Cure for Noise-Induced Hearing Loss?

Normally, when mammals (including humans) are exposed to very loud sounds, permanent hearing loss may result due to cochlear hair cell injury. However, an experimental drug code-named LY411575 was found to regenerate new hair cells by suppressing a protein called Notch.

In essence, this drug restored hearing to mice deafened by loud noise.

Listen to an explanation by Harvard researcher Dr. Edge in this video.

However, human trials are a very long way off… so prevention is still the best way to avoid permanent noise-induced hearing loss. Wear hearing protection whenever loud sounds may be present!

Reference:
Notch Inhibition Induces Cochlear Hair Cell Regeneration and Recovery of Hearing after Acoustic Trauma. Neuron Volume 77, Issue 1, 58-69, 9 January 2013

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Submental Intubation [video]

Holy moly... Never realized submental intubation was actually a procedure that really is performed. Check out this video (or watch below) showing a submental intubation being performed.

First, an incision is created right below the jawline slightly off from midline. Dissection is bluntly carried right to the floor of the mouth under the tongue. The endotracheal tube is than grasped and pulled through this opening resulting in a submental intubation.

Seems quick and elegant with minimal bleeding... but I have some big issues with this procedure. There are multiple avoidable risks associated with this approach including:

1) Permanent lip paralysis. The nerve that innervates the lower lip crosses right through this region.
2) Chronic submandibular sialadenitis. The duct that carries spit from the submandibular gland (one of the major glands that produce spit) to the mouth can potentally be injured resulting in stenosis and chronic salivary gland inflammation if not infection.
3) Permanent numbness of the bottom of the mouth. The nerve that provides sensation to the region under the tongue crosses right through this area.
4) Permanent tongue paralysis. The nerve that allows for tongue movement crosses through this area.

Rather than a submental intubation, why not perform a tracheostomy or cricothyroidotomy. With either of these alternative procedures, the risks are minimal (there is no risk of nerve damage).

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ENT Doctor iPhone App Games

This was bound to happen sooner or later… thanks to @hobsonent who brought this to my attention.

This Nose Doctor iPhone app game basically is to try and remove nasal hair as well as boogers from different characters' noses using different instruments.

Another iPhone app game is Ear Doctor which deals more with ear problems (obviously).

Although these iPhone apps makes a game out of it, do ENT doctors actually professionally remove boogers, earwax, and nasal hair? We do… Regularly… For real… We are indeed professional ear and nose-pickers.

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What are Hot Dogs Made of? Pathological Analysis...

Ever since the publication of The Jungle by Upton Sinclair in 1906 about the US meat industry, there has been a negative connotation on what hot dogs are actually made of. Urban legend will report anything and everything can potentially be found in a hot dog including rats, human extremities, feces, etc.

So this begs the question of what really is found inside a hot dog when looked under the microscope to bring light of truth upon this murky question.

in 2008, Ohio pathologists took a look at 8 different brands of hot dogs and this is what they found:

• The average meat content in a hot dog was only 5.7% (range 2.9% - 21%). Water actually made up most of a hot dog content consisting of 57% (range 44% - 69%). What meat was seen was recognizable as muscle, but did show evidence of degenerative changes. Also, the higher the meat content, the more expensive the hot dog was.

• No brain tissue was seen in any samples (especially important when considering mad-cow disease is localized in brain tissue and can be transmitted to humans who eat contaminated tissue causing fatal Crutzfeldt-Jakob disease).
• Besides meat, other tissue types were seen including connective tissue, blood vessels, nerves, and fat (all expected in meat/muscle).
• However, cartilage and bone was also found in some samples, perhaps accrued during the butchering and processing of the meat.
• Unexpectedly, skin was found in one hot dog. Plant material was also unexpectedly found which may have been added as a way to add bulk to the meat.

There you have it!

What about hamburger meat? Click here for more info...

Reference:

Applying morphologic techniques to evaluate hotdogs: what is in the hotdogs we eat? Ann Diagn Pathol. 2008 Apr;12(2):98-102. doi: 10.1016/j.anndiagpath.2007.04.012. Epub 2007 Oct 24.

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Exactly What is Fast Food Hamburger Meat Made of? Pathological Analysis...

I freely admit that in my youth, I loved eating burgers from fast food joints like McDonald's. But after getting married and being encouraged to eat healthier by my wife who felt fast food burgers were unhealthy (disgusting) because they weren't actually made of meat, I've always wondered what hamburger meat was truly made of...

Well... a group of pathologists actually performed a pathologic analysis on 8 different fast food hamburger meat. No... they did not identify the fast food chain where they got the meat.

What they found was both reassuring as well as alarming. Here are the key interesting findings:

• Actual meat content in a typical burger is only 12% (range: 2.1%-14.8%). The meat itself did appear normal which is reassuring. Most of the burger is actually made of water comprising 49% of the weight (range: 37%-62%)
• No brain tissue was seen in any samples (especially important when considering mad-cow disease is localized in brain tissue and can be transmitted to humans who eat contaminated tissue causing fatal Crutzfeldt-Jakob disease).
• Besides meat, other tissue types were seen including connective tissue, blood vessels, nerves, and fat (all expected in meat/muscle).
• However, cartilage and bone was also found in some samples, perhaps accrued during the butchering and processing of the meat.
• Plant material was also unexpectedly found which may have been added as a way to add bulk to the meat.
• Intracellular parasites (Sarcocystis) was also seen in a few samples which is why meat should always be cooked prior to eating (whether burger or restaurant grade A meat).

So there you have it... fast food hamburger meat actually does contain meat, though it only makes a small part of it.

What about hot dogs? Click here for more info...

Reference:
Fast food hamburgers: what are we really eating? Annals of Diagnostic Pathology 12 (2008) 406–409

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Nasacort Steroid Nasal Spray to be Available Over-The-Counter!

Sanofi announced today that the FDA has approved Nasacort steroid nasal spray to be made available over-the-counter (OTC) starting sometime spring 2014.

Nasacort is a steroid nasal spray used to treat allergies in patients start from the age of 2 years old. It will also be the very first steroid nasal spray made OTC in the United States which can be both a blessing as well as a curse.

Why?

With Nasacort going OTC which will certainly make it more convenient for patients, I also anticipate that the other prescription steroid nasal sprays including nasonex, qnasl, zetonna, veramyst, etc will become much harder to prescribe due to insurance requiring patients to use OTC Nasacort first. Worst case, insurance may even simply stop paying for the prescription steroid nasal sprays.

After all, this is exactly what happened with prescription reflux and anti-histamine medications.

Source:
FDA Approves Sanofi's Nasacort(R) Allergy 24HR for Over-the-Counter Use. Wall Street Journal 10/11/13

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Surgeons Should be Good at Social Media

Not just surgeons, but also any procedural intensive medical specialties like interventional cardiology and radiology should be reasonably good at social media.

Why?

Because we have built-in time points within our daily routine schedule that enable such activities.

Let me explain... Between every surgical case, there is downtime that lasts anywhere from 15 minutes to as long as 45 minutes.

It is the time during which the operating room is being cleaned, sterilized, and new instruments are brought in and set up.

Before the days of social media, this is the time when many surgeons would read the newspaper/magazine, eat in the cafeteria, surf the internet, chat with staff, etc. Of course, any consults and paperwork that are pending would first be addressed.

But now... this time can be used for social media activities.

This time can now be used to read/write blogs, read/post tweets, and generally think of ideas worthy of sharing.

OR... if you are just sitting there waiting for a surgical case to start, check out my tweets or blog!

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First Implantation of Human Artificial Larynx Announced!

Image taken from DNA

ProTip SAS and Strasbourg University Hospitals announced that a fully artificial larynx was implanted into a human for the first time.

Made entirely of titanium, the surgery was performed in two stages into a man with throat cancer that required his entire voicebox to be removed (laryngectomy).

Stage 1:
In June 2012, the larynx was removed and a titanium tracheal ring was implanted in its place.

Stage 2:
In November 2012, a removable valve-based device was inserted into/onto the titanium tracheal ring via the mouth.

According to reports, this device allows for both breathing as well as phonation.

What is still unclear to me from reports scavenged on the internet are the following questions which I'm sure will become more clear as more information is provided:

1) What does the voice sound like?
2) How is breathing and phonation exactly accomplished?
3) How much is swallowing impacted?
4) What is the risk of extrusion?
5) How is the valve constructed to enable voice production?
6) How is aspiration prevented during swallow?


Source:
ProTip and Strasbourg University Hospitals announce the first human implantation of an artificial larynx. MNT 10/9/13

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Ear Tube Placement in Kids WITHOUT Sedation (Starting at 12 Months of Age)

A recent report describes how using a relatively old technology, ear tube placement can now be performed in children starting at 12 months of age with chronic ear infections or hearing loss due to fluid buildup without the need for sedation of any kind nor aggressive restraints (ie papoose). Historically, ear tube placement in the office without sedation is typically performed starting at around 12 years of age using standard local anesthesia techniques. Any younger, a child could not be trusted to stay still during the procedure due to presence of some discomfort.

In any case, a Texan ear group reports how they accomplished this simple procedure at such young ages.

First, the ear canal is cleaned as much as possible of all earwax and debris. The ear canal is than filled with an anesthetic liquid (concoction of lidocaine, epinephrine, and sodium bicarbonate). Over 10 minutes, iontophoresis was than used to induce profound local anesthesia to the ear canal and eardrum. The liquid was than suctioned out and ear tube placement was performed with a reported 90% success rate (78 of 86 ears; 17 subjects were 3 years old or younger; 8 were 12 months old).

The key to success required 3 "new" elements.

• Iontophoresis device made by Acclarent. There are other iontophoresis devices in the market (Medtronic and Otomed), but none adapted for simultaneous bilateral ear canal usage that works within 10 minutes. Iontophoresis works by applying a gentle electric current in order to actively move charged drug molecules into the skin. In this particular case, positively charged lidocaine and epinephrine.
• Optimal anesthetic solution for iontophoresis. Dubbed "EMGIM", it contains 1:12,000 epinephrine with 3.3% lidocaine hydrochloride and 0.7% sodium bicarbonate. The solution is prepared fresh prior to use by combining 10 mL of 4% lidocaine hydrochloride with 1 mL of 1:1,000 epinephrine. After mixing the lidocaine and epinephrine, 1 mL of 8.4% sodium bicarbonate is added.
• Ear tube delivery device and placement system. Typically, a competent ENT can place an ear tube in about 10-20 seconds. However, when dealing with kids who may potentially move unexpectedly and operating within a very small ear canal space, a faster and more reliable way of placing a tube was required. Hence, this new device. [link]

Of course, during the actual procedure, age-appropriate distraction was needed to minimize movement, especially given aggressive restraint was not used.

Sounds great as sedation is something to be avoided if at all possible. However, there is one problem... the Acclarent iontophoresis device is NOT yet FDA approved contrary to what the report states (direct communication with Acclarent executives October 1, 2013). Hopefully in 2014. As such, beyond a research setting, this in-office technique is not yet available for use in the United States.

As an aside, there are FDA-approved iontophoresis devices for use in pediatric head and neck surgical procedures mainly for sub-cutaneous mass excisions and abscess incision and drainage. Check out Phoresor for such applications using lidocaine infused electrodes. It's even sold on Amazon.


References:
Otologic Iontophoresis: A No-Papoose Technique. Annals of Otology. Rhinology & Laryngology 122(8):487-491. Aug 2013.

In-Office Tympanostomy Tube Placement Under Local Anesthesia Using a Novel Tube Delivery Device. Triological Meeting Poster. Dec 2012.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg. 1999 Jun;34(6):946-9.

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Presentation on Social Media Given at AAO-HNS Meeting in Vancouver, BC

It was with great honor and pleasure that I was asked by the American Academy of Otolaryngology-Head and Neck Surgery to co-present a 90 minute long mini-seminar on social media in medicine on October 2, 2013 in Vancouver, BC.

Dr. Wendy Stern (Vice Chair - Public Relations Committee of the Board of Governors of the American Academy of Otolaryngology/Head and Neck Surgery) along with Dr. John Carter (AAO-HNS Section for Residents and Fellows) organized this talk coordinating 4 speakers including:

• Dr. Lawrence Simon (Assistant Professor at Louisiana State University) providing an overview of social media and its pervasiveness
• Myself from the view of a private practice
• Dr. Julie Wei (Division Chief at Nemours Childrens Hospital in Orlando, FL) from the perspective of an academic medical practice
• Dr. Lee Eisenberg (Associate Clinical Professor at Columbia University) portraying the medical-legal pitfalls of social media

During this presentation, it was great to hear, see, and meet other otolaryngologists active in social media including @ENTinTraining, @ent_amy,@ithinkalot as well as blogger Dr. Bruce Campbell (Reflections in a Head Mirror; aka @headmirror).

One of my former mentors at Duke University, Dr. Richard Scher, was also present.

Here's a few tweets related to this event...

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Aspirin Allergy and Desensitization Protocols

For patients who suffer from terrible allergies, asthma, nasal polyps, and also suffer an allergy to aspirin, desensitization to aspirin can profoundly improve overall allergies and airway hyper-reactivity through an as yet unknown mechanism. It is hypothesized that aspirin desensitization works by decreasing leukotriene production and downregulating cystienyl leukotriene receptors resulting in a decrease in histamine and tryptase release from mast cells which causes allergy symptoms.

However, there are two problems regarding patients who wish to pursue aspirin desensitization: not many physicians perform it due to risk of life-threatening anaphylaxis and lack of standardized protocols.

Here are some sample published protocols for aspirin desensitization. Keep in mind that regardless of which protocol is administered, the aspirin desensitized state only exists as long as regular aspirin continues to be taken. If the patient forgets to take aspirin for a few days (typically 48 hours), the protocol has to be repeated.

Protocol #1:
Aspirin dissolved in water at 1mg/cc concentration. On day 1, patient is given 10mg, 30mg, 60mg, and 100mg of aspirin spaced 6 hours apart. On day 2, an additional 100mg, 150mg, and 300mg is given spaced 8 hours apart. The patient is discharged home on 300mg or 350mg of aspirin to be taken twice a day as well as zantac 150mg twice a day for GI prophylaxis. If needed, proton pump inhibitors can also be taken.

Protocol #2:
Aspirin is administered at intervals of 10–30 min in the following dosages: 0.1 mg, 0.3 mg, 1 mg, 3 mg, 10 mg, 30 mg, 40 mg, 81 mg, 162 mg, and 325mg. The dilution and dosing may be altered depending on the patient's clinical situation.

Protocol #3:
Aspirin is administered starting at 1 mg and doubling each dose every 30 min up to a final dose of 100 mg (therefore lasting 3.5 hours).

Protocol #4:
Aspirin given in 5 sequential doses of 5, 10, 20, 40, and 75 mg given every 30 minutes (the protocol lasting 2.5 hours).

Depending on the physician, patient's clinical characteristics, and comfort level of all concerned, these protocols may be performed in an office-setting to even in the intensive care unit of a hospital.

Pre-treatment with anti-histamines, singulair, or systemic steroids may or may not be administered. Beta-blockers typically is stopped 24 hours prior to protocol initiation. Monitoring during the protocol include blood pressure, pulse, and peak expiratory flow measurements every 30 min as well as checking for any reactions involving the skin, nose, eye, or breathing. Once the protocol is completed, monitoring is continued for an additional 3-6 hours.

Keep in mind that our office does not perform aspirin desensitization and provides this information for educational purposes. Please contact your local allergist to determine if they perform aspirin desensitization. Your best bet is your closest tertiary care academic medical center as locations where such protocols are performed.

Trivia: When a patient suffers from asthma, nasal polyps, and aspirin allergy, it is known as Samter's triad.

References:
Hypersensitivity to ASA in patients with coronary artery disease: rapid desensitisation is feasible. European Society of Cardiology Council. E-journal of Cardiology Practice 3.

Selection of patients for ASA desensitization treatment. J Allergy Clin Immunol 118: 801–804.

Rapid oral challenge-desensitisation for patients with ASA-related urticariaangioedema. J Allergy Clin Immunol 105: 997–1001.

Rational approach to aspirin dosing during oral challenges and desensitization of patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2009 Feb;123(2):406-10. doi: 10.1016/j.jaci.2008.09.048. Epub 2008 Dec 3.

Selection of aspirin dosages for aspirin desensitization treatment in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2007 Jan;119(1):157-64. Epub 2006 Nov 13.

ASA sensitivity: the role for ASA challenge and desensitisation in postmyocardial infarction patients. Cardiology 91: 8–13.

Rapid desensitisation procedure for patients with ASA hypersensitivity undergoing coronary stenting. Am J Cardiol 95: 509–510.

Aspirin Hypersensitivity and Desensitization Protocols. Ther Adv in Drug Safe. 2011;2(6):263-270.

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