma
  • hemi-thyroidectomy
  • hemoccult
  • hemorrhage
  • hero
  • herpes
  • hiccups
  • high
  • highest
  • hipaa
  • hiss
  • history
  • hitch
  • hitech
  • hives
  • hns
  • hoarse
  • hoarse voice
  • hoarseness
  • hoax
  • hole
  • hollow
  • home
  • homemade
  • homeopathic
  • homeopathy
  • honey
  • hootsuite
  • hormone
  • horrible
  • Hospital
  • hospitalization
  • hot
  • hot dog
  • hours
  • house
  • how
  • how it works
  • how long
  • how much
  • how to
  • howard krein
  • hpv
  • hpv16
  • hsv
  • html
  • huber
  • human
  • humans
  • humidity
  • humor
  • humorous
  • hunting
  • hydrogen
  • hydrops
  • hygiene
  • hyper
  • hypernasal
  • hypersensitivity
  • hypertrophy
  • hypo
  • hypo nasal
  • hypotension
  • hypothesis
  • hypoxic
  • ibuprofen
  • icd
  • icd10
  • icd9
  • ice cream
  • icu
  • identical
  • identify
  • ifttt
  • ig
  • ige
  • igg
  • ill
  • illegal
  • illness
  • illusion
  • illustrated
  • illustration
  • images
  • imbalance
  • immune
  • immunizations
  • immunocap
  • immunotherapy
  • imovie
  • impediment
  • implant
  • improve
  • in office
  • In The News
  • in utero
  • incident
  • incidentaloma
  • incision
  • incisionless
  • inclusion
  • incorrect
  • increase
  • induced
  • industry
  • infant
  • infection
  • infections
  • infectious
  • infertility
  • inflammation
  • influenza
  • influenze
  • info
  • infographic
  • infographics
  • infomercial
  • information
  • informed
  • infusion
  • inhalation
  • inhibitor
  • injection
  • injury
  • inner
  • inner ear
  • inscop
  • insect
  • inside
  • instant
  • institute
  • instruction
  • instructions
  • instrument
  • insufficiency
  • insurance
  • intelligence
  • intelligent
  • interactive
  • intermittent
  • international
  • internet
  • interpreter
  • interview
  • intubated
  • intubation
  • invasive
  • iodine
  • iontophoresis
  • iowa
  • ipad
  • iphone
  • ipod
  • iq
  • irritation
  • it
  • italy
  • itch
  • itunes
  • ivy
  • jahi
  • jail
  • james
  • jamie
  • japan
  • jaw
  • jawbone
  • jeni
  • jenner
  • jennifer aniston
  • jim kelly
  • jitter
  • job
  • joe
  • john
  • john mayer
  • john woo
  • jones
  • Journal
  • jpmorgan
  • jugular
  • juice
  • julie andrews
  • julie wei
  • june
  • kardashian
  • kardasian
  • karna
  • karnapidasana
  • katie couric
  • kaypentax
  • keith urban
  • kevin
  • keyword
  • kid
  • kids
  • killer
  • kim
  • kind
  • kiss
  • kissing
  • kit
  • kits
  • knife
  • knowledge
  • korean
  • kristin chenoweth
  • kristin williams
  • lab
  • label
  • labelled
  • laboratory
  • lacey
  • lactation
  • lake
  • laminectomy
  • langer
  • language
  • lansoprazole
  • lap band
  • larry
  • larry hagman
  • larva
  • laryngeal
  • laryngectomy
  • laryngitis
  • laryngopharyngeal
  • laryngopharyngeal reflux
  • laryngospasm
  • larynx
  • las vegas
  • laser
  • last season
  • lateral
  • laura kaeppelar
  • laura kueny
  • law firm
  • lawrence simon
  • lawsuit
  • lawyer
  • lazaro arbos
  • lead
  • leak
  • learn
  • learning
  • lebron
  • Lecture
  • lectures
  • lee
  • lee eisenberg
  • lefort
  • leg
  • legal
  • lego
  • lemierre
  • length
  • les
  • letter
  • leukemia
  • levels
  • levon
  • liability
  • lidocaine
  • life
  • life-threatening
  • lift
  • light
  • like
  • limb
  • limbaugh
  • line
  • lining
  • linx
  • lion
  • lip
  • lip reading
  • liquid
  • lisa
  • lisinopril
  • list
  • listen
  • listerine
  • lithium
  • live
  • liver
  • living
  • lizard
  • local
  • location
  • lock
  • locked
  • long
  • loss
  • lost
  • loud
  • loudness
  • loudon
  • louisiana
  • low
  • lpr
  • lsn
  • lump
  • lung
  • lymphoma
  • lytro
  • mac
  • machine
  • macrophage
  • made
  • magazine
  • maggot
  • maggots
  • magic ears
  • magnetic
  • mail
  • major
  • make
  • mal
  • male
  • malpractice
  • mammogram
  • man
  • management
  • manassas
  • mandatory
  • mandible
  • mandibular
  • many
  • map
  • marcaine
  • mariana
  • marie
  • marilyn
  • marinomed
  • marketing
  • maroney
  • marriage
  • mask
  • mass
  • massage
  • master
  • maxillary
  • maxwell
  • mayo
  • mca
  • mckayla
  • mcmath
  • md
  • measles
  • measure
  • meat
  • med
  • medal
  • medgadget
  • media
  • medial
  • medical
  • medical mystery
  • medicare
  • medication
  • medicine
  • medigus
  • medtronic
  • mega
  • melatonin
  • melena
  • membrane
  • men
  • meniere's
  • meningioma
  • meningitis
  • mensa
  • merck
  • merger
  • mesh
  • messaging
  • meta
  • metabolism
  • metabolizer
  • metal
  • metallic
  • meth
  • methamphetamine
  • methylamphetamine
  • methylene
  • mexico
  • mi
  • mic
  • micah johnson
  • mice
  • michael
  • microbial
  • microbiota
  • microflora
  • microphone
  • microscope
  • microscopic
  • microwave
  • middle
  • migraine
  • milk
  • minaj
  • mineral
  • mineral oil
  • minimally
  • minimally invasive
  • miradry
  • mirror
  • misdiagnosis
  • miserable
  • miss america
  • miss korea
  • miss oregon
  • miss usa
  • miss wisconsin
  • missed
  • mit
  • mms
  • mobile
  • mod
  • model
  • modern
  • modification
  • mohler
  • mom
  • money
  • monitoring
  • monroe
  • more
  • morning
  • morphine
  • mortality
  • most
  • mother
  • mother's
  • motley crue
  • mouth
  • mouthwash
  • mouthwatering
  • movement
  • movie
  • mozart
  • mri
  • mrsa
  • msnbc
  • mucosa
  • mucosal
  • mucus
  • mumps
  • mundane
  • murmur
  • muscle
  • music
  • musicians
  • my fair lady
  • myoclonus
  • myoguide
  • myringotomy
  • mystery
  • myth
  • nadal
  • nail
  • name
  • nar
  • narcotic
  • nares
  • narrow
  • nasacort
  • nasal
  • nasal congestion
  • nasal obstruction
  • nasal packing
  • nasal spray
  • nasopure
  • nate bell
  • nathan sykes
  • nation
  • national institute of health
  • natural
  • NBC
  • ncs
  • necessity
  • neck
  • needle
  • negative
  • neglect
  • negligent
  • neilmed
  • nejm
  • nerve
  • netatmo
  • neti-pot
  • netter
  • network
  • neural
  • neuralgia
  • neuro
  • neuroanatomy
  • neurologica
  • neurology
  • neuroma
  • neuropathy
  • Neuropsychiatric
  • neurosurgeon
  • New
  • new england
  • new jersey
  • new york times
  • newborn
  • news
  • newsletter
  • newspaper
  • nexium
  • next
  • nfl
  • nicki
  • night
  • nightclub
  • nih
  • nina
  • nissen
  • nitrate
  • nmda
  • no
  • nobel
  • nodule
  • nodules
  • noise
  • noisy
  • non
  • non-acid
  • non-acidic
  • non-organic
  • non-par
  • non-sedated
  • non-verbal
  • normal
  • northern
  • northern virginia
  • nose
  • nosebleed
  • nosejob
  • nostril
  • nostrils
  • not
  • note
  • nova
  • nrr
  • nsaid
  • nsaids
  • nuclear
  • number
  • nurse
  • nutrition
  • nutritional
  • ny
  • NYT
  • oae
  • observation
  • obstetrics
  • obstruction
  • obstructive
  • obstructive sleep
  • ocd
  • ocean
  • ochsner
  • off
  • office
  • oil pulling
  • oklahoma
  • old
  • older
  • olfactory
  • olympic
  • omeprazole
  • one
  • online
  • open
  • opera
  • operating
  • operating room
  • operation
  • operative
  • operavox
  • ophthalmic
  • opinion
  • opioid
  • opposite
  • optimization
  • options
  • or
  • oral
  • oral mass
  • oral sex
  • oralair
  • orbit
  • orbital
  • orchestra
  • organic
  • ortho
  • orthopedic
  • orthopedics
  • osa
  • osha
  • otalgia
  • otc
  • oticon
  • otitis
  • otoacoustic
  • otolaryngology
  • otoscope
  • otovent
  • out
  • outbreaks
  • outer
  • output
  • outrageous
  • over
  • overdose
  • overlay
  • owl
  • oxidant
  • oxygen
  • pa
  • pacifier
  • packing
  • page
  • pain
  • painting
  • palsy
  • paltrow
  • pandas
  • paper
  • paper patch
  • papillary
  • papilloma
  • papillomas
  • papillomatosis
  • paradoxical
  • paradoxical vocal cord
  • paralysis
  • paralyzed
  • paralyzed vocal cord
  • parasitic
  • parent
  • parkinson's disease
  • parotid
  • parotidectomy
  • partial
  • past
  • patch
  • path
  • pathology
  • pathway
  • patient
  • patient portal
  • patient satisfaction
  • patient satisfaction score
  • pay
  • pediatric
  • pen
  • pencil
  • penis
  • pennsylvania
  • pepcid
  • pepsin
  • peptest
  • perfection
  • perforation
  • perform
  • performance
  • perfortion
  • periodic
  • peripheral
  • permanent
  • peroxide
  • person
  • personal
  • personality
  • peru
  • pettygrove full
  • PFAPA
  • ph
  • pharmacy
  • pharyngitis
  • pharynx
  • phillips
  • phlegm
  • phlegmy
  • phonak
  • phone
  • photo
  • photograph
  • photoshop
  • Physician
  • physics
  • picker
  • picture
  • pida
  • piercing
  • pill
  • pillow
  • pinterest
  • pipes
  • pitch
  • pitch perfect
  • pitcher
  • placebo
  • plants
  • plastic
  • plate
  • pluck
  • plug
  • plugs
  • PND
  • pneumonia
  • pocket
  • point
  • poison
  • poisoning
  • poke
  • policy
  • polio
  • politician
  • pollen
  • polyp
  • pool
  • poop
  • poor
  • pop
  • popping
  • popular
  • popularity
  • pork
  • port
  • portable
  • pose
  • position
  • positive
  • possible
  • post
  • post-nasal drainage
  • posterior
  • posterior tongue tie
  • postop
  • pouch
  • pound
  • pov
  • powder
  • power
  • ppi
  • practice
  • preamp
  • prednisone
  • pregnancy
  • pregnant
  • premium
  • prescription
  • present
  • presentation
  • presentations
  • preservative
  • president
  • presley
  • press ganey
  • pressure
  • prevacid
  • prevent
  • price
  • prick
  • prilosec
  • prince william
  • Prince William Hospital
  • principle
  • private
  • prize
  • pro
  • probe
  • problem
  • problems
  • procedure
  • process
  • product
  • profanity
  • professional
  • professor
  • prognosis
  • program
  • programming
  • progress
  • projection
  • pronunciation
  • proof
  • protect
  • protection
  • protocol
  • proton
  • provider
  • pseudo
  • pseudoephedrine
  • pterygopalatine
  • public
  • publication
  • publish
  • pulling
  • pulse
  • pump
  • purchase
  • purify
  • pus
  • putney
  • pyridostigmine
  • q
  • q-tips
  • q&a
  • qb
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  • radiation
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  • satisfaction
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  • scan
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  • science
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  • scraping
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  • screwdriver
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  • SLIT
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  • stick
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  • stoma
  • stomach
  • stomach wrap
  • stone
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  • stool
  • story
  • straighten
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  • strep
  • Streptococcus
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  • strobe
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  • stuck
  • study
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  • submental
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  • subscriber
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  • supplements
  • supreme
  • surface
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  • surgery
  • surgical
  • survey
  • survival
  • suzi quatro
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  • syndrome
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  • system
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  • tablet
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  • the doctors
  • theory
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  • thigh
  • thinking
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  • Throat Stones
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  • tne
  • to
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  • tonsil
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  • tonsillitis
  • tonsilloliths
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  • toothbrush
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  • top
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  • torax
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  • TV
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  • tylenol
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  • type
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  • ufc
  • ulcer
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  • umami
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  • united states
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  • unnecessary
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  • upper
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  • upper respiratory infection
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  • URI
  • urine
  • us
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  • uv
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  • vac
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  • valsalva
  • valve
  • vampire
  • vancouver
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  • vein
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  • vertigo
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  • vice president
  • video
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  • viral cold
  • virginia
  • virus
  • vision
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  • vitamin
  • vitamins
  • vivian
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  • vocal
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  • vocal cord dysfunction
  • vocal cord paralysis
  • vocal cords
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  • voice
  • voice council
  • voicebox
  • volume
  • vomit
  • vpi
  • wait
  • wall street journal
  • wanted
  • warning
  • warrenton
  • washington
  • washington post
  • washingtonian
  • wasp
  • water
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  • wax
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  • way
  • weak
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  • wealth
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  • web
  • webpage
  • Website
  • week
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  • weekend
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  • weight loss
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  • wendy nguyen
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  • whoop
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  • whooping cough
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  • wife
  • wilson
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  • window
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  • woman
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  • working
  • works
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  • world
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  • xlear
  • xylitol
  • yankees
  • years
  • yellow
  • yodel
  • yoga
  • young
  • youth
  • youtube
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